Urticaria and Angioedema

Urticaria and angioedema can manifest throughout pregnancy with an impact ranging from a decline in one’s quality of life to a potentially life-threatening situation in some cases of hereditary angioedema. Management should be tailored for each patient based on her history, personal priorities, severity of disease, and potential complications. As medication use is typically avoided in pregnancy if possible, due to actual or perceived risks to the fetus, women are often undertreated. In women with pre-existing chronic urticaria/angioedema, a thorough conversation between the clinician and patient should take place, ideally prior to conception, on the risks and benefits of therapy throughout pregnancy and lactation. Both acute and chronic urticaria present similarly in pregnant and nonpregnant patients. They should both be managed with second-generation H1 antihistamines as first-line therapy as they have reassuring human safety data during pregnancy. First-generation H1 antihistamines are generally considered second-line agents due to their sedating effects. Systemic steroids may have a role in short-term management but should never be used as chronic treatment for urticarial lesions. The use of omalizumab for chronic urticaria during pregnancy appears to be a safe and effective option, but data remain limited, and therefore omalizumab should be used only after a failure of first-line treatment. Special considerations exist for lactating mothers with urticaria. Second-generation H1 antihistamines again are the preferred therapy due to very low levels being detected in breast milk. Hereditary angioedema (HAE) is due to dysfunction of C1 inhibitor and can have an unpredictable course during pregnancy with a slight majority of women reporting an aggravation of symptoms. The safest option for acute exacerbations, short-term prophylaxis, and chronic prophylaxis is C1-INH concentrate. Other therapies for HAE including attenuated androgens, fresh frozen plasma, tranexamic acid, icatibant, and ecallantide have not been shown to be safe to use during pregnancy or have had inferior outcomes.