What are the treatment options for a pregnant woman with pregnancy rhinitis and rhinorrhea?

Treatment of Pregnancy Rhinitis and Rhinorrhea

Saline nasal irrigation should be your first-line treatment for pregnancy rhinitis, used frequently throughout the day, as it is completely safe at any gestational age and provides effective congestion relief. 1

Initial Management Approach

Non-Pharmacological Interventions (Start Here)

• Saline nasal irrigation is the cornerstone of treatment and should be used multiple times daily for symptom control 1
• Warm facial compresses, steamy showers, adequate hydration, and sleeping with the head elevated provide additional symptomatic relief 1
• Mechanical nasal dilators (alar dilators) are safe and can help relieve nasal congestion without medication 2, 3
• Regular exercise may help reduce nasal congestion 2

These measures are particularly important because pregnancy rhinitis affects approximately 20-39% of pregnant women, typically starts after the second month of pregnancy, and resolves within 2 weeks after delivery 4, 2, 5

Pharmacological Treatment (When Non-Pharmacological Measures Are Insufficient)

Intranasal Corticosteroids (Preferred Medication Option)

• Budesonide, fluticasone, or mometasone nasal sprays are safe to use at recommended doses throughout pregnancy after the first trimester and effectively reduce nasal inflammation and congestion 4, 1
• Budesonide has the most robust safety evidence from pregnancy studies and should be used at the lowest effective dose 1
• Use these medications when quality of life is significantly impaired, as pregnancy rhinitis can affect both maternal well-being and potentially fetal development 2, 5

Important caveat: One study of fluticasone propionate in 53 women with pregnancy rhinitis showed no difference from placebo in symptom scores, suggesting intranasal corticosteroids may not be effective specifically for pregnancy rhinitis (as opposed to allergic rhinitis) 4. However, they remain safe to use when indicated 4, 1

Antihistamines (Second-Line Option)

• First-generation antihistamines like chlorpheniramine are preferred over second-generation agents based on longer safety track records 6
• Cetirizine has not been associated with congenital abnormalities but has less extensive pregnancy data 6
• Antihistamines should be avoided during the first trimester when possible 7

Medications to Use With Extreme Caution or Avoid

Topical Nasal Decongestants:

• Oxymetazoline and similar agents provide temporary relief but must be limited to 3 days maximum to prevent rhinitis medicamentosa (rebound congestion) 1, 2
• Pregnancy rhinitis patients tend to overuse these medications, creating an additional problem 2, 3

Oral Decongestants:

• Pseudoephedrine and phenylephrine should NOT be used during pregnancy, particularly in the first trimester, due to association with congenital malformations 1, 8

Oral Corticosteroids:

• Should be avoided, especially during the first trimester, due to increased risk of cleft lip/palate, preeclampsia, preterm birth, and low birth weight 4
• Only justified in severe cases after the first trimester, particularly if causing asthma exacerbation, and requires consultation with the patient's obstetrician 4

Differential Diagnosis Considerations

Rule Out Bacterial Sinusitis

• Pregnancy rhinitis can be difficult to distinguish from sinusitis, which may present with nasal congestion as the only symptom during pregnancy 2, 3
• Nasendoscopy of a decongested nose is the diagnostic method of choice; look for purulent discharge 3
• If bacterial sinusitis is confirmed, treat with amoxicillin or azithromycin (safe first-line antibiotics in pregnancy) 1, 8
• Avoid tetracyclines, fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycosides 1, 8

Consider Other Rhinitis Types

• Allergic rhinitis worsens in approximately one-third of pregnant patients due to nasal vascular pooling from vasodilation and increased blood volume 4
• Drug-induced rhinitis from ACE inhibitors, beta-blockers, or overuse of topical decongestants should be considered 4
• True pregnancy rhinitis is defined as nasal congestion present for 6 or more weeks without signs of infection or known allergic cause, resolving within 2 weeks postpartum 2, 3

Common Pitfalls to Avoid

• Do not allow patients to chronically use topical decongestants beyond 3 days, as this creates rhinitis medicamentosa on top of pregnancy rhinitis 2, 3
• Do not prescribe oral decongestants at any point during pregnancy due to teratogenic concerns 1, 8
• Do not dismiss symptoms as trivial—pregnancy rhinitis significantly reduces quality of life and may affect fetal development 2, 5
• Do not use off-label budesonide irrigations or corticosteroid nasal drops during pregnancy 4