Managing hayfever during pregnancy

Hayfever during pregnancy is common — affecting around 1 in 5 pregnant women — and notoriously harder to manage, because the standard treatment ladder shifts. Some medications are well-established as safe in pregnancy. Others are clearly to be avoided. A few sit in a middle zone where the conversation with your midwife or GP matters more than any general guidance.

This is the framework. It is not a substitute for clinical advice on your specific medications.

What is generally considered safe

Saline nasal rinse

The most strongly endorsed first-line treatment in pregnancy. Mechanical, non-pharmaceutical, no systemic absorption. Use a high-volume bottle or neti pot with sterile or pre-boiled water — never tap water.

Pregnant women often experience pregnancy rhinitis — congestion driven by elevated oestrogen and increased blood flow to nasal tissue — entirely separate from hayfever. Saline rinses help both.

Intranasal corticosteroids (most)

Several INCS are widely used in pregnancy and considered low-risk because so little is systemically absorbed.

• Budesonide has the best safety data and is often the first choice.
• Fluticasone propionate and mometasone furoate are also commonly used.
• Beclomethasone has been used for decades with no clear safety signal.

The point of using INCS in pregnancy is the same as outside it — daily, consistent, started early. Talk to your midwife if you're newly starting one rather than continuing.

Loratadine and cetirizine

These are the two oral antihistamines with the largest body of safety data in pregnancy and are usually recommended as first-line if a tablet is needed. Both have been used by millions of pregnant women with no clear evidence of harm.

Cetirizine carries the small sedation risk it does outside pregnancy — fexofenadine or loratadine are alternatives if drowsiness matters.

What sits in the middle

Fexofenadine

Less safety data in pregnancy than loratadine or cetirizine, but no signal of harm. Many specialists will continue a woman on fexofenadine if she was already on it pre-pregnancy and finds it works well. Discuss with your midwife or GP.

Bilastine

Newer drug, much less pregnancy safety data. Most clinicians will switch to loratadine or cetirizine during pregnancy as a precaution.

Antihistamine eye drops

Topical olopatadine and azelastine have minimal systemic absorption and are generally considered low-risk. Discuss specifically with your midwife.

What to avoid

Pseudoephedrine and other oral decongestants

Vasoconstrictor effects. Possible association with congenital abnormalities in first trimester in some studies. Generally avoided throughout pregnancy.

Decongestant nasal sprays (oxymetazoline, xylometazoline)

Same vasoconstrictor concern, plus the rebound congestion problem that affects everyone.

First-generation antihistamines (diphenhydramine, chlorphenamine, promethazine)

These cross the placenta readily. While occasionally prescribed for specific obstetric reasons (notably promethazine for hyperemesis), they're not appropriate for routine hayfever management.

Oral steroids and montelukast

Not first-line. Decisions about these should be made by a specialist, not based on general guidance.

Non-medication strategy matters more in pregnancy

Because the pharmaceutical options are narrower, the environmental and behavioural side of the routine carries more weight than usual.

• Bedroom setup: HEPA purifier, allergen-barrier covers, humidity below 50%, 60°C bedding wash. All standard, all safe.
• Evening shower with hair wash before bed. Even more important than usual.
• Saline rinses twice daily in peak season.
• Wraparound sunglasses on commutes and walks.
• Windows closed from sunrise; ventilate in the evening if needed.
• Avoid drying laundry outside during pollen season.

Things to discuss specifically with your midwife or GP

• Whether to continue a medication you were on before pregnancy
• First-trimester specific concerns vs. later pregnancy
• Whether to step up to a steroid spray or add eye drops
• Anything you're being offered by a pharmacist that isn't on the safe list above
• Severe symptoms that aren't responding to the safe options

Most midwives and GPs are comfortable with this conversation and will give you a clear answer for your specific situation.

The bottom line

You don't have to suffer through hayfever in pregnancy, and you don't have to take risks to manage it. Saline rinse plus a well-established INCS (often budesonide) plus loratadine or cetirizine is a strong, evidence-backed combination used routinely by women in pregnancy. Combined with the bedroom and behavioural side of the routine, it's enough for most women through peak season.

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If a medication question isn't covered clearly here, the right next step is always your midwife or GP, not the internet, not a pharmacist's casual answer, and not the cautious assumption that everything is unsafe.