Can a pregnant patient use nasal spray for nasal congestion or allergies?

Nasal Spray Use During Pregnancy

Pregnant patients should use intranasal corticosteroid sprays (budesonide, fluticasone, or mometasone) as the safest and most effective option for nasal congestion, while strictly avoiding all decongestant nasal sprays (like oxymetazoline) throughout pregnancy due to documented fetal heart rate changes and potential malformations. 1, 2

First-Line Treatment Approach

Start with saline nasal rinses before any medication. The American Academy of Otolaryngology recommends saline nasal irrigation as the safest first-line treatment with no fetal risk. 1, 3 This should be attempted for several days before escalating to pharmacologic therapy.

If saline alone provides inadequate relief:

• Add an intranasal corticosteroid spray - budesonide, fluticasone propionate, fluticasone furoate, or mometasone are all safe throughout pregnancy, including the first trimester. 4, 1, 2
• These medications control nasal inflammation effectively and have extensive safety data showing no increased risk of major malformations, preterm delivery, low birth weight, or pregnancy-induced hypertension. 1
• Use at the lowest effective dose: typically 1-2 sprays per nostril once daily. 5

Critical Medications to Avoid

All decongestant nasal sprays must be avoided:

• Oxymetazoline and similar topical decongestants cause documented fetal heart rate changes and have systemic absorption despite topical administration. 1, 2
• The American College of Allergy, Asthma, and Immunology specifically warns about decongestants causing fetal cardiovascular effects throughout pregnancy, with particular concern in the first trimester. 1
• Oral decongestants (phenylephrine, pseudoephedrine) are associated with fetal gastroschisis, small intestinal atresia, and maternal hypertension. 4, 1, 3

First-generation antihistamines should be avoided due to sedative and anticholinergic properties. 4, 3

Why Decongestant Sprays Are Dangerous

The evidence clearly demonstrates systemic effects despite topical administration:

• Cerebrovascular adverse events (stroke, optic neuropathy, retinal artery occlusion) have been reported with intranasal decongestants, proving systemic absorption. 2
• Fetal heart rate changes documented at 25 weeks gestation confirm transplacental passage affecting the fetus. 1, 2
• Expert panels from the Rhinology society explicitly recommend against oral decongestants due to gastroschisis risk and hypertension—principles that apply equally to topical agents. 4, 2

Additional Safe Options

• Nasal saline lavage/douching - can be used liberally throughout pregnancy. 4, 6
• Mechanical nasal dilators (external nasal strips) - safe physical method to improve airflow. 7, 8
• Second-generation antihistamines (loratadine, cetirizine) - if allergic rhinitis is the cause, these are generally safe but less effective than intranasal corticosteroids for congestion alone. 6

Common Pitfalls to Avoid

• Do not assume "topical = safe" - oxymetazoline nasal spray has documented systemic effects and fetal impact despite being applied only to nasal mucosa. 1, 2
• Do not use decongestant sprays "just for a few days" - even short-term use carries fetal risk, and rebound congestion (rhinitis medicamentosa) develops after 3 days, creating a cycle of dependence. 1, 7, 8
• Do not confuse pregnancy rhinitis with bacterial sinusitis - pregnancy rhinitis (affecting 20% of pregnant women) is self-limited and resolves within 2 weeks postpartum; it does not require antibiotics, only symptomatic management. 7, 8

When to Escalate Care

Monitor for signs requiring urgent evaluation:

• High fever persisting despite treatment
• Severe headache or visual changes
• Periorbital swelling
• Symptoms suggesting orbital cellulitis, meningitis, or abscess formation 2, 3

These complications require immediate specialist consultation and possible imaging, as they indicate bacterial sinusitis rather than simple rhinitis.