Rhinitis of Pregnancy

Rhinitis of pregnancy is nasal congestion lasting 6 weeks or more during pregnancy, with no signs of respiratory infection or allergy and no other known cause, which resolves completely within 2 weeks after delivery. It affects 20 to 40 percent of pregnant women, most often in the second and third trimesters, and more often in smokers and in women with pre-existing rhinitis.

• Mechanism: rising oestrogen and progesterone, expanded blood volume and nasal vascular engorgement, placental growth hormone effects, mucosal oedema and increased glandular secretion.
• Consequences: poor sleep, snoring and sleep disordered breathing. Maternal sleep apnoea is associated with hypertension, pre-eclampsia, gestational diabetes and fetal growth restriction.
• Other causes of nasal symptoms in pregnancy must be considered: allergic rhinitis (a third of women worsen, a third are unchanged, a third improve), viral infection, sinusitis, decongestant overuse, drugs such as methyldopa and hydralazine, structural disease, pre-eclampsia oedema, thyroid disease, cocaine use.

• Persistent nasal blockage, worse lying down and at night, clear rhinorrhoea, snoring, mouth breathing, postnasal drip, reduced smell, mild epistaxis. Itchy eyes, fever and purulent discharge are absent.
• Examination: swollen turbinates (pale or erythematous), clear mucus, no polyps or pus. Check blood pressure and urinalysis.
• Red flags: facial pain, swelling and fever with purulent discharge (sinusitis); unilateral obstruction or bleeding (tumour, polyp, foreign body); hypertension with proteinuria or headache (pre-eclampsia); loud snoring with witnessed apnoeas and daytime sleepiness; persistent epistaxis; loss of smell; clear watery fluid after head injury; orbital swelling; symptoms persisting beyond 2 weeks postpartum.

• Clinical, by exclusion of infection and allergy.
• Allergy history. Skin prick testing is avoided in pregnancy; specific IgE blood tests can be used if needed.
• Anterior rhinoscopy or nasal endoscopy for polyps, septal deviation or tumour.
• Epworth and STOP-BANG questionnaires; polysomnography if sleep apnoea is suspected.
• Blood pressure and urinalysis, particularly in the third trimester.
• Review all drugs, including decongestant sprays.

• Non-drug measures first: saline nasal irrigation or spray several times daily; nasal dilator strips; raise the head of the bed 30 to 45 degrees; sleep on the left side; steam inhalation; humidifier; avoid smoke and irritants; stay hydrated; exercise regularly; limit excessive weight gain.
• Intranasal corticosteroids (low systemic absorption) if measures are insufficient: budesonide 64 micrograms per spray, 2 sprays in each nostril once daily (best pregnancy data, maximum 4 sprays in total daily); beclometasone 50 micrograms per spray, 2 sprays per nostril twice daily; or fluticasone propionate 50 micrograms per spray, 2 sprays per nostril once daily. Effect builds over several days.
• Antihistamines for an allergic component: loratadine 10 mg orally once daily or cetirizine 10 mg orally once daily. Chlorphenamine 4 mg every 4 to 6 hours (maximum 24 mg daily) is used at night for short courses (sedating).
• Ipratropium bromide nasal spray 0.03 percent, 2 sprays per nostril two to three times daily, for troublesome watery discharge.
• Decongestants: oxymetazoline 0.05 percent or xylometazoline 0.1 percent, 1 to 2 sprays per nostril up to twice daily for a maximum of 3 days (rebound congestion with longer use). Avoid oral pseudoephedrine and phenylephrine in the first trimester (link with gastroschisis) and in hypertension.
• Bacterial sinusitis: amoxicillin 500 mg orally three times daily for 5 to 7 days. Avoid doxycycline and fluoroquinolones.
• Suspected obstructive sleep apnoea: refer for assessment and consider continuous positive airway pressure.
• Reassure that it resolves within 2 weeks of delivery. Refer to ENT if symptoms persist after delivery, or for polyps, structural problems, recurrent epistaxis or apnoea.