What cough suppressants and rhinitis medications are safe for use during pregnancy, especially in the third trimester?

Safe Cough Suppressants and Rhinitis Medications in Third Trimester Pregnancy

Intranasal corticosteroids are the safest and most effective first-line treatment for rhinitis symptoms during pregnancy, including the third trimester, due to their excellent safety and efficacy profile. 1

First-Line Medications for Rhinitis in Pregnancy

Intranasal Corticosteroids

• Intranasal corticosteroids have a strong safety profile during pregnancy, with minimal systemic absorption 1
• Meta-analyses have shown that inhaled corticosteroids do not increase risks of major malformations, preterm delivery, low birth weight, or pregnancy-induced hypertension 1
• Budesonide has the strongest safety evidence and is preferred if initiating treatment during pregnancy 2, 3
• Other options include fluticasone and mometasone, which also have favorable safety profiles 4

Sodium Cromolyn

• Sodium cromolyn nasal spray (Pregnancy Category B) is considered very safe during pregnancy due to its topical application and reassuring gestational data 1
• Main limitation is the need for frequent dosing (4 times daily) and reduced efficacy compared to other options 1
• Can be considered a first-line option for allergic rhinitis in pregnant women 5

Antihistamine Options

Second-Generation Antihistamines

• Cetirizine and loratadine have the most safety data and are preferred during pregnancy 6, 4
• Cetirizine is particularly recommended for the third trimester 6
• Loratadine is considered safe in the second and third trimesters 6, 5

First-Generation Antihistamines

• Chlorphenamine (chlorpheniramine) has a long safety record and is often chosen by clinicians for pregnant patients 6, 5
• Diphenhydramine is commonly used but should be used with some caution due to historical concerns about cleft palate, though recent studies have not confirmed this risk 1
• Hydroxyzine should be avoided, especially during early pregnancy 6

Decongestants

Topical Decongestants

• Short-term use (up to 7 days) of intranasal decongestants may be safer than oral options 2
• Risk of rebound congestion (rhinitis medicamentosa) with prolonged use 7
• Should be used cautiously and for limited duration 1

Oral Decongestants

• Oral decongestants should generally be avoided during pregnancy, especially in the first trimester 1, 8
• Conflicting reports associate phenylephrine and pseudoephedrine with congenital malformations 1
• Risk increases when combined with acetaminophen or salicylates 1

Leukotriene Modifiers

• Montelukast (Pregnancy Category B) has reassuring animal reproductive studies and limited human safety data 4
• Should be reserved for patients who had uniquely favorable responses before pregnancy 1, 4
• Small observational study (9 patients) showed no adverse events 1, 4

Non-Pharmacological Approaches

• Saline nasal irrigation/lavage is completely safe and can provide symptomatic relief 3
• Nasal alar dilators (external nasal strips) can help improve nasal breathing 7
• Proper positioning during sleep (elevated head) may reduce congestion 3

Cough Suppressants

• Dextromethorphan is generally considered safe for short-term use in pregnancy 2
• Codeine and other opioid-based cough suppressants should be avoided, especially for prolonged use 2

Important Considerations and Pitfalls

• Always weigh potential benefits against risks when treating pregnant women 6, 4
• Avoid assuming all medications within the same class have equivalent safety profiles 6
• Recognize that untreated severe rhinitis can negatively impact sleep, quality of life, and potentially worsen asthma control 5, 9
• Pregnancy rhinitis (hormone-induced nasal congestion) affects approximately 20% of pregnant women and resolves within 2 weeks after delivery 7
• Differentiate between allergic rhinitis, infectious rhinitis, and pregnancy rhinitis for appropriate treatment 3, 9