What is the best treatment approach for a pregnant patient experiencing rhinorrhea and rhinitis?

Treatment of Rhinorrhea and Rhinitis During Pregnancy

Saline nasal irrigation should be used as first-line therapy multiple times daily, followed by intranasal corticosteroids (budesonide, fluticasone, or mometasone) if symptoms persist, while oral decongestants must be avoided entirely during pregnancy. 1

Initial Conservative Management

Start with non-pharmacological interventions that are completely safe at any gestational age:

• Saline nasal irrigation is the cornerstone of treatment and should be used frequently throughout the day (multiple times) for effective congestion relief 1, 2
• Warm facial compresses, steamy showers, adequate hydration, and sleeping with the head elevated provide additional symptomatic relief 1
• These conservative measures should be maximized before advancing to pharmacological therapy 3

Pharmacological Treatment Algorithm

For Mild to Moderate Symptoms:

If saline irrigation alone is insufficient, add intranasal corticosteroids:

• Budesonide nasal spray is the preferred intranasal corticosteroid due to the most robust safety evidence from pregnancy studies 1, 2
• Fluticasone or mometasone are acceptable alternatives and are safe after the first trimester at recommended doses 1
• Use the lowest effective dose for symptom control 1, 2
• Intranasal corticosteroids effectively reduce nasal inflammation and congestion 1

For Allergic Rhinitis Component:

If allergic triggers are identified, consider additional agents:

• Intranasal cromolyn has an excellent safety profile and should be considered first-line for allergic symptoms (rhinorrhea, sneezing, itching) 4, 5
• Second-generation antihistamines (cetirizine or loratadine) have comparable safety data to first-generation antihistamines and can be used 3, 6
• Avoid first-generation antihistamines (like diphenhydramine) due to sedative/anticholinergic properties and association with cleft palate 3

For Severe Symptoms:

• Combination therapy with intranasal corticosteroids plus antihistamines may be necessary 3
• Oral corticosteroids should be avoided, especially in the first trimester, due to increased risk of cleft lip/palate, preeclampsia, preterm birth, and low birth weight 1
• Short courses (3-5 days) of oral corticosteroids may be considered only for severe, refractory cases after the first trimester 3

Critical Medications to AVOID

These medications pose unacceptable fetal risks:

• Oral decongestants (pseudoephedrine, phenylephrine) should NOT be used during pregnancy, particularly in the first trimester, due to association with gastroschisis, small intestinal atresia, and other congenital malformations 3, 1, 2
• Topical nasal decongestants (oxymetazoline) should be limited to maximum 3 days if absolutely necessary to avoid rhinitis medicamentosa, though preferably avoided 2
• Anti-leukotrienes (montelukast) should be avoided for rhinitis treatment during pregnancy due to lack of efficacy data in rhinitis and limited teratogenicity data 3

Special Considerations

Differential Diagnosis Matters:

• Distinguish pregnancy-induced rhinitis from allergic rhinitis, as treatment approaches differ 7
• Pregnancy rhinitis typically starts after the second month of pregnancy and resolves within 2 weeks after delivery 3, 1
• Allergic rhinitis worsens in approximately one-third of pregnant patients due to nasal vascular pooling from vasodilation and increased blood volume 3, 1
• Consider drug-induced rhinitis from ACE inhibitors or beta-blockers if patient is on these medications 3, 1

If Bacterial Sinusitis Develops:

• Amoxicillin or azithromycin are safe first-line antibiotics 1, 2
• Avoid tetracyclines, fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycosides 1, 2

Allergen Immunotherapy:

• Immunotherapy may be continued during pregnancy if already initiated and not causing significant reactions, but doses should not be increased 3
• Do not initiate or build up immunotherapy during pregnancy due to anaphylaxis risk 3

Common Pitfalls to Avoid

• Do not reach for oral decongestants as a quick fix—the teratogenic risks outweigh any symptomatic benefit 3, 1
• Do not assume all antihistamines are equally safe—diphenhydramine has cleft palate associations 3
• Do not overlook the efficacy of simple saline irrigation—it should be used aggressively before escalating therapy 1, 2
• Do not confuse pregnancy rhinitis (which resolves postpartum) with allergic rhinitis (which may worsen during pregnancy)—this distinction guides treatment intensity 7