Advertisement

Medical management of rhinitis in pregnancy

Published:February 04, 2022DOI:https://doi.org/10.1016/j.anl.2022.01.014

      Abstract

      Medical treatment options for patients with rhinitis during pregnancy need careful considerations. It is important to distinguish between the causes of rhinitis, as this can influence treatment. Conservative options are important for patients with pregnancy-induced rhinitis (PIR) and pre-existing allergic or non-allergic rhinitis. Education and knowledge that PIR symptoms will resolve after pregnancy can offer some relief. Other strategies such as exercise, positioning, saline nasal douching/lavage, and nasal valve dilators are safe in pregnancy and can have a benefit in these patients with rhinitis of any aetiology. The main medical therapies usually used in rhinitis cannot always be directly translated to pregnant patients due to potential teratogenic effects. Topical corticosteroids have generally shown to be safe with budesonide having the strongest recommendations. Oral corticosteroids are mostly used in moderate-severe disease and should be avoided in the first trimester. Oral decongestants have associations with cardiac, ear, gut and limb abnormalities and are not recommended in the first trimester. Loratadine and cetirizine have been the most well-studied second-generation antihistamines and are generally considered safe. There has been no reported increased risk of teratogenicity with anticholinergics or cromones, with the latter being one of the first line options in pregnant women with allergic rhinitis. The role of allergen immunotherapy needs further research, but current guidance states it can be continued if already initiated prior to pregnancy. The management of rhinitis in pregnancy can therefore be complex. This review aims to evaluate the current medical management options for rhinitis in pregnancy.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Auris Nasus Larynx
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Dykewicz MS
        • Hamilos DL.
        Rhinitis and sinusitis.
        J Allergy Clin Immunol. 2010; 125: S103-S115
        • Dykewicz MS
        • Wallace DV
        • Amrol DJ
        • Baroody FM
        • Bernstein JA
        • Craig TJ
        • et al.
        Rhinitis 2020: A practice parameter update.
        J Allergy Clin Immunol. 2020; 146: 721-767https://doi.org/10.1016/j.jaci.2020.07.007
        • Schatz M
        • Zeiger RS.
        Diagnosis and management of rhinitis during pregnancy.
        Allergy Proc. 1988; 9: 545-554
        • Ellegård E
        • Karlsson G.
        Nasal congestion during pregnancy.
        Clin Otolaryngol Allied Sci. 1999; 24: 307-311
        • Ellegård E
        • Hellgren M
        • Toren K
        • Karlsson G.
        The incidence of pregnancy rhinitis.
        Gynecol Obstet Invest. 2000; 49: 98-101
        • Gilbey P
        • McGruthers L
        • Morency AM
        • Shrim A.
        Rhinosinusitis-related quality of life during pregnancy.
        Am J Rhinol Allergy. 2012; 26: 283-286
        • Baudoin T
        • Šimunjak T
        • Bacan N
        • Jelavić B
        • Kuna K
        • Košec A.
        Redefining Pregnancy-Induced Rhinitis.
        Am J Rhinol Allergy. 2021; 35: 315-322https://doi.org/10.1177/1945892420957490
        • MacKenzie J.
        The physiological and pathologicalrelations between the nose and the sexual apparatus of man.
        Alienst Neurol. 1898; 19: 219-239
        • Armengot M
        • Basterra J
        • Marco J.
        Nasal mucociliary function during the menstrual cycle in healthy women.
        Rev Laryngol Otol Rhinol. 1990; 111: 107-109
        • Philpott CM
        • El-Alawi M
        • Murty GE.
        The effect of the steroid sex hormones on the nasal airway during the normal menstrual cycle.
        Clin Otol. 2004; 29: 138-142
        • Hamano N
        • Terada N
        • Maesako KI
        • Ikeda T
        • Fukuda S
        • Wakita J
        • et al.
        Expression of histamine receptors in nasal epithelial cells and endothelial cells -the effect of sex hormones.
        Int Arch Allergy Appl Immunol. 1998; 115: 220-227
        • Ellegård E
        • Karlson G.
        Nasal congestion during the menstrual cycle.
        Clin Otol. 1994; 19: 400-403
        • Philpott CM
        • Wild DC
        • Wolstensholme CR
        • Murty GE.
        The presence of ovarian hormone receptors in the nasal mucosa and their relationship to nasal symptoms.
        Rhinology. 2008; 46: 221-225
        • Ellegård E
        • Karlson G.
        IgE-mediated reactions and hyperreactivity in pregnancy rhinitis.
        Arch Otolaryngol Head Neck Surg. 1999; 125: 1121-1125
        • Adam MP
        • Polifka JE
        • Friedman JM.
        Evolving knowledge of the teratogenicity of medications in human pregnancy.
        Am J Med Genet C Semin Med Genet. 2011; 157C: 175-182https://doi.org/10.1002/ajmg.c.30313
        • Jin AJ
        • Chin CJ.
        Complementary and alternative medicine in chronic rhinosinusitis: a systematic review and qualitative analysis.
        Am J Rhinol Allergy. 2019; 33: 194-202
        • Bonizzoni G
        • Caminati M
        • Ridolo E
        • Landi M
        • Ventura MT
        • Lombardi C
        • et al.
        Use of complementary medicine among patients with allergic rhinitis: an Italian nationwide survey.
        Clin Mol Allergy. 2019; 17: 1-3
        • Griffin AS
        • Cabot P
        • Wallwork B
        • Panizza B.
        Alternative therapies for chronic rhinosinusitis: a review.
        Ear Nose Throat J. 2018; 97: E25-E33
        • Ellegård EK.
        Special considerations in the treatment of pregnancy rhinitis.
        Women's Health. 2005; 1: 105-114
        • Rambur B.
        Pregnancy rhinitis and rhinitis medicamentosa.
        J Am Acad Nurse Pract. 2002; 14: 527-530https://doi.org/10.1111/j.1745-7599.2002.tb00086.x
        • Tongtako W
        • Klaewsongkram J
        • Mickleborough TD
        • Suksom D.
        Effects of aerobic exercise and vitamin C supplementation on rhinitis symptoms in allergic rhinitis patients.
        Asian Pac J Allergy Immunol. 2018; 36: 222-231https://doi.org/10.12932/AP-040417-0066
        • Richardson H
        • Seebohm P.
        Nasal airway response to exercise.
        J Allergy. 1968; 41: 269-284
        • Forsyth RD
        • Cole P
        • Shephard RJ.
        Exercise and nasal patency.
        J Appl Physiol. 1983; : 860-865
        • Syaballo NC
        • Bundgaard A
        • Widdicombe JG.
        Effects of exercise on nasal airflow resistance in healthy subjects and in patients with asthma and rhinitis.
        Bull Eur Physiopathol Respir. 1985; 21: 507-513
        • Hasegawa M.
        Posture induced nasal obstruction in patients with allergic rhinitis.
        Clin Otolaryngol. 1994; 19: 135-137
        • Rundcrantz H
        Postural variations of nasal patency.
        Acta Otolaryngol. 1969; 68: 435-443
        • Stroud RH
        • Wright ST
        • Calhoun KH.
        Nocturnal nasal congestion and nasal resistance.
        Laryngoscope. 1999; 109: 1450-1453
        • Kawamoto Y
        • Ueno Y
        • Nakahashi E
        • Obayashi M
        • Sugihara K
        • Qiao S
        • et al.
        Prevention of allergic rhinitis by ginger and the molecular basis of immunosuppression by 6-gingerol through T cell inactivation.
        J Nutr Biochem. 2016; 27: 112-122https://doi.org/10.1016/j.jnutbio.2015.08.025
        • Seo JH
        • Kwon SO
        • Lee SY
        • Kim HY
        • Kwon JW
        • Kim BJ
        • et al.
        Association of antioxidants with allergic rhinitis in children from Seoul.
        Allergy Asthma Immunol Res. 2013; 5: 81-87https://doi.org/10.4168/aair.2013.5.2.81
        • Kurup VP
        • Barrios CS.
        Immunomodulatory effects of curcumin in allergy.
        Mol Nutr Food Res. 2008; 52: 1031-1039
        • Proefrock K.
        Botanical prescriptions for conditions of the eye including cataracts, glaucoma, allergy, and conjunctivitis.
        in: Proceedings of the Southwest Conference on Botanical Medicine. 2001: 70 (Tempe, AZ: Southwest College of Naturopathic Medicine Press)
        • Adams S
        • Lopata AL
        • Smuts CM
        • Baatjies R
        • Jeebhay MF.
        Relationship between serum omega-3 fatty acid and asthma endpoints.
        Int J Environ Res Public Health. 2018; 16: 43https://doi.org/10.3390/ijerph16010043
        • Hoff S
        • Seiler H
        • Heinrich J
        • Kompauer I
        • Nieters A
        • Becker N
        • et al.
        Allergic sensitisation and allergic rhinitis are associated with n-3 polyunsaturated fatty acids in the diet and in red blood cell membranes.
        Eur J Clin Nutr. 2005; 59: 1071-1080https://doi.org/10.1038/sj.ejcn.160221
        • Garavello W
        • Somigliana E
        • Acaia B
        • Gaini L
        • Pignataro L
        • Gaini RM.
        Nasal lavage in pregnant women with seasonal allergic rhinitis: a randomized study.
        Int Arch Allergy Immunol. 2010; 151: 137-141https://doi.org/10.1159/000236003
        • Turnbull GL
        • Rundell OH
        • Rayburn WF
        • Jones RK
        • Pearman CS.
        Managing pregnancy-related nocturnal nasal congestion. The external nasal dilator.
        J Reprod Med. 1996; 41: 897-902
      1. National Institute for Health and Care Excellence (NICE). Allergic rhinitis CKS. 2018. https://cks.nice.org.uk/topics/allergic-rhinitis/

        • Scadding GK
        • Kariyawasam HH
        • Scadding G
        • Mirakian R
        • Buckley RJ
        • Dixon T
        • et al.
        BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007).
        Clin Exp Allergy. 2017; 47: 856-889
        • Hoyte FCL
        • Nelson HS.
        Recent advances in allergic rhinitis. F1000Res. 2018;7:F1000 Faculty Rev-1333.
        2018https://doi.org/10.12688/f1000research.15367.1
      2. FDA. Pregnancy and lactation labelling. 2022 https://www.fda.gov/drugs/labeling-information-drug-products/pregnancy-and-lactation-labeling-drugs-final-rule

        • Pernia S
        • DeMaagd G.
        The new pregnancy and lactation labeling rule.
        P T. 2016; 41: 713-715
        • Joint Formulary Committee
        British National Formulary (online) London: BMJ Group and.
        Pharmaceutical Press, 2022 (Available from) ([Accessed on 7 Jan])
        • Norjavaara E
        • de Verdier MG.
        Normal pregnancy outcomes in a population-based study including 2,968 pregnant women exposed to budesonide.
        J Allergy Clin Immunol. 2003; 111: 736-742
        • Lal D
        • Jategaonkar AA
        • Borish L
        • Chambliss LR
        • Gnagi SH
        • Hwang PH
        • et al.
        Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations.
        Rhinology. 2016; 54: 99-104https://doi.org/10.4193/Rhino15.228
        • Ellegård EK
        • Hellgren M
        • Karlsson NG.
        Fluticasone propionate aqueous nasal spray in pregnancy rhinitis.
        Clin Otolaryngol Allied Sci. 2001; 26: 394-400
        • Park-Wyllie L
        • Mazzotta P
        • Pastuszak A
        • Moretti ME
        • Beique L
        • Hunnisett L
        • et al.
        Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies.
        Teratology. 2000; 62: 385-392
        • Bandoli G
        • Palmsten K
        • Forbess Smith CJ
        • Chambers CD
        A review of systemic corticosteroid use in pregnancy and the risk of select pregnancy and birth outcomes.
        Rheum Dis Clin North Am. 2017; 43: 489-502https://doi.org/10.1016/j.rdc.2017.04.013
        • Black MJ
        • Remsen KA.
        Rhinitis medicamentosa.
        Can Med Assoc J. 1980; 122: 881-884
        • Johnson DA
        • Hricik JG
        The pharmacology of alphaadrenergic decongestants.
        Pharmacotherapy. 1993; 13 (110S–115S)
        • Toll K
        • Graf P
        Phenylpropanolamine's decongestive effect on the nasal mucosa of pregnant women with nasal stuffiness.
        Rhinology. 2006; 44: 274-277
        • Yau W-P
        • Mitchell AA
        • Lin KJ
        • Werler MM
        • Hernández-Díaz S
        Use of decongestants during pregnancy and the risk of birth defects.
        Am J Epidemiol. 2013; 178: 198-208
        • Rothman KJ
        • Fyler DC
        • Goldblatt A
        • Kreidberg MB.
        Exogenous hormones and other drug exposures of children with congenital heart disease.
        Am J Epidemiol. 1979; 109: 433-439
        • Kallen BA
        • Olausson PO.
        Use of oral decongestants during pregnancy and delivery outcome.
        Am J Obstet Gynecol. 2006; 194: 480-485
        • Hoffman JI
        • Kaplan S.
        The incidence of congenital heart disease.
        J Am Coll Cardiol. 2002; 39: 1890-1900
        • Ellegård EK.
        Special considerations in the treatment of pregnancy rhinitis.
        Womens Health (Lond). 2005; 1: 105-114https://doi.org/10.2217/17455057.1.1.105
        • Stephansson O
        • Granath F
        • Svensson T
        • Haglund B
        • Ekbom A
        • Kieler H
        Drug use during pregnancy in Sweden - assessed by the prescribed drug register and the medical birth register.
        Clin Epidemiol. 2011; 3: 43-50
        • Gilboa SM
        • Strickland MJ
        • Olshan AF
        • Werler MM
        Correa A. Use of antihistamine medications during early pregnancy and isolated major malformations.
        Birth Defects Res A Clin Mol Teratol. 2009; 85: 137-150
        • Seto A
        • Einarson T
        • Koren G.
        Pregnancy outcome following first trimester exposure to antihistamines: meta-analysis.
        Am J Perinatol. 1997; 14: 119-124
        • Bousquet J
        • van-Cauwenberge P
        • Khaltaev N
        WHO Panel Members: Allergic rhinitis and its impact on asthma. ARIA. In collaboration with the World Health Organization.
        J Allergy Clin Immunol. 2001; 108: S1-S315
        • Gray SL
        • Anderson ML
        • Dublin S
        • Hanlon JT
        • Hubbard R
        • Walker R
        • et al.
        Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study.
        JAMA Intern Med. 2015; 175: 401-407
        • Einarson A
        • Bailey B
        • Jung G
        • Spizzirri D
        • Baillie M
        • Koren G
        Prospective controlled study of hydroxyzine and cetirizine in pregnancy.
        Ann Allergy Asthma Immunol. 1997; 78: 183-186
        • Weber-Schoendorfer C
        • Schaefer C.
        The safety of cetirizine during pregnancy. A prospective observational cohort study.
        Reprod Toxicol. 2008; 26: 19-23
        • Källén B.
        Use of antihistamine drugs in early pregnancy and delivery outcome.
        J Mater-Fetal Neonat Med. 2002; 11: 146-152
        • Moretti ME
        • Caprara D
        • Coutinho CJ
        • Bar-Oz B
        • Berkovitch M
        • Addis A
        • et al.
        Fetal safety of loratadine use in the first trimester of pregnancy: a multicenter study.
        J Allergy Clin Immunol. 2003; 111: 479-483https://doi.org/10.1067/mai.2003.130
        • Diav-Citrin O
        • Shechtman S
        • Aharonovich A
        • Moerman L
        • Arnon J
        • Wajnberg R
        • et al.
        Pregnancy outcome after gestational exposure to loratadine or antihistamines: a prospective controlled cohort study.
        J Allergy Clin Immunol. 2003; 111: 1239-1243https://doi.org/10.1067/mai.2003.1499
        • National Asthma Education and Prevention Program
        Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007 [published correction appears in J Allergy Clin Immunol.
        J Allergy Clin Immunol. 2008; 120 (Jun;121(6):1330]) (2007Suppl): S94-S138https://doi.org/10.1016/j.jaci.2007.09.043
        • Zuberbier T
        • Aberer W
        • Asero R
        • Bindslev-Jensen C
        • Brzoza Z
        • Canonica GW
        • et al.
        The EAACI/GA 2 LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update.
        Allergy. 2014; 69 (Jul): 868-887
        • Einarson A
        • Levichek Z
        • Einarson TR
        • Koren G.
        The antiemetic effect of cetirizine during pregnancy.
        Ann Pharmacother. 2000; 34: 1486-1487
        • Gonzalez-Estrada A
        • Geraci SA.
        Allergy medications during pregnancy.
        Am J Med Sci. 2016; 352: 326-331https://doi.org/10.1016/j.amjms.2016.05.030
        • Norris AA
        Pharmacology of sodium cromoglycate.
        Clin Exp Allergy. 1996; 4: 5-7
        • Wilson J.
        Disodium cromoglicate use during pregnancy.
        Acta Ther. 1982; 8 (Suppl): 45-51
        • Schatz M
        • Zeiger RS
        • Harden K
        • Hoffman CC
        • Chilingar L
        • Petitti D.
        The safety of asthma and allergy medications during pregnancy.
        J Allergy Clin Immunol. 1997; 100: 301-306
        • Keles N.
        Treatment of allergic rhinitis during pregnancy.
        Am J Rhinology. 2004; 18: 23-28
        • Wood CC
        • Fireman P
        • Grossman J
        • Wecker M
        • MacGregor T.
        Product characteristics and pharmacokinetics of intranasal ipratropium bromide.
        J Allergy Clin Immunol. 1995; 95: 1111-1116
        • Durham SR
        • Yang WH
        • Pedersen MR
        • Johansen N
        • Rak S.
        Sublingual immunotherapy with once-daily grass allergen tablets: a randomized controlled trial in seasonal allergic rhinoconjunctivitis.
        J Allergy Clin Immunol. 2006; 117 (doi:10.1016/j.jaci.2005.12.1358): 802-809
        • Demoly P
        • Emminger W
        • Rehm D
        • Backer V
        • Tommerup L
        • Kleine-Tebbe J
        Effective treatment of house dust mite-induced allergic rhinitis with 2 doses of the SQ HDM SLIT-tablet: Results from a randomized, double-blind, placebo-controlled phase III trial.
        J Allergy Clin Immunol. 2016; 137 (e8. doi:10.1016/j.jaci.2015.06.036): 444-451
        • Nurmatov U
        • Dhami S
        • Arasi S
        • Roberts G
        • Pfaar O
        • Muraro A
        • et al.
        Allergen immunotherapy for allergic rhinoconjunctivitis: a systematic overview of systematic reviews.
        Clin Transl Allergy. 2017; 7 (Published 2017 Aug 8. doi:10.1186/s13601-017-0159-6): 24
        • Flicker S
        • Marth K
        • Kofler H
        • Valenta R
        Placental transfer of allergen-specific IgG but not IgE from a specific immunotherapy-treated mother.
        J Allergy Clin Immunol. 2009; 124 (e1): 1358-1360https://doi.org/10.1016/j.jaci.2009.09.024
        • Glovsky MM
        • Ghekiere L
        • Rejzek E.
        Effect of maternal immunotherapy on immediate skin test reactivity, specific rye I IgG and IgE antibody, and total IgE of the children.
        Ann Allergy. 1991; 67: 21-24
        • Metzger WJ
        • Turner E
        • Patterson R
        The safety of immunotherapy during pregnancy.
        J Allergy Clin Immunol. 1978; 61: 268-272https://doi.org/10.1016/0091-6749(78)90202-6
        • Shaikh WA.
        A retrospective study on the safety of immunotherapy in pregnancy.
        Clin Exp Allergy. 1993; 23: 857-860https://doi.org/10.1111/j.1365-2222.1993.tb00264.x