LOSS, Thais Baratela 
FERIA, Mariana Bastos 
ESPÓSITO, Mário Pinheiro 
LOSS, Thais Baratela; FERIA, Mariana Bastos; ESPÓSITO, Mário Pinheiro. Gestational Rhinitis. Multidisciplinary Scientific Journal. Special Edition of Health. Year 02, Vol. 04. pp 114-122, November 2017. ISSN:2448-0959
Changes in the physiology of the nasal mucosa are relatively common in gestation. Gestational rhinitis is a relatively common condition and little discussed in the national literature that has gained importance in recent years and constitutes a rhinitis defined as "nasal congestion lasting six weeks or more during gestation in the absence of upper airway infection and allergic phenomena, with complete disappearance of the symptoms until the second week of puerperium. " The basic therapeutic orientation starts with environmental control and other forms of therapeutic intervention have been investigated in order to become safe and effective options in approaching the symptoms.
Key Words: Rhinitis, Gestation, Nasal Obstruction, Causes, Guidance.
Changes in the physiology of the nasal mucosa are relatively common in gestation; pre-existing allergic rhinitis, as well as asthma, may improve, worsen or remain unchanged during pregnancy (1,4).
Pregnancy can variably modify the natural history of allergic manifestations, through alterations: hormonal, vascular and immunological (2,5).
Gestational rhinitis is a relatively common condition and little discussed in the national literature that has been gaining importance in recent years, mainly due to the discovery of its association with snoring and obstructive sleep apnea syndrome (OSAS) in pregnancy and, indirectly, with preeclampsia (3).
The first studies that related the symptom of nasal obstruction with female hormones appeared in the late nineteenth century, 1 but it was only in 1943 that Mohun presented a series of cases of the entity that would be the precursor of gestational rhinitis, calling it "vasomotor rhinitis of gestation "- nasal symptoms would appear from the third to the seventh month of gestation and would normally normalize up to ten days postpartum (1).
Estrogens and placental growth hormone are involved in the onset of symptoms, the severity being directly related to the concentration of these hormones in the blood. At this stage, there is a decrease in the permeability of the nostrils, with the hyperemic, swollen and congested nasal mucosa. In addition to nasal obstruction, vasodilatation due to hormonal changes and increased blood volume during this period, episodes of epistaxis (nasal bleeding) also occur (1,3,4,5,7).
Some studies have estimated, in relation to the most common complications, that pregnant women with rhinitis are about six times more likely to develop rhinosinusitis, and 1/3 of them may present with associated asthma attacks (6,7).
The basic therapeutic orientation begins with environmental control (3,5, .6), many other forms of therapeutic intervention have been investigated in order to become safe and effective options in the treatment of symptoms.
2. GENDING RINITE
The appearance of nasal symptoms in pregnant women without previous symptoms of rhinitis constitutes a rhinitis defined as "nasal congestion lasting six weeks or more during gestation, absence of upper airway infection and allergic phenomena, with complete disappearance of symptoms until the second week of puerperium. " It is estimated that up to 70 to 90% of pregnant women develop rhinitis, especially during the third trimester (7).
Gestational rhinitis is a condition characterized by persistent nasal obstruction – apart from the septal, tumor, infectious and allergic causes – that begins at any stage of pregnancy, disappearing around two weeks after childbirth (6). It is accompanied by intense nasal pruritus, watery coryza, sometimes abundant, and ocular, pharyngeal and auricular pruritus may also coexist (1).
Vasomotor rhinitis present in pregnancy can cause severe nasal congestion and compromise the quality of life of the pregnant woman, occurring in more than 20% of pregnancies. The most prevalent presentations are: allergic rhinitis, rhinitis
vasomotor, drug rhinitis, and bacterial rhinosinusitis. One third of women with rhinitis worsen with pregnancy. Rhinitis greatly decreases the quality of life of pregnant women, is a risk factor for associated asthma, and is also a predisposing condition for the onset of sinusitis; the treatment of rhinitis should therefore be optimized throughout gestation (5).
2.1 Signs and Symptoms
Physical examination usually shows numbed nasal turbinates, wet, pale nasal mucosa, edemaciate, with presence of hyaline secretion. It is a nonspecific disorder, with no evident cause of infectious or allergic processes, but rather a change in the autonomic nervous system with a preponderant action of parasympathetic fibers in the blood vessels of the nasal mucosa (1).
Clinical diagnosis may be suspected only by the symptom of worsening of nasal obstruction (which was not previously present) in pregnant patients and not secondary to other conditions – the differential diagnosis includes rhinosinusitis, allergic rhinitis itself, drug rhinitis, acute infection or subacute upper airway and gravid granuloma (3).
2.2 Hormonal Components
The effects of hormonal action on nasal morphology and function have been the target of several national and international studies (1,4,5,7).
In gestation, the hormonal influence on the respiratory nasal epithelium becomes even more pronounced, and there may be worsening of the symptoms of pre-existing allergic rhinitis (7).
During pregnancy, there are several hormonal and blood changes that may influence nasal congestion. Progesterone relaxes the smooth muscle of the nasal vessels, increasing blood volume and estrogen elevates the hyaluronic acid component and inhibits acetylcholinesterase, causing a predominance of parasympathetic SNA in the nasal submucosa, causing edema of the nasal mucosa (5).
Estrogens and placental growth hormone are involved in the onset of symptoms; there is a decrease in the permeability of the nasal cavities and, by specific tests (rhinomanometry, anterior rhinometry, mucociliary clearence), the nasal patency significantly reduced, correlating the hormonal elevation curves with the uncomfortable nasal obstructive symptomatology. The hormonal component may influence vasodilation: the mucosa of the nasal turbinates is hyperemic, swollen, and congested. The effects of hormonal action on nasal morphology and function have been the target of several national and international studies (6).
It is assumed that placental trophoblastic hormone may stimulate nasal mucosa hypertrophy during gestation. In addition, estrogen may contribute to this effect by increasing the histamine receptor in the microvasculature and epithelial cells. Progesterone, too, may play a role in optimizing local vasodilation in the nose by increasing the circulating blood volume that occurs physiologically in pregnancy (3).
2.3 Guidelines and Treatment
The treatment of rhinitis in pregnancy consists of strict environmental control, avoiding exposure to specific agents such as: house dust mites, fungi, pollens, antigens from domestic and cheap animals, among others; and irritants of the nasal mucosa5,6. The abuse of topical nasal decongestants should always be discouraged, since it may be complicated by the appearance of drug rhinitis; the ideal is not to use drugs in the first trimester of pregnancy, when the risk of fetal abnormalities is higher (5).
Although there should be a dialogue with the patient's obstetrician, proper use of the corticosteroid, particularly the intranasal topic of poor absorption, appears to be a safe method of treatment. Antihistamines, disodium cromoglycate and systemic decongestants, such as pseudoephedrine, may also be used for short periods due to possible effects on placental vascularization5.
In a literature review, Caparroz et al. (2016) (3), regarding the treatment, points out that most of the studies show a consensus regarding the importance of educational measures as first choice and adjuvant measure in the management of gestational rhinitis, mainly because the symptoms resolve spontaneously after childbirth With guidance early in pregnancy, patients tend to resort less to topical decongestants and will be less likely to develop associated drug rhinitis.
The mechanism of action of corticosteroids, often indicated as a form of treatment (9), is related to anti-inflammatory effects in the nasal mucosa, through the control of protein synthesis. It acts by inhibiting local infiltration of mast cells, eosinophils, lymphocytes and the production and release of cytokines, decreased vascular permeability, secretion of the mucous glands, and production of leukotrienes and prostaglandins (10).
The main topical corticosteroids are beclomethasone, tirancinolone, budesonide, mometasone, ciclesonide and fluticasone; the advantage of topical application is the lower chance of systemic effect, however, the consequences can be verified depending on the dose and formulation of the drug (9).
Intranasal corticosteroid therapy should be considered when controlling for rhinitis with antihistamines and / or decongestants; beclomethasone and budesonide are recommended because of their greater previous clinical experience. Recently, fluticasone has been shown to be safe and effective in the treatment of gestational vasomotor rhinitis (4).
Topical corticosteroid intranasal such as beclomethasone may be used at usual doses without significant adverse effects (1).
Geller, 2003, attentive to the fact that the ideal is not to use drugs in the first trimester gestational, when the risk of fetal abnormalities is higher – about 1% to 5% of these abnormalities are caused by drugs. The risk categories established by the FDA for the treatment of rhinitis during pregnancy are listed in the tables below (4):
Unlike pharmacotherapy, immunotherapy aims to alter the immune system; its routes of administration are sublingual, subcutaneous and intranasal (10).
Immunotherapy, if initiated, may be continued, however, it is recommended that it not be initiated during pregnancy. However, maintenance of this should be done with caution, provided there is benefit for the mother and in the absence of systemic reactions (1).
This conduct does not increase the risk of perinatal complications, although post-immunotherapeutic anaphylactic reactions are potentially dangerous for the mother-fetus binomial. Maintenance doses of immunotherapy may be maintained or even reduced in pregnancy. The progressive increase in doses and concentrations, when really necessary, should be cautious (4).
The diagnosis of rhinitis during the gestational period is of great importance, trying to avoid the complications of an untreated rhinitis, as well as the asthmatic crisis and secondary infections of the sinuses and upper respiratory tract.
The role of hormones in these conditions has been suggested by many studies, but knowledge about the pathophysiology of gestational rhinitis is still scarce.
Management of rhinitis during pregnancy requires the least intervention with the greatest possible symptomatic relief. Considering the impact on the quality of life of the pregnant woman, both the otorhinolaryngologist and the obstetrician should be attentive to the early diagnosis and management of this entity, considering the safety profile and level of evidence of the measures and medications currently available.
1 – ROITHMANN R .; RODRIGUES E.M .; CANELLA P.L.A. "Rhinitis in pregnancy". Available at: http://www.moreirajr.com.br/revistas.asp?fase=r003&id_materia=875. Accessed on: May, 2017.
2 – MABRU R.L. "Rhinitis of pregnancy". South Med. 1986; 79: 965-71.
3 – – CAPARROZ F.A .; GREGÓRIO L.L .; BONGIOVANNI G .; IZZU S.C .; KOSUGI M. "Rhinitis in pregnancy – literature review". Braz. j. otorhinolaryngol. 2016. Jan / Feb; 82 (1).
4 – GELLER M. "Allergological behavior in pregnancy". Rev. bras. allerg. immunopatol. 2003; 26 (3): 79-88.
5 – CONSENSUS IN RINITE – Available at: http://www.aborlccf.org.br/consensos/Consenso_sobre_Rinite-SP-2014-08.pdf. Accessed on: May, 2017.
6 – REIS J.S. "Gestational rhinitis. Diagnosis and treatment. An important experience to be reported. " Rev AMF. 2010 Jun / Aug; 8 (43): 10-3.
7 – BALBANI A.P.S; MELLO JÚNIOR J.F .; MARONE S.A.M .; BUTUGAN "Hormonal influence on the pathophysiology of rhinitis. Available at: http://www.asbai.org.br/revistas/Vol234/inf.htm. Accessed on: May, 2017.
8 – MION O. "Rhinitis – how to diagnose and treat". Brazilian Journal of Medicine. 2013. Apr / May; 70 (5): 154-63.
9 – ABRAHÃO M; DEBONI M; GREGGIO B. "Rhinitis – how to diagnose and treat". Available at: http://www.moreirajr.com.br/materia=5586. Accessed on: May, 2017.
10 – ELLEGARD E. "Pregnancy rhinitis". Immunol Allergy Clin N Am. 2006; 26: 119-35.
 Physician at the Faculdades Integradas Aparício Carvalho and R2 in Otorhinolaryngology at Hospital Otorrino de Cuiabá.
 PhD in Paracatu / MG and R3 in Otorhinolaryngology at Otorrino Hospital in Cuiabá.
 . Coordinator of the Medical Residency in Otorhinolaryngology and Cervical-Facial Surgery of the Otorrino Hospital of Cuiabá / MT.