In a 27‑week pregnant patient with hypertension presenting with cold and nasal congestion, which decongestant is appropriate to use?

Avoid Oral Decongestants—Use Saline Rinses and Intranasal Corticosteroids Instead

Do not give oral decongestants to this pregnant hypertensive patient. Oral decongestants are contraindicated in pregnancy, particularly in hypertensive patients, as they increase the risk of fetal gastroschisis and can worsen maternal hypertension 1.

Recommended Treatment Approach

First-Line Therapy

• Hypertonic saline nasal rinses: Safe, effective, and should be the initial intervention 2
• Intranasal corticosteroids (beclomethasone or budesonide): Safe for pregnancy with no teratogenic effects in humans, commonly used in pregnant asthmatics 1, 2

Why Oral Decongestants Are Contraindicated

The 2016 Rhinology expert panel guidelines explicitly state that oral decongestants should not be used during pregnancy 1. The reasoning is twofold:

1. Fetal risk: Oral decongestants may increase the risk of gastroschisis (abdominal wall defect)
2. Maternal hypertension: These agents contribute to elevated blood pressure, which is particularly dangerous in your already-hypertensive patient at 27 weeks gestation

This is critical because your patient already has hypertension requiring management with agents like nifedipine or labetalol 3, and adding a vasoconstrictive decongestant would directly counteract blood pressure control.

Alternative Symptomatic Relief

If nasal congestion persists despite saline rinses and intranasal steroids:

• First-generation antihistamines (chlorpheniramine): Can be used cautiously, though they should generally be avoided due to sedative and anticholinergic properties 1
• Second-generation antihistamines (cetirizine, loratadine): Safer profile with less sedation 2, 4, 5

Important Clinical Caveats

Topical (intranasal) decongestants: While the guidelines note there are "no data available for intranasal decongestants" regarding teratogenicity 1, the lack of evidence combined with the systemic absorption potential makes them a poor choice, especially given safer alternatives exist.

Intranasal corticosteroid selection: Beclomethasone and budesonide have the longest safety track record in pregnancy 2, 6, 5. Newer agents (fluticasone, mometasone) lack first-trimester data and should be avoided when alternatives exist.

Hypertension Management Reminder

Ensure her baseline hypertension is optimally controlled with pregnancy-safe agents (extended-release nifedipine or labetalol as first-line) 3, as this will indirectly help with pregnancy rhinitis symptoms by improving overall vascular tone.