The short answer: Budesonide nasal spray is the best-studied intranasal corticosteroid in pregnancy — it's the only one that ever held FDA Pregnancy Category B status, backed by data from over 6,600 in-utero exposures with a generally reassuring fetal safety profile. Current US clinical guidelines name intranasal corticosteroids as the preferred first-line treatment for nasal symptoms in pregnancy, while explicitly flagging oral decongestants as something to avoid in the first trimester. If you've been white-knuckling your way through a stuffed nose because you're scared to use a spray, the evidence doesn't support that level of caution.
You're 21 weeks pregnant with twins. You haven't slept through the night in weeks — not because the babies are keeping you up, but because you wake up mouth-breathing, face throbbing, completely unable to get air through your nose. You've been avoiding the Rhinocort sitting in your medicine cabinet because you're not sure if it's safe. Your OB said "try to avoid medications," which is not the same as "that specific spray will harm your babies," but it's impossible to un-hear.
This is pregnancy rhinitis. It's caused by the same estrogen surge that causes approximately everything else weird about pregnancy — it swells the nasal mucosa, increases mucus secretions, and in some cases gets dramatically worse in multiple pregnancies due to higher circulating hormone levels. A 2025 narrative review by Dumitru et al. flags it as both underdiagnosed and undertreated, which tracks with the experience of many pregnant people who are told to just deal with it.
You don't have to just deal with it.
What Makes Budesonide Different From Other Nasal Sprays
Not all intranasal corticosteroids have the same pregnancy data behind them. Budesonide is genuinely in a different category.
A 2005 review by Gluck & Gluck examined more than 6,600 in-utero budesonide exposures — a dataset large enough to detect signals that smaller studies would miss — and found no increase in congenital malformations. One analysis within the review noted a marginally elevated odds ratio for minor cardiovascular defects with intranasal use (OR 1.58), which the authors attributed to likely confounding given the overall reassuring picture. That's the foundation for why budesonide was the only intranasal corticosteroid ever assigned FDA Pregnancy Category B (all others were Category C). The B designation doesn't mean proven safe; it means animal studies showed no risk and human data was either reassuring or sufficient. Category C means animal studies showed some adverse effect or data is simply lacking. That's a meaningful distinction when you're trying to make a call at 2am.
The randomized controlled trial data is worth looking at directly. A 2005 RCT by Silverman et al. followed 313 pregnancies in women with asthma — a population requiring higher doses than a nasal spray delivers — and found a healthy delivery rate of 81% in the budesonide group versus 77% in the placebo group. Congenital malformations: 2% budesonide, 3% placebo. No statistically significant difference.
What the Broader Evidence Says
The 2018 literature review by Alhussien et al. looked across multiple intranasal corticosteroids and found no significant association between budesonide, mometasone, or fluticasone furoate and congenital malformations. The one exception was triamcinolone, which showed elevated risk — which is why that specific spray gets a different recommendation in pregnancy.
The takeaway isn't "all nasal sprays are fine." It's that budesonide specifically has a substantial evidence base and a consistently reassuring profile.
Vlastarakos et al., 2008 put it plainly in their clinical review: budesonide is the treatment of choice for nasal symptoms in pregnant patients, and — this part matters — untreated symptoms may cause more harm than appropriately used medication. Chronic mouth breathing disrupts sleep architecture. Severe sleep disruption in pregnancy has downstream effects on fetal development, maternal blood pressure, and delivery outcomes. The choice isn't "medication vs. nothing." It's "medication vs. a different kind of risk."
What the Guidelines Actually Say
The 2020 Joint Task Force Rhinitis Practice Parameter — the main US clinical guideline — designates intranasal corticosteroids as preferred monotherapy for rhinitis, with oral decongestants explicitly flagged to avoid in the first trimester due to vasoconstrictive effects.
That's the same guideline your allergist, ENT, or OB should be referencing.
The Dumitru et al. review recommends a stepped approach: start with non-pharmacologic options (saline rinses, nasal strips, humidifiers, sleeping with the head elevated), then move to intranasal corticosteroids for cases that don't respond. If saline rinses were cutting it for you, you wouldn't be reading this at 2am.
One Practical Note on Nasal Steroids Generally
The dose from a nasal spray is tiny compared to oral or systemic steroids. Systemic absorption from intranasal corticosteroids is minimal — budesonide in particular has high first-pass liver metabolism, which further limits any systemic exposure. This is not the same risk profile as taking prednisone tablets.
At Imprint, we look at physical wellbeing during pregnancy as foundational infrastructure for everything that comes after — including the early weeks of newborn care when you'll need to be functional. Chronic sleep disruption from untreated rhinitis isn't a minor inconvenience in a twin pregnancy at 21 weeks. It compounds.
The spray has been studied in over 6,600 pregnancies. The guidelines recommend it. The systematic review data is reassuring. At some point the question flips: what's the evidence-based case for not using it?
