Treatment of Allergic Rhinitis in Pregnancy

First-Line Treatment Approach

The American College of Allergy, Asthma, and Immunology recommends saline nasal rinses and intranasal corticosteroids, such as budesonide, fluticasone, or mometasone, as first-line treatments for allergic rhinitis during pregnancy, with second-generation antihistamines like loratadine or cetirizine as safe alternatives when additional symptom control is needed 1, 2
Saline nasal rinses should be initiated as primary therapy for all pregnant patients with allergic rhinitis, as they are completely safe and effective for symptom relief 1, 2
Intranasal corticosteroids are the most effective maintenance therapy and should be used regularly rather than as-needed, with budesonide, fluticasone, and mometasone considered safe alternatives based on extensive clinical experience 1, 2

The American College of Allergy, Asthma, and Immunology advises that oral decongestants, such as phenylephrine and pseudoephedrine, should not be used, especially during the first trimester, due to associations with fetal gastroschisis, small intestinal atresia, and maternal hypertension 1, 2, 3
Aspirin and NSAIDs are Category D and must be discontinued due to risks of premature ductus arteriosus closure, intrauterine growth restriction, and perinatal mortality 1, 2

The American Academy of Allergy, Asthma, and Immunology recommends continuing existing immunotherapy at the current maintenance dose if already established before pregnancy, but not initiating or increasing doses during pregnancy due to anaphylaxis risk 1, 2, 3

The first trimester carries the highest risk for medication-induced teratogenicity, so exercise particular caution during weeks 1-12 4, 5
Untreated severe allergic rhinitis can worsen asthma control and pose greater maternal-fetal risks than appropriate pharmacotherapy, with approximately one-third of pregnant women with asthma having worsening symptoms during pregnancy, often triggered by untreated allergic rhinitis 3, 6

The American Academy of Allergy, Asthma, and Immunology recommends that Ryaltris (azelastine-fluticasone combination) should not be used during pregnancy due to insufficient safety data on azelastine in pregnant women, despite fluticasone having reassuring pregnancy data 7, 8

The American College of Allergy, Asthma, and Immunology suggests initiating treatment with intranasal corticosteroid spray, such as budesonide (Pregnancy Category B with most extensive human data) or fluticasone propionate (extensive reassuring data), for optimal efficacy 7, 8, 9
The American Academy of Allergy, Asthma, and Immunology recommends using intranasal corticosteroids regularly for maintenance rather than as-needed dosing for optimal efficacy, and adding second-generation oral antihistamines, such as loratadine or cetirizine, if intranasal corticosteroids provide insufficient control 8, 9, 10

The American College of Allergy, Asthma, and Immunology suggests that sodium cromolyn (Pregnancy Category B) may be considered as an additional safe option, though it requires frequent four-times-daily dosing and has reduced efficacy compared to intranasal corticosteroids 7, 8
The American Academy of Allergy, Asthma, and Immunology recommends that montelukast (Pregnancy Category B) can be used if there was a favorable pre-pregnancy response, though it is primarily reserved for patients with concurrent asthma 7, 8

The American College of Obstetricians and Gynecologists notes that allergen immunotherapy can be continued at maintenance doses if already established before pregnancy, but should not be initiated or dose-escalated during pregnancy due to anaphylaxis risk 10