What is the recommended treatment for allergic rhinitis in pregnant women?

Treatment of Allergic Rhinitis in Pregnancy

Saline nasal rinses and intranasal corticosteroids (budesonide, fluticasone, or mometasone) are first-line therapy for allergic rhinitis in pregnancy, with second-generation antihistamines (loratadine or cetirizine) as safe alternatives when additional symptom control is needed. 1

First-Line Treatment Algorithm

Step 1: Initiate Saline Nasal Rinses

• Begin with saline nasal lavage for all pregnant patients with allergic rhinitis, as this is completely safe and provides effective symptom relief without any fetal risk. 2, 1

Step 2: Add Intranasal Corticosteroids for Persistent Symptoms

• Intranasal corticosteroids are the most effective maintenance therapy and should be used regularly (not as-needed) for optimal control of nasal inflammation. 2, 1
• Budesonide, fluticasone, and mometasone are considered safe based on extensive clinical experience and lack of association with congenital malformations. 1, 3
• These agents should be prioritized over oral antihistamines due to superior efficacy and minimal systemic absorption. 3
• Studies of pregnant women have not shown that inhaled budesonide increases the risk of abnormalities when administered during pregnancy, with data from over 2,500 infants showing congenital malformation rates similar to the general population (3.6-3.8% vs. 3.5%). 4

Step 3: Add Second-Generation Antihistamines if Needed

• Loratadine or cetirizine are safe second-generation antihistamines when intranasal corticosteroids alone provide insufficient relief. 1, 5
• Loratadine has been studied in 2,147 pregnant women without increased risk of major congenital malformations. 3
• First-generation antihistamines (like chlorpheniramine) have more extensive safety data from 200,000 first-trimester exposures showing no increased teratogenic risk, but should be avoided due to sedative and anticholinergic properties. 2, 6

Medications to Strictly Avoid

Oral Decongestants - Do Not Use

• Oral decongestants (phenylephrine, pseudoephedrine) should not be used, especially during the first trimester, due to associations with fetal gastroschisis, small intestinal atresia, and maternal hypertension. 2, 1, 7

NSAIDs and Aspirin - Contraindicated

• Aspirin and NSAIDs are Category D and must be discontinued due to risks of premature ductus arteriosus closure, intrauterine growth restriction, and perinatal mortality. 2

Allergen Immunotherapy Management

• Continue existing immunotherapy at the current maintenance dose if already established before pregnancy, but do not initiate new immunotherapy or increase doses during pregnancy due to anaphylaxis risk. 2, 1
• Sublingual immunotherapy is generally contraindicated during pregnancy. 2

Critical Clinical Considerations

First Trimester Precautions

• The first trimester (weeks 1-12) carries the highest risk for medication-induced teratogenicity, so exercise particular caution during this period when most major organ malformations occur. 1, 7, 4

Untreated Disease Risks

• Untreated severe allergic rhinitis can worsen asthma control and pose greater maternal-fetal risks than appropriate pharmacotherapy. 1
• Approximately one-third of pregnant women with asthma experience worsening symptoms during pregnancy, often triggered by untreated allergic rhinitis. 1
• Women with poorly or moderately controlled asthma face increased risks of preeclampsia, prematurity, low birth weight, and small-for-gestational-age infants. 4

Common Pitfalls to Avoid

• Do not withhold intranasal corticosteroids based solely on pregnancy status - the benefits of controlling maternal symptoms and preventing asthma exacerbations outweigh theoretical risks, with extensive human data supporting safety. 4, 3
• Do not use nasal decongestants for more than a few days - pregnancy rhinitis patients tend to overuse them, leading to rhinitis medicamentosa. 8, 9
• Do not confuse pregnancy rhinitis with allergic rhinitis - pregnancy rhinitis is defined as nasal congestion in the last 6+ weeks of pregnancy without allergic cause, resolving within 2 weeks postpartum, and may not respond to the same treatments. 8, 9