Women are subjected to unique changes as a result of cyclical hormonal changes in the period of the menstrual cycle, pregnancy, and menopause. The physiological changes affect the whole parts of the human body due to the effects of progesterone and estrogen. These 2 hormones affect the central nervous system. The majority of the hormonal changes cause no harm to the pregnant woman and her fetus . However, in certain conditions, the hormonal changes lead to various rhinological problems like PR, epistaxis, and nasal blockage . The PR might harm the quality of life in terms of snoring and obstructive sleep apnea with their sequelae . Our results reported that the prevalence of PR was 11.65%, which was in the range of the previous studies from different geographical areas (9 to 53.3%) [10, 11, 14, 16,17,18,19,20]. The difference may be attributed to the following reasons: the difference in the place and design of the study (population or hospital-based study), inclusion and exclusion criteria, geographical location, the economic state of the patient, and ignorance of mild symptoms by the pregnant women. We cannot estimate the accurate prevalence of PR in our study owing to the exclusion of pregnant women with previous sinonasal diseases and surgeries and high percentages of pregnant lost to follow-up or because they did not wish to participate in the study.
PR is considered a diagnosis of exclusion of other sinonasal pathologies such as septal deviation, nasal polyposis, allergic rhinitis, intrinsic rhinitis, and pyogenic gravidarum because there is no laboratory or specific test. The diagnosis depends on a thorough history and proper nasal examination either by anterior rhinoscopy or endoscopy. This is supported by certain subjective scales such as DIP (discharge-inflammation-polyps/edema), VAS, and NOSE scale, or by objective tests (rhinomanometry and acoustic rhinometry) . Therefore, the VAS, NOSE, and DIP scoring systems are useful for the assessment of the PR.
The cardinal symptom of the PR is nasal obstruction. It harms sleep quality through mouth breathing, snoring, and obstructive sleep apnea syndrome. Besides, weight gain during pregnancy aggravates these conditions [21, 22]. As a result of the nasal obstruction, there is a decrease in the inspiration of nitric oxide, which is mainly produced in the maxillary sinuses, therefore, the vascular resistance in the lungs will be decreased. The low nitric oxide hurts the fetus, thus resulting in sinister complications to the mother and her fetus, including intrauterine growth retardation, a low Apgar score of the newborn, maternal hypertension, and preeclampsia [23, 24]. Furthermore, nasal obstruction with its sequel may lead to the overuse and abuse of sympathomimetics nasal decongestants resulting in rhinitis medicamentosa which does not improve following parturition . Therefore, it is of utmost importance to manage the pregnant woman with rhinitis properly to relieve patient discomfort, avoid the above-mentioned complications and sequels, and avoidance of the side effects of the drugs such as antibiotics and oral steroids on the mother and fetus. The gestational age and BMI of the patients showed statistically significant differences between pregnant women with and without PR (P value = 0.001). While other factors such as the age, occupation, parity, and sex of the baby did not show significant differences between the two groups (P value > 0.05).
Rhinorrhea is considered one of the symptoms of PR. In the current study, rhinorrhea was the most common associated symptom with nasal obstruction. Of note, rhinorrhea with nasal obstruction increases the impact on pregnant women.
Tobacco smoke has a detrimental effect on the nasal mucociliary mechanism, therefore, it might aggravate or initiate nasal pathologies including the PR. The prevalence of active smokers among the Iraqi population was 29–31% for men and 3–4% for women [26, 27]. This prevalence is much lower than the Sweeden female population . Fortunately, no patient gave a history of active smoking in our study. However, if the prevalence of the PR is more in smokers, then the prevalence of PR in the non-smoker female population may be so low . This might be an additional factor for the relatively low prevalence of PR in our study.
Although the mechanisms of the PR remain obscure whether it is due to physiological changes during pregnancy or due to an aggravating nasal disease before the pregnancy. This is supported by several investigations that studied the association between demographic characteristics and PR, like age and social environment . Our study did not show a significant association between the age and occupation of the pregnant women with and without PR (P value > 0.05).
PR can develop at any time in pregnancy [18, 28, 29]. In our study, the majority of the pregnant women were in the second trimester. However, there was a statistically significant difference between women with and without PR regarding gestational age (first trimester). This finding was consistent with a prior study, which reported that all cases of PR were found in the first trimester . This may be explained by increasing blood volume and hormonal alteration which are typically noticed in the first two trimesters . However, it was inconsistent with other investigations [10, 14, 17, 18].
In the current study, around 60% of the women carry a female fetus, this was in agreement with another study . This may be due to the effects of hormones of both mother and fetus female on the initiation and severity of the PR . However, no significant association was found between the sex of the baby between the two groups of pregnant women.
There is an ambiguity concerning many aspects of the PR, despite, the term PR was created in the late nineteenth century by McKenzie . We started with the definition of the PR by Ellegard and Karlsson , the definition excludes the other symptoms of rhinitis as they are well known to the otolaryngologists such as rhinorrhea, facial pain, and postnasal discharge. Furthermore, the minimum duration of the PR is 8 weeks (6 weeks in the last period of the pregnancy and 2 weeks after delivery); therefore, it could be classified into subacute and chronic. Another issue that needs to be clarified, PR occurs due to hormonal changes in the pregnancy, so why not all pregnant women are affected by the condition? The third aspect, there is no scoring system for the severity of the condition which affects its course. The fourth issue is that PR, like other forms of rhinitis, predisposes to infective rhinitis and leads to chronic rhinosinusitis. As a result of the above-mentioned issues, we recommend further studies to answer these questions.
The limitations of the study included first, a relatively small sample size which did not reflect the actual prevalence rate of the PR. Second, the study period was short.