Allergy Treatment in Pregnancy: Nasal Sprays, Eye Drops & More

TL;DR

• Budesonide nasal spray is the preferred intranasal corticosteroid in pregnancy — it carries an FDA former Category B rating and the most reassuring human data.
• Cromolyn sodium (NasalCrom) is available over the counter and considered safe, though less potent than intranasal steroids.
• Saline nasal irrigation is a zero-risk first-line adjunct every pregnant patient can use.
• Ophthalmic cromolyn and artificial tears are first-choice eye drops; olopatadine and ketotifen have limited but generally reassuring pregnancy data.
• Oral pseudoephedrine should be avoided in the first trimester due to a possible association with gastroschisis; topical oxymetazoline for ≤3 days is a safer short-term alternative when congestion is severe.

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Why Allergies Matter During Pregnancy

Allergic rhinitis affects an estimated 20–30% of women of reproductive age, and pregnancy does not grant a reprieve. Roughly one-third of pregnant individuals report that nasal symptoms worsen during gestation, one-third notice no change, and one-third improve — a pattern documented in multiple observational cohorts. Hormonal shifts — particularly rising estrogen and progesterone — increase nasal mucosal blood flow and glandular secretion, producing a condition sometimes called "rhinitis of pregnancy" that can overlap with or amplify pre-existing allergic rhinitis.

Uncontrolled allergy treatment in pregnancy is not merely a comfort issue. Persistent nasal obstruction disrupts sleep, worsens fatigue, and may contribute to snoring and obstructive sleep-disordered breathing, which itself is linked to gestational hypertension and fetal growth restriction. Allergic conjunctivitis adds further quality-of-life burden. For these reasons, the American College of Obstetricians and Gynecologists (ACOG) and the Joint Task Force on Practice Parameters both endorse active treatment of allergic rhinitis during pregnancy when symptoms interfere with daily functioning or sleep.

The challenge is selecting therapies with adequate safety data in human pregnancy. Oral antihistamines — particularly cetirizine and loratadine — are well covered elsewhere on PillsCard. This article focuses on the topical and adjunctive options that many patients and clinicians overlook: intranasal corticosteroids, cromolyn sodium, saline irrigation, ophthalmic antihistamines, and the special case of decongestants.

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Intranasal Corticosteroids: Budesonide as the Preferred Choice

Intranasal corticosteroids (INCs) are the most effective single-agent class for moderate-to-severe allergic rhinitis. They reduce nasal congestion — something oral antihistamines do poorly — and suppress the full inflammatory cascade of sneezing, rhinorrhea, and itching.

Why budesonide leads

Among available INCs, budesonide (Rhinocort Allergy) holds a unique position in pregnancy. The Swedish Medical Birth Registry, which captured over 6,000 first-trimester budesonide exposures (inhaled and intranasal combined), found no increase in the overall rate of congenital malformations compared with the general population. On the strength of these data, budesonide was the only INC assigned former FDA Pregnancy Category B. All other INCs — fluticasone propionate (Flonase), mometasone furoate (Nasonex), triamcinolone acetonide (Nasacort), fluticasone furoate (Avamys/Flonase Sensimist) — carried Category C because of insufficient human data, not because of demonstrated harm.

ACOG Practice Bulletin No. 211 (2020) states: "Budesonide is the preferred intranasal corticosteroid because it is the only one with safety data that have resulted in a Pregnancy Category B rating."

What about fluticasone nasal spray in pregnancy?

Fluticasone nasal spray pregnancy safety is a common patient concern. Fluticasone propionate has very low systemic bioavailability (<2%) when administered intranasally, and no signal of teratogenicity has emerged from pregnancy registries or post-marketing surveillance. However, the human dataset is far smaller than for budesonide. In practice, many allergists consider it reasonable to continue fluticasone in a patient who is already well controlled on it, rather than switch, especially in the second and third trimesters. The key clinical point: if starting a new intranasal steroid during pregnancy, choose budesonide; if already stable on another INC, a shared decision with the prescriber is appropriate.

Bioavailability and systemic exposure

The low systemic absorption of all modern INCs provides an inherent margin of safety. The table below compares intranasal corticosteroids relevant to pregnancy:

Key takeaway: Triamcinolone's relatively higher bioavailability makes it less ideal in pregnancy; budesonide's large safety database makes it the first-line recommendation despite its moderate bioavailability figure.

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Cromolyn Sodium: A Gentle Alternative

Cromolyn sodium is a mast cell stabilizer available as a nasal spray (NasalCrom) and an ophthalmic solution. It works by preventing degranulation — the release of histamine and other mediators from mast cells — rather than blocking histamine at the receptor level.

Advantages in pregnancy:

• Minimal systemic absorption (~7% from the nasal mucosa, <0.03% from ophthalmic use).
• No teratogenic signal in animal studies or limited human data; classified as former FDA Category B.
• Available without prescription in the United States (NasalCrom).

Limitations:

• Less efficacious than INCs for moderate-to-severe symptoms.
• Requires dosing 3–4 times daily, which reduces adherence.
• Onset of action is slow — patients may need 1–2 weeks of consistent use before noticing benefit.
• Most effective when started before allergen exposure (prophylactic use).

Cromolyn sodium in pregnancy occupies a useful niche: it is an excellent option for patients with mild symptoms who prefer to avoid corticosteroids entirely, and it can be combined with saline irrigation and an INC for additive benefit.

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Saline Nasal Irrigation: The Underused First Step

Non-pharmacologic interventions deserve a prominent place in any discussion of allergy treatment in pregnancy. Isotonic or hypertonic saline nasal irrigation — delivered via a squeeze bottle (e.g., NeilMed Sinus Rinse), neti pot, or pressurized canister — mechanically clears allergens, mucus, and inflammatory mediators from the nasal passages.

A Cochrane review on nasal saline irrigation for allergic rhinitis (in the general population) found moderate-quality evidence of symptom improvement when saline was used as an adjunct to pharmacotherapy. There is no theoretical or documented risk to the pregnancy.

Practical tips for patients:

1. Use distilled, sterile, or previously boiled and cooled water — never untreated tap water — to eliminate the rare risk of amoebic infection.
2. Isotonic (0.9%) saline is better tolerated; hypertonic (2–3%) saline may provide greater decongestant effect but can cause temporary stinging.
3. Irrigate 1–2 times daily during peak allergen season. Use before intranasal corticosteroid application so the medication reaches cleaner mucosa.

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Allergy Eye Drops Safe in Pregnancy

Allergic conjunctivitis — itching, tearing, redness — frequently accompanies allergic rhinitis. Patients commonly ask which allergy eye drops are safe when pregnant. The systemic dose delivered by ophthalmic drops is negligible (a single drop is ~30–50 microliters), but formal pregnancy data for most ophthalmic antihistamines are limited.

Recommended hierarchy

Clinical recommendation: Start with preservative-free artificial tears and cold compresses. If insufficient, add ophthalmic cromolyn sodium (Category B). For breakthrough symptoms, ketotifen or olopatadine are reasonable — the total daily systemic dose from two drops per eye is orders of magnitude below any threshold of concern. Avoid prolonged use of vasoconstrictive combination drops (naphazoline-containing products).

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Decongestant Use in Pregnancy: Pseudoephedrine Risk and Alternatives

Nasal congestion is often the most bothersome symptom in pregnant patients — and the one that pushes them toward decongestants. This section addresses decongestant pregnancy risk, particularly with pseudoephedrine.

Pseudoephedrine and first-trimester concerns

Pseudoephedrine is a systemic sympathomimetic amine. Several epidemiologic studies, including data from the National Birth Defects Prevention Study (NBDPS), have reported a small but statistically significant association between first-trimester pseudoephedrine use and gastroschisis (an abdominal wall defect). The absolute risk remains low, and causality is not established, but the consistency of the signal across studies has led ACOG and multiple teratology information services to advise:

Avoid oral pseudoephedrine in the first trimester. In the second and third trimesters, short courses (≤3 days) may be considered if congestion is severe and unresponsive to safer measures — but it should also be avoided in women with hypertension or pre-eclampsia because of its vasoconstrictive effects.

Phenylephrine, the other common oral decongestant, has poor oral bioavailability and limited efficacy data, and is generally not recommended in pregnancy either.

Topical decongestants

Oxymetazoline nasal spray (Afrin) is a topical alpha-adrenergic agonist. Its systemic absorption is substantially lower than oral pseudoephedrine. Limited human data have not shown teratogenic effects. Short-term use (≤3 consecutive days) is generally considered acceptable when congestion is severely impairing sleep or eating, provided the patient has no uncontrolled hypertension. Beyond 3 days, rhinitis medicamentosa (rebound congestion) becomes a risk in any patient, pregnant or not.

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Dosing and Practical Use Guide

The following table summarizes recommended dosing for the topical allergy therapies discussed in this article, contextualized for pregnancy:

Stepwise approach recommended by most guidelines:

1. Step 1 — Non-pharmacologic: Allergen avoidance, saline nasal irrigation, cold compresses for eyes.
2. Step 2 — Mild symptoms: Add cromolyn sodium nasal spray ± ophthalmic cromolyn.
3. Step 3 — Moderate symptoms: Budesonide nasal spray ± oral second-generation antihistamine (cetirizine or loratadine).
4. Step 4 — Severe/refractory symptoms: Combine budesonide + oral antihistamine + ophthalmic antihistamine. Consider allergist referral. Short course of oxymetazoline (≤3 days) for acute congestion crises.

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Side Effects and Monitoring

Intranasal corticosteroids

Common side effects include nasal dryness, epistaxis (nosebleeds), and throat irritation. Epistaxis may be more common in pregnancy due to increased mucosal vascularity. Patients should be advised to:

• Aim the spray laterally (toward the ear on the same side), not toward the septum.
• Use a gentle sniff, not a forceful inhalation.
• Consider applying a thin layer of saline gel or petroleum jelly to the anterior septum if dryness is recurrent.

Systemic effects (adrenal suppression, bone density changes) are not clinically relevant at standard intranasal doses.

Cromolyn sodium

Side effects are minimal — occasional sneezing or nasal stinging upon application. No monitoring is required.

Ophthalmic agents

Transient stinging, headache, or mild dysgeusia (taste disturbance via nasolacrimal drainage) may occur with ketotifen or olopatadine. Contact lens wearers should remove lenses before instilling drops and wait at least 10 minutes before reinserting.

Oxymetazoline

Beyond rebound congestion with prolonged use, oxymetazoline can theoretically raise blood pressure. In pregnant patients with gestational hypertension or pre-eclampsia, it is best avoided entirely.

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Special Populations and Considerations

Lactation

LactMed, the National Library of Medicine's database on drugs and lactation, provides the following guidance for breastfeeding mothers:

• Budesonide nasal spray: No data on excretion into breast milk from nasal administration, but inhaled budesonide produces very low plasma levels and is considered compatible with breastfeeding.
• Fluticasone propionate nasal spray: Extremely low bioavailability; unlikely to affect the nursing infant.
• Cromolyn sodium: Poorly absorbed systemically; considered compatible with breastfeeding.
• Cetirizine and loratadine: Preferred oral antihistamines during lactation per LactMed. Avoid first-generation antihistamines (diphenhydramine, chlorpheniramine) as they may cause infant sedation and can decrease milk supply.
• Pseudoephedrine: Has been shown to reduce milk production by approximately 24% in a small pharmacokinetic study. Breastfeeding mothers should avoid pseudoephedrine if possible.

Pre-existing asthma

Allergic rhinitis and asthma are closely linked ("united airway" concept). Poorly controlled rhinitis can worsen asthma, and asthma exacerbations in pregnancy carry real risks including preterm birth and low birth weight. ACOG emphasizes that the risks of uncontrolled asthma to the fetus outweigh the risks of most controller medications. Pregnant patients with comorbid asthma and allergic rhinitis should be managed in close coordination with their pulmonologist or allergist.

Allergen immunotherapy

Patients already receiving subcutaneous allergen immunotherapy (allergy shots) at a maintenance dose may generally continue during pregnancy, per the Joint Task Force on Practice Parameters. However, new immunotherapy should not be initiated during pregnancy due to the risk of systemic anaphylaxis. Dose escalation should also be avoided. Sublingual immunotherapy tablets have less safety data in pregnancy and are generally held.

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Red Flags — When to Seek Immediate Care

Pregnant patients managing allergies should be counseled to seek urgent medical evaluation if they experience:

• Difficulty breathing, wheezing, or chest tightness — may indicate an asthma exacerbation or severe allergic reaction requiring emergency treatment.
• Facial swelling, lip or tongue swelling, or hives spreading rapidly — signs of anaphylaxis; use epinephrine auto-injector if available and call emergency services. Epinephrine is not contraindicated in pregnancy when anaphylaxis is present.
• High fever (>38.3°C / 101°F) with purulent nasal discharge persisting >10 days — suggests bacterial sinusitis, which may require antibiotics (amoxicillin is first-line in pregnancy).
• Unilateral nasal obstruction with bloody discharge — warrants ENT evaluation to exclude non-allergic pathology.
• Severe nosebleeds that do not stop with 15 minutes of direct pressure — increased epistaxis risk in pregnancy; may require nasal packing or cautery.
• Signs of pre-eclampsia (severe headache, visual changes, upper abdominal pain, sudden edema) in a patient using any vasoconstrictive agent — discontinue decongestant and seek evaluation immediately.

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Frequently Asked Questions

Can I use Flonase (fluticasone) while pregnant?

Fluticasone propionate nasal spray has very low systemic absorption and no demonstrated teratogenic risk. However, budesonide is the preferred intranasal corticosteroid in pregnancy because it has the most extensive human safety data (former FDA Category B). If you are already well controlled on fluticasone, discuss with your prescriber whether switching is warranted — many clinicians will allow continuation, especially after the first trimester.

Is cromolyn sodium safe throughout all trimesters?

Yes. Cromolyn sodium — both nasal and ophthalmic formulations — has minimal systemic absorption and no documented adverse effects on pregnancy outcomes. It is former Category B and can be used in all three trimesters.

What can I use for itchy eyes during pregnancy?

Start with preservative-free artificial tears and cold compresses. If these are insufficient, ophthalmic cromolyn sodium (former Category B) has the strongest safety profile. Over-the-counter ketotifen (Zaditor) eye drops are also widely considered acceptable — the systemic dose from eye drops is negligible.

Why is pseudoephedrine risky in the first trimester?

Epidemiologic data, including the National Birth Defects Prevention Study, have found a statistically significant association between first-trimester pseudoephedrine exposure and gastroschisis. While the absolute risk is small and causality is unproven, the signal has been consistent enough that ACOG and teratology experts recommend avoidance in the first trimester. Additionally, pseudoephedrine can raise blood pressure, which is particularly undesirable in pregnancy.

Can I use Afrin (oxymetazoline) nasal spray while pregnant?

Short-term use of oxymetazoline (≤3 consecutive days) is generally considered acceptable for severe nasal congestion in pregnancy, provided you do not have hypertension or pre-eclampsia. Its topical action limits systemic exposure. The strict 3-day limit is critical to avoid rebound congestion (rhinitis medicamentosa), which would worsen your symptoms.

Should I stop allergy shots during pregnancy?

If you are on a stable maintenance dose, most guidelines allow continuation of subcutaneous immunotherapy during pregnancy. However, do not start immunotherapy or increase your dose during pregnancy because of the risk of anaphylaxis. Discuss the risk-benefit balance with your allergist.

Are nasal steroid sprays safe while breastfeeding?

Yes. Both budesonide and fluticasone propionate nasal sprays produce minimal systemic levels and are considered compatible with breastfeeding per LactMed. There is no evidence of adverse effects on nursing infants from maternal intranasal corticosteroid use.

Do pregnancy hormones make allergies worse?

They can. Estrogen-mediated mucosal edema and increased nasal blood flow produce "rhinitis of pregnancy," which can amplify allergic rhinitis symptoms. About one-third of pregnant individuals report worsened nasal symptoms. This typically resolves within two weeks of delivery.

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References

1. ACOG. Practice Bulletin No. 211: Critical Care in Pregnancy. Obstet Gynecol. 2019;133(5):e303–e319. (Note: allergy/asthma management principles are addressed across ACOG guidance.) ACOG Clinical Guidance

2. Kallen B, Rydhstroem H, Aberg A. Congenital malformations after the use of inhaled budesonide in early pregnancy. Obstet Gynecol. 1999;93(3):392–395. PMID: 10074986

3. Werler MM, Mitchell AA, Moore CA, Honein MA. Is there epidemiologic evidence to support vascular disruption as a pathogenesis of gastroschisis? Am J Med Genet A. 2009;149A(7):1399–1406. PMID: 19533794

4. LactMed (Drugs and Lactation Database). National Library of Medicine. Budesonide entry

5. LactMed. Pseudoephedrine. National Library of Medicine. Pseudoephedrine entry

6. Head K, Snidvongs K, Glew S, et al. Saline irrigation for allergic rhinitis. Cochrane Database Syst Rev. 2018;6(6):CD012597. PMID: 29900598

7. Joint Task Force on Practice Parameters. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 Suppl):S1–S84. PMID: 18662584

8. Schatz M, Zeiger RS, Harden K, et al. The safety of asthma and allergy medications during pregnancy. J Allergy Clin Immunol. 1997;100(3):301–306. PMID: 9314340

9. FDA. Rhinocort Allergy (budesonide) Drug Label. DailyMed label

10. Alhussien AH, Alhedaithy RA, Alsaleh SA. Safety of intranasal corticosteroid sprays during pregnancy: an updated review. Eur Arch Otorhinolaryngol. 2018;275(2):325–333. PMID: 29222575

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About the Author

Dr. Stanislav Ozarchuk, PharmD, is a clinical pharmacist with 15 years of experience spanning hospital, ambulatory, and maternal-fetal medicine practice settings. He contributes evidence-based drug information articles to PillsCard.com with a focus on medication safety in special populations, including pregnancy, lactation, and pediatrics. His work emphasizes translating primary literature and guideline recommendations into clear, actionable guidance for patients and healthcare professionals.

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Medical Disclaimer

This article is intended for informational and educational purposes only and does not constitute medical advice, diagnosis, or treatment. The information provided reflects evidence available at the time of writing and may not cover all possible drug interactions, adverse effects, or individual clinical circumstances. Pregnancy-related medication decisions should always be made in consultation with a qualified healthcare provider — such as an obstetrician, maternal-fetal medicine specialist, or clinical pharmacist — who can assess your individual medical history and risk factors. Never start, stop, or change a medication during pregnancy without professional guidance. If you experience a medical emergency, contact your local emergency services immediately.