The diagnosis and treatment of allergic rhinitis during pregnancy and lactation.

Rhinitis, including allergic rhinitis, in pregnancy represents a challenge to the physician in terms of its diagnosis and therapy. Although several unique in-fluences of pregnancy adversely affect nasal mucosa, there is growing recognition that most symptomatic nasal problems are expressions of diagnostic entities that have been or will be experienced by the patient in the nonpregnant state. In approaching gestational rhinitis, emphasis should be placed on making an early, accurate diagnosis so that limited, specific, and informed medicinal intervention can be used. Simultaneously, the physician should keep in mind that rhinosinusitis in pregnancy is not necessarily a benign clinical problem. It is important to remember that upper airway disease, if uncontrolled, has a significant adverse effect on quality of life and may exacerbate coexisting asthma, which could affect the pregnancy outcome adversely [82]. Specialty consultation with otolaryngology or allergy may be necessary in the symptomatic pregnant woman before an accurate diagnosis and successful therapeutic recommendations can be made. The medico-legal atmosphere in the United States poses problems in making clinical statements about the absolute safety of medicinal intervention during pregnancy. For physicians who choose to take up this therapeutic challenge,suitable pharmacologic agents are available to manage the pregnant patient who has rhinitis or rhinosinusitis to achieve the desired therapeutic outcome. Suggested guidelines for the treatment of allergic conjunctivitis and rhinitis are summarized in Box 2. In the individual clinical situation, management decisions must be made only after establishing an exact clinical diagnosis, giving full consideration to the therapeutic risks, benefits, and alternatives, and documenting this in the patient's record. Moreover, the physician's interpretation of the benefit-risk ratio and the therapeutic decisions based thereon must be fully explained to, and approved by, the pregnant patient before intervention is initiated.A significant number of women who suffer from rhinitis of pregnancy are allergic. Under these circumstances, the best first-line approach is avoidance of allergens, which can reduce symptoms significantly. Often, what is chosen first is either a medication or the decision to allow the pregnant patient to suffer the symptoms, which can affect the pregnancy outcome adversely. Limited allergy consultation can be useful under these circumstances to identify pertinent allergens and to direct avoidance effectively. If avoidance is unsuccessful, then,with the informed consent of the patient and documentation in the chart, medicinal intervention can begin as shown (see Box 2). Although many women and caregivers may choose not to intervene with medications based on fear of teratogenicity, such notions are contradicted by a significant amount of medical evidence. This is especially true of drug intervention for rhinitis and rhinosinusitis after the first trimester.

Diagnosis and treatment of allergic rhinitis and sinusitis during pregnancy and lactation.

Upper airway congestive symptoms during pregnancy have been recognized since the late 19th century (1). Among randomly selected pregnancies, as many as 18-30% of patients will report substantial symptoms of rhinitis and sinusitis, and this figure may be higher among patients with pre-existing atopic disease (2-4). "Rhinitis of pregnancy" can take many forms. In another chapter in this review, Dr. Elergard discusses a form of rhinitis in pregnancy that occurs as a result of physiologic changes specific to pregnancy. This is to be distinguished from other forms of rhinitis coincident sometimes aggravated by pregnancy such as allergic rhinitis and sinusitis. The incidence of allergic conditions is 20-30% among women of childbearing years (5). Of those pregnant women with known allergies, some studies suggest that as many as 10-30% will experience increasing allergic symptoms during their pregnancy returning to their normal pre-pregnancy state after delivery (5-7). Postulated causes include those responsible for "rhinitis of pregnancy" such as increased circulating blood volume giving rise to nasal vascular engorgement and hormonal influences on nasal mucosal secretions and have been discussed in another chapter of this review (8,9).