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For those with chronic hives, their safe, effective treatment before pregnancy, during pregnancy, and while breastfeeding is essential to the health of both mother and baby. If you're even considering pregnancy, talk to your doctor. You'll also need to discuss a personalized treatment plan that will control your hive's symptoms during pregnancy and lactation.

"Chronic" hives refers to red, itchy bumps that crop up suddenly on the skin and then come and go at random for 6 weeks or longer. Sometimes, hives are accompanied by "angioedema" -- a buildup of fluids under the skin that causes swelling -- usually in the eyelids and lips. This is considered a medical emergency that requires an immediate trip to the emergency department.

The hormonal changes that come with pregnancy can make chronic hives better, worse, or have no effect at all. In one study of 288 women with chronic hives, almost one-third had symptoms that were twice as bad during pregnancy.

Interestingly, the worst flareups were seen in those with mild hives who weren't treated before becoming pregnant. Women who had worse hives symptoms in a previous pregnancy were also more likely to have more severe symptoms during the next pregnancy. And finally -- no surprise -- symptoms got worse in individuals with chronic hives who weren't treated during their pregnancy.

The first choice for the treatment of chronic hives during pregnancy is one of the non-sedating second-generation antihistamines. These newer antihistamines, including loratadine (Claritin), desloratadine (Clarinex), cetirizine (Zyrtec), and levocetirizine (Xyzal), are safe and effective when used at the standard dose.

However, the safety of second-generation antihistamines during pregnancy has not been tested at higher-than-standard doses. If the standard dose does not control your symptoms, talk to your physician about whether increasing the dose is right for you.

"In general, the newer antihistamines, especially the over-the-counter non-sedating ones, are considered safe, but we do have to be careful," said Jonathan Silverberg, MD, PhD, of George Washington University School of Medicine and Health Sciences in Washington, D.C.

"You need to be judicious about the use of antihistamines and the dose during pregnancy," agreed Jenny Murase, MD, of the University of California, San Francisco, and director of Medical Dermatology Consultative Services and Patch Testing for the Palo Alto Foundation Medical Group. The smallest dose needed to control hives symptoms should be used during pregnancy, especially during the first trimester, she added.

Older, first-generation antihistamines, however, which have a marked sedative effect, should not be used during pregnancy or while breastfeeding. These drugs include chlorpheniramine (Chlor-Trimeton), dimenhydrinate (Dramamine), cyproheptadine (Periactin), tripelennamine (Pyribenzamine), dexchlorpheniramine (Polaramine), hydroxyzine (Vistaril), diphenhydramine (Benadryl), and clemastine (Tavegyl).

Although both first- and second-generation antihistamines pass into breast milk in low concentrations, the older antihistamines can cause sedation in nursing infants. They also interact with alcohol and other drugs, including pain medications, and can interfere with sleep and impair driving ability.

If the standard dose of a non-sedating second-generation antihistamine doesn't control hives symptoms, the addition of omalizumab (Xolair), an injectable medication classified as a "biologic," is recommended.

Should hives symptoms persist beyond these treatments, the pros and cons of other drug therapies, such as cyclosporine or a short course of oral corticosteroids should be discussed with your doctor so you can make an informed decision. These treatments may be helpful for relieving symptoms of redness and itching in the short-term.

However, the use of cyclosporine during pregnancy is associated with an increased risk of high blood pressure or preeclampsia, premature delivery, and low birth weight. The use of corticosteroids is also associated with side effects. Since corticosteroids pass into breast milk, however, you may need to stop nursing your infant during treatment.

Finally, a word about pruritic urticarial papules and plaques of pregnancy or "PUPPP," which are similar to hives, but typically if they occur, show up mostly during the third trimester of pregnancy.

PUPPP is linked to maternal weight gain, and is most often seen in women during their first pregnancy or in those carrying multiple fetuses. The good news: PUPPP doesn't pose a risk to either mother or child and usually disappears 1-2 weeks after delivery.

Additional Resources:

Read previous installments in this series:

For Your Patients: All About Hives

For Your Patients: Understanding the Many Different Types of Hives

For Your Patients: How Will My Doctor Diagnose Hives?

For Your Patients: What's the Best Treatment for Hives?

For Your Patients: Is Stress Causing My Hives?

"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.