Treatment of Allergic Rhinitis in Pregnancy
Saline nasal rinses and intranasal corticosteroids (particularly budesonide, fluticasone, or mometasone) are the first-line treatments for allergic rhinitis during pregnancy, with second-generation antihistamines like loratadine or cetirizine as safe alternatives when additional symptom control is needed. 1, 2, 3
First-Line Treatment Approach
Topical Nasal Therapies (Preferred)
Saline nasal rinses/lavage should be initiated as primary therapy for all pregnant patients with allergic rhinitis, as they are completely safe and effective for symptom relief 1, 2, 3
Intranasal corticosteroids are the most effective maintenance therapy and should be used regularly rather than as-needed 1, 2, 3
- Budesonide has the strongest safety data in pregnancy (FDA Category B) with no increased risk of congenital malformations in over 2,500 exposed pregnancies 4, 5, 6
- Fluticasone and mometasone are also considered safe alternatives based on extensive clinical experience 2, 3, 7
- Use at the lowest effective dose for the shortest necessary duration 2, 3
- These medications have minimal systemic absorption, making them safer than oral alternatives 5
Oral Antihistamines (When Additional Control Needed)
Second-generation antihistamines are preferred over first-generation agents 1
First-generation antihistamines should be avoided due to sedative and anticholinergic properties that can impair maternal function 1, 2, 3
Additional Safe Options
Intranasal cromolyn (sodium cromoglycate) can be used as first-line therapy, particularly for allergic rhinitis, with no teratogenic concerns 8, 5
Montelukast (leukotriene receptor antagonist) is FDA Category B and may be considered if the patient had a favorable response before pregnancy, though it should not be first-line for rhinitis alone 1
Medications to Strictly Avoid
Oral Decongestants (Contraindicated in First Trimester)
Phenylephrine and pseudoephedrine should not be used, especially during the first trimester, due to associations with fetal gastroschisis, small intestinal atresia, and maternal hypertension 1, 2, 3, 7
If absolutely necessary for severe symptoms unresponsive to other therapies, may consider brief use after the first trimester only 1, 8
Other Contraindications
Aspirin and NSAIDs are Category D and must be discontinued due to risks of premature ductus arteriosus closure, intrauterine growth restriction, and perinatal mortality 1
Topical nasal decongestants (oxymetazoline, phenylephrine) should be avoided as they are ineffective for allergic rhinitis and risk rhinitis medicamentosa with overuse 1, 9
Allergen Immunotherapy Considerations
Continue existing immunotherapy at the current maintenance dose if already established before pregnancy 1
Do not initiate or increase doses during pregnancy due to anaphylaxis risk 1
Sublingual immunotherapy is generally contraindicated during pregnancy 1
Clinical Pearls and Pitfalls
Critical timing consideration: The first trimester carries the highest risk for medication-induced teratogenicity, so exercise particular caution during weeks 1-12 2, 10
Common pitfall: Product labels often state medications should be avoided in pregnancy despite substantial human safety data—this leads to undertreatment. Untreated severe allergic rhinitis can worsen asthma control and pose greater maternal-fetal risks than appropriate pharmacotherapy 1, 8, 5, 6
Asthma comorbidity: Approximately one-third of pregnant women with asthma have worsening symptoms during pregnancy, often triggered by untreated allergic rhinitis. Aggressive treatment of rhinitis is essential to maintain asthma control 1, 6
Pregnancy rhinitis vs. allergic rhinitis: Distinguish pregnancy-induced rhinitis (appears after second month, resolves within 2 weeks postpartum) from allergic rhinitis, as pregnancy rhinitis may not respond to corticosteroids and is best managed conservatively 1, 9