Nasal obstruction in pregnancy can be due to all the causes listed in Table 1. Of these ‘Rhinitis of Pregnancy’, allergic rhinitis, bacterial rhinosinusitis and rhinitis medica mentosa are the most common.[1] During pregnancy, nasal symptoms of women who have allergic rhinitis improve in 34%, worsen in 15% and remain unchanged in the remainder. The improvement in symptoms may be due to the elevated cortisol levels in pregnancy. [2],[3]

Rhinitis of Pregnancy

Nasal obstruction of pregnancy or ‘rhinitis of pregnancy’ occurs in up to 30% of pregnant women.[4],[5] It is common in the second and third trimester and may persist for 1-2 months after delivery.[6] Some feel this is better stated as rhinitis ‘during’ pregnancy because of the many controversies surrounding this entity what was first reported by MacKenzie in 1898[7]. Symptoms include blocked nose, sneezing, rhinorrhoea and nasal itch.  Nasal congestion is caused by oedema and increased blood volume in the nasal mucosa, hyperactive seromucinous glands and increased glandular secretion. Women who already have nasal obstruction prior to becoming pregnant may suffer considerable exacerbation of their blocked nose. Conversely the rhinitis of pregnancy itself leaves women more susceptible to obstruction and infection from common ‘cold’ viruses, and resultant bacterial sinusitis.  Sinusitis has been reported to be six times more common in pregnant than non-pregnant women.[8] Other common symptoms are ear fullness and popping sounds secondary to eustachian tube dysfunction.

The incidence of rhinitis in any one pregnancy is independent of symptoms that have occurred in previous pregnancies. In one study only 6 of 11 women who had rhinitis in a previous pregnancy, had rhinitis in the following pregnancy. Conversely, 9 of 39 women who did not have rhinitis in a previous pregnancy, had symptoms in the following pregnancy. [9]

TABLE 1

Causes of Blocked Nose

Congenital Choanal atresia, Septal deviation
Traumatic Septal deviation
Infection Acute/chronic viral/bacterial/fungal rhinitis/sinusitis
Neoplastic Benign: Nasal polyps, inverted papillomaPyogenic granuloma
Malignant: Adenocarcinoma
Allergy Allergic rhinitis
Autoimmune Wegener’s Granulomatosis, sarcoidosis, atrophic rhinitis
Iatrogenic Surgical, Drug induced
Non Allergic Rhinitis with Eosinophilia  
Foreign body  
Hormonal Rhinitis of pregnancy
Pharmacological Rhinitis medicamentosa
Vasomotor[10] Secondary to odours, alcohol, emotion/stress, temperature change, pressure change, bright light, spicy food, GORD
Occupational Bakers

Aetiology  

Nasal obstruction during pregnancy is related to endocrine factors and similar aetiology is seen in nasal blockage associated with the menstrual cycle. Cyclical changes in female nasal mucous have also been shown.1 Topically applied oestrogens have produced congestion of the nasal mucosa and increased nasal resistance. However, increased levels of oestradiol and progesterone were not found in a study of pregnant women with nasal congestion compared to a control group of women without nasal congestion5 ,8 and the regular use of the combined oral contraceptive pill has not been associated with increasing symptoms.[11] The allergic manifestations in some pregnant women may be due to oestrogen deficiency, which results in low cortisol levels and a shorter cortisol half-life than those present in normal pregnancy. Animal models have shown that vasoactive intestinal peptide (VIP), stimulated by progesterone and oxytocin, leads to increased nasal congestion.

Electron micrographic and histochemical studies performed on the inferior turbinates of pregnant women have shown hyperactive tunical, goblet and seromucinous glands. There was also increased enzymic activity, particularly in pregnant women with nasal blockage, indicating increased vascularity and metabolic activity. Increased cholinesterase activity suggests an over activity of the parasympathetic system leading to increased glandular secretion and vascular congestion. This over activity of the parasympathetic system may be an allergic response to placental or foetal proteins.10

Circulating blood volume increases to 40% above non-pregnancy levels by the third trimester. This may lead to increased nasal vascular pooling and increased nasal resistance.1 The generalised increase in interstitial fluid volume, also most marked in the third trimester of pregnancy, directly affects the nasal mucosa, contributing to congestion.

Rhinitis Medicamentosa

This is rebound nasal blockage/rhinitis caused by the repeated use of topical nasal vasoconstrictors (Xylometazoline & ephedrine etc).  After 5 -7 days of continual use, the mucosa becomes less responsive, resulting in increased usage, shorter duration of action and less decongestive effect. In one group of women treated for nasal blockage in pregnancy, nearly half were suffering from over use of these ‘over the counter’ medications.8

There are several mechanisms of action for this effect.[12]

  1. 1 Sympathomemetic amines have longer beta receptor activity causing rebound swelling.
  2. 2 The prolonged vasoconstriction causes tissue hypoxia with a resulting reactive hyperemia, rebound swelling, and vasodilatation.
  3. 3 Alpha2 agonists lead to a decrease in endogenous noradrenaline and once the exogenous drug disappears, rebound congestion develops.
  4. 4 The medication causes increased parasympathetic activity, vascular permeability, and oedema formation by altering vasomotor tone, thus creating the rebound congestion.

Management

History

The relevant points include the length of history, the side of obstruction, any previous injury/surgery, exacerbating and relieving factors, associated symptoms consistent with sinusitis, sense of smell, history of atopy and response to previous treatments. Underlying systemic disorders need to be considered, as well as association with previous allergic rhinitis, asthma and eczema. Sinusitis is more common in this group due to associated blockage of the sinus ostia. Drug history is important as is use and overuse of decongestants. Compliance with and method of use of steroid nasal sprays is important.

Examination

Anterior rhinoscopy allows assessment of the anterior nasal septum and the turbinates and excludes any anterior nasal polyps. Prominent turbinates are often confused for nasal polyps. However, they are different in colour, and the easiest differentiating feature is that polyps are insensate to touch whereas turbinates are not. Rigid nasendoscopy allows complete examination of the nasal cavity as well as assessment of the postnasal space.

Investigations

RadioAllergoSorbentTest (RAST) is an allergen-specific IgE antibody test and is used to screen for allergy to common environmental allergens as well as pets, animal dander, and if suspected, specific food allergy.9 Skin prick allergy testing in pregnancy is not recommended because of the risk, albeit low, of systemic reactions.1

Nasal rhinometry assesses airflow and is particularly used in research. Nitric oxide levels in the nose are elevated in inflammatory conditions such as rhinitis, and are decreased in nasal obstruction, such as nasal polyposis. Assessment of smell is performed by ‘scratch and sniff’ cards (UPSIT[i]) cards or ‘Sniffin’ Sticks’ (UEST[ii])[13],[14].

CT scanning is used to assess the anatomy of the nose and sinuses and also to assess the degree of sinusitis and/or polyposis. Unnecessary radiological imaging is to be avoided, especially in the first trimester of pregnancy unless it is urgent or acute. In practice, diagnostic radiography during pregnancy not involving direct abdominal/pelvic high dosage, is not associated with any significant adverse events.[15],[16],[17],[18]

Treatment
General

Allergen avoidance remains important in known allergic rhinitis[19]. Tumble-drying clothes, showering after returning home and closing windows on high pollen count days, can reduce pollen exposure. Mould allergens can be avoided by limiting indoor plants, frequent emptying of kitchen waste and good ventilation in the bathroom and laundry. House dust mite exposure and animal dander can be reduced by frequent hovering, the use of anti allergenic bed covers and removal of pets. The avoidance of cigarette smoke and other non specific irritants is also important.  Exercise appropriate for physical condition and gestational age may reduce symptoms.[20]

Medical Treatment

Medication should be prescribed during pregnancy only when the benefit outweighs the risk. Many drugs come with information advising against use in pregnancy because studies have not been done to prove safety. [21] Intranasal sodium cromoglycate and topical steroids are considered first line treatments. Intranasal fluticasone has not been shown to affect maternal cortisol or affect fetal growth when used in the first trimester.18 First generation antihistamines are favoured over their second generation counterparts as there is more conclusive long term evidence for their safety. Oral decongestants (linked with the development of gastroschisis) and intranasal decongestants should be used sparingly.

Topical treatments

Figure 2

Direction of nasal spray

Figure 1

 Reclined, head back position

 

 

Compliance and method of use is important in the success of these treatments. Nasal drops must be used in the reclined head down position (Figure 1). Nasal sprays should be directed backward, toward the eyes and toward the ears (Figure 2). Dryness of the nasal septum can occur with the use of sprays. Directing the spays away from the nasal septum and the use of vaseline can prevent drying, crusting and bleeding from the anterior nasal septum.

Topical saline preparations (e.g. Sterimar saline spray) can offer symptomatic relief and are completely safe.1 , 19 , [22]

Topical sodium cromoglycate has an excellent safety profile and is useful for rhinitis control,1 ,3 ,18 ,19 although it does require qid dosage.

Topical steroids: Intranasal steroids (e.g., fluticasone, mometasone, budesonide and beclomethasone) can be used for more severe nasal obstruction. There are few documented epidemiological studies with the use of intranasal corticosteroids (e.g. budesonide, fluticasone propionate, mometasone) during pregnancy. However, inhaled corticosteroids used alone are not teratogenic, do not affect birthweight and are commonly used by pregnant women who have asthma.3 ,18 ,[23],[24],[25],[26] Intranasal fluticasone has  not been shown to affect maternal cortisol or affect fetal growth when used in the first trimester.18 Fluticasone and mometasone have low systemic absorption and are favoured by most rhinologists. They are effective in the control of rhinitis but may require a few weeks to achieve maximal benefit.

Whilst the direct injection of steroids (triamcinolone) into the turbinates is described in the literature, it is not commonly practiced. Topical steroids provide similar symptomatic relief. With direct injection there is also the risk of embolisation into the retinal circulation, with resultant blindness. This is particularly so with the increased nasal mucosa vascularity of pregnancy.21

Topical ipratropium bromide is useful for symptomatic control of water rhinorrhoea. It is safe to use for acute asthma in pregnancy.24 ,25

Topical decongestants: Topical preparations such as Xylometazoline are readily available ‘over the counter’. They cause direct vasoconstriction and shrinkage of the nasal mucosa. However the hormonal vasodilatation of nasal mucosa is relatively resistant to topical vasoconstrictors and over use is common. This leads to a resultant rebound nasal congestion (rhinitis medicamentosa).21   They are also rapidly absorbed systemically and there is concern (although not established) that local vasoconstriction may cause placental insufficiency and/or exacerbate hypertension of pregnancy. They should be used sparingly.

Systemic Treatment

Corticosteroids: systemic use in rhinitis is rare. There are variable reports of increased risk of oral clefts when given in the first trimester.18 ,25 Guidelines state usage should be restricted to life threatening conditions. However steroids are used when medically indicated (e.g. acute asthma attack). Also when given in the third trimester to prevent infant respiratory distress syndrome they have not resulted in drug related abnormalities. 3 ,[27]

Antihistamines: are used to treat allergic rhinitis. There has been argument for and against the safety of these drugs in pregnancy.[28] Even though these drugs have been used safely in pregnancy, there remains concern (that have not been substantiated), regarding teratogenicity. Chlorpheniramine and tripelenamine are preferred1 ,3 , [29] and if not tolerated, cetirzine and loratadine could be considered.18 ,19 ,26 As always the relative risk versus benefits must be considered. They should be avoided in late pregnancy (risk of potentiating neonatal seizures) and should not be used in women at risk of low birth weight infants. If regular high does use at term is used, the infant should be observed for possible withdrawal.1

Leukotrienes: no controlled studies have been done to assess the use in pregnancy.26 However the use of Montelukast and could be considered in patients not responsive to other medications.25

Oral decongestants: should be avoided in the first trimester as case control studies have linked their use with the development of gastroschisis and vascular disruption.3 Following the first trimester pseudoephedrine could be used.18 ,19

Antibiotics: These should be used for specific infections associated with nasal obstruction such as acute bacterial sinusitis. Penicillins (amoxicillin), cephalosporins and marcolides (erythromycin) are commonly used and are safe. Renal and liver function as well as serum drug levels can be monitored if there are concerns.

Avoid: Sulfonamides (haemolytic anaemia & hyperbilirubinaemia), Tetracycline (teeth discolouration and impaired bone growth), Trimethoprim (hyperbilirubinaemia), Aminoglycosides (renal and neural arch anomalies {first trimester} ototoxicity and nephrotoxicity {third trimester}) and Chloramphenicol (grey baby syndrome)[iii] in pregnancy.

Immunotherapy: This should not be commenced during pregnancy. However it can be continued if it is providing benefit and is not causing systemic reactions.1 ,18  Prophylactic dosage reduction by 20 to 50% is recommended to further decrease the risk of a systemic reaction.24

Surgical Treatment

Ideally surgery is postponed until after delivery or later in the pregnancy. Surgical options include:

Inferior Turbinate Reduction: This can be preformed using electro-cautery, cryosurgery, laser or radiofrequency – all under local anaesthesia. Direct trimming of turbinates requires general anaesthesia and has a higher risk of blood loss.

Nasal polypectomy: intranasal polypectomy under local anaesthetic can be considered if severe nasal symptoms are present.

Endoscopic sinus surgery for more extensive polypectomy and sinus clearance can be undertaken. However a preoperative CT scan of the sinuses must be undertaken and the relative risk of general anaesthetic needs to be considered.

Conclusion

Nasal blockage in pregnancy is common. The usual causes of nasal obstruction as well as ‘rhinitis of pregnancy’ need to be considered. ‘Rhinitis of pregnancy’ is common, and can occur in up to 30% of women. It is thought due to elevated VIP levels, as well as perhaps allergy to placental or fetal proteins.

In some women allergic rhinitis can improve with pregnancy due to elevated levels of serum cortisol.

The mainstay of treatment is a topical nasal steroid. Sodium cromoglycate is a safe alternative. Decongestants are often over used and should be used sparingly as they commonly lead to rebound nasal congestion. Further investigation and treatment, such as CT scanning and surgery, are ideally delayed till after delivery.

References:


[i] University of Pennsylvania Smell Identification Test

[ii] University of Erlangen Smell Test

[iii] Because of lack the necessary liver enzymes to metabolize this drug; chloramphenicol accumulates in the baby, causing hypotension, cyanosis and often death.

 


[1] Shatz M, Zeiger RS. Diagnosis and Management of Rhinitis during Pregnancy. Allergy Proc 9(5):545-554, 1988

[2] Torsiglieri AJ Jr, Tom LW, Keane WM, Atkins JP Jr. Otolaryngologic manifestations of pregnancy. Otolaryngol Head Neck Surg 1990;102:293-297.

[3] Mazzotta P.  Loebstein R.  Koren G. Treating Allergic Rhinitis in Pregnancy. Safety considerations.   Drug Safety.  20(4):361-75, 1999 Apr.

[4] Mabry RL. The management of nasal obstruction during pregnancy. Ear Nose Throat J 1983;62:28 16-19.

[5] Bende M, Hallgarde U, Sjogren C, Uvnas-Moberg K. Nasal congestion during pregnancy. Clin Otolaryngol 1989;14:385-387.

[6] Derkay CS. Eustachian tube and nasal function during pregnancy: a prospective study. Otolaryngol Head Neck Surg 1988;99:558-566.

[7] MacKenzie JN. The physiological and pathological relations between the nose and the sexual apparatus of man. Alienist Neurol 1898;19:219-239

[8] Sorri M, Hartikainen-Sorri AI, Karja J. Rhinitis during pregnancy. Rhinology 18:83-86. 1980

[9] Mabry RL. Rhinitis of Pregnancy. Southern Medical  Journal 79(8):965-971 1986 Aug.

[10] Wheeler PW. Wheeler SF. Vasomotor Rhinitis. American Family Physician. 72(6):1057-62, 2005 Sep 15.

[11] Toppozada H, Michaels L, Toppozada M, El-Ghazzawi I, Talaat M, Elwany S. The human respiratory nasal mucosa in pregnancy. An electron microscopic and histochemical study. J Laryngol Otol 1982;96:613-626.

[12] Garfield CF. Rhinitis Medicamentosa. Updated May 2, 2006. In emedicine http://www.emedicine.com/ped/topic2010.htm

[13] Kobal G. A New Extension to the University of Erlangen Smell Test (UEST). Chemical Senses. 30 (suppl 1) 210-211 2005

[14] Hummel T et al. Screening of olfactory function with a four-minute odor identification test: reliability, normative data, and investigations in patients with olfactory loss. Annals of Otol, Rhinol. & Laryngol. 110(10)976-81, Oct 2001

[15] Toppenberg KS . Hill DA. Miller DP. Safety of radiographic imaging during pregnancy. American Family Physician. 59(7):1813-8, 1820, 1999 Apr 1.

[16] Thompson SK et al. Acute non-traumatic maternal illnesses in pregnancy: imaging approaches. Emergency Radiology. 11(4):199-212, 2005 Jun.

[17] Kusama T.  Ota K. Radiological protection for diagnostic examination of pregnant women. Congenital Anomalies.  42(1):10-4, 2002 Mar.

[18] Lowe SA. Diagnostic radiography in pregnancy: risks and reality. Australian & New Zealand Journal of Obstetrics & Gynaecology.  44(3):191-6, 2004 Jun.

[19] Keles N. Treatment of Allergic Rhinitis during Pregnancy. American Journal of Rhinology. 18(1):23-8, 2004 Jan-Feb.

[20] Dykewicz MS et al. Diagnosis and Management of Rhinitis: Complete Guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 81(5 pt 2): 478-518 1998

[21] Holt GR and Mabry RL. ENT Medications in pregnancy. Otolaryngology-Head and Neck Surgery. 1983; 91(3): 338-341

[22] Lekas MD. Rhinitis during pregnancy and rhinitis medicamentosa. Otolaryngol Head Neck Surg. 107(6 pt 2): 845-9 Dec 1992

[23] Clifton VL, Rennie N, Murphy VE. Effect of inhaled glucocorticoid treatment on placental 11beta-hydroxysteroid dehydrogenase type 2 activity and neonatal birthweight in pregnancies complicated by asthma. Australian & New Zealand Journal of Obstetrics & Gynaecology.  46(2):136-40, 2006 Apr.

[24] Lemiere C. Blais L. Are inhaled corticosteroids taken during pregnancy harmless? Journal of Allergy & Clinical Immunology. 116(3):501-2, 2005 Sep.

[25] Schatz M. Asthma treatment during pregnancy. What can be safely taken? Drug Safety. 16(5):342-50, 1997 May.

[26] The use of newer asthma and allergy medications during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) and The American College of Allergy, Asthma and Immunology (ACAAI). Annals of Allergy, Asthma, & Immunology. 84(5):475-80, 2000 May.

[27] Ambro BT.  Scheid SC.   Pribitkin EA. Prescribing guidelines for ENT medications during pregnancy.   Ear, Nose, & Throat Journal.  82(8):565-8, 2003 Aug

[28] Hansen L, Sobol SM, Abelson TI. Otolaryngologic manifestations of pregnancy. J Fam Pract 1986;23:151-155

[29] Lippincott L.H, Amedee RG. ENT issues in pregnancy. Journal of the Louisiana State Medical Society, 151 (7), 350-4, 1999 Jul.

 

gotop