Management of Epistaxis in Pregnancy

Initial Management Approach

The American Academy of Otolaryngology-Head and Neck Surgery recommends managing epistaxis in pregnancy using the same first-line conservative measures as in non-pregnant patients: firm sustained compression to the lower third of the nose for 10-15 minutes with the patient sitting upright and head tilted slightly forward, followed by topical vasoconstrictors if bleeding persists 1, 2, 3.
Apply firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 3.
The patient should breathe through their mouth and spit out any blood rather than swallowing it, according to the American Academy of Otolaryngology-Head and Neck Surgery 5.
Simple compression alone stops bleeding in the majority of cases, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 3, 5.

Topical vasoconstrictors, such as oxymetazoline or phenylephrine spray, should be applied after clearing any clots, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 7.
This resolves 65-75% of epistaxis cases that don't respond to compression alone, according to the American Academy of Otolaryngology-Head and Neck Surgery 7.

Apply petroleum jelly or other moisturizing/lubricating agents to the nasal mucosa, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 7.
Regular saline nasal sprays should be used to maintain mucosal moisture, according to the American Academy of Otolaryngology-Head and Neck Surgery 4, 5.
Avoid nasal trauma, nose-picking, and forceful nose-blowing, as advised by the American Academy of Otolaryngology-Head and Neck Surgery 1.

Nasal packing is indicated if bleeding continues after 15 minutes of compression and vasoconstrictor use, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 3.
Resorbable packing materials, such as Nasopore, Surgicel, or Floseal, should be used rather than non-resorbable packing, according to the American Academy of Otolaryngology-Head and Neck Surgery 3.
Nasal endoscopy should be performed or referred to identify the bleeding site, especially important in pregnancy to rule out lesions like pyogenic granuloma, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2, 7.

Bleeding not controlled after 15 minutes of continuous pressure requires urgent ENT evaluation, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4, 5.
Signs of hemodynamic instability, such as tachycardia, hypotension, or dizziness from blood loss, necessitate immediate specialist consultation, according to the American Academy of Otolaryngology-Head and Neck Surgery 4, 6.
Recurrent or bilateral epistaxis suggesting hereditary hemorrhagic telangiectasia requires urgent evaluation, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2.

Do not have the patient tilt their head backward, as this causes blood to flow into the airway and stomach, according to the American Academy of Otolaryngology-Head and Neck Surgery 4, 5.
Do not compress the nasal bridge, as compression must be applied to the soft lower third of the nose where the bleeding vessels are located, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 3, 6.
Do not check if bleeding has stopped before 10-15 minutes, as premature release of pressure prevents clot formation, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 3.

Do not discontinue psychiatric or other medications for a single epistaxis episode, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4.
First-line conservative treatments should be attempted before considering any medication adjustments, according to the American Academy of Otolaryngology-Head and Neck Surgery 4.
Document any anticoagulant or antiplatelet use, as this increases bleeding risk, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 6.