Anaphylaxis in pregnancy: diagnostic blind spots, epinephrine hesitancy, and emerging prevention strategies

Anaphylaxis during pregnancy is uncommon but remains one of the most critical emergencies in obstetric medicine because maternal deterioration and fetal hypoxia evolve simultaneously. Despite established treatment recommendations, diagnostic uncertainty and persistent concerns regarding epinephrine use continue to contribute to jeopardize preventable morbidity/mortality. This review examines recent advances in the recognition, management, and prevention of pregnancy-associated anaphylaxis, with emphasis on emerging concepts that may improve maternal-fetal safety.

Physiological pregnancy-related cardiovascular and respiratory adaptations can obscure classic manifestations of anaphylaxis, creating important diagnostic blind spots and increasing the risk of delayed recognition. Growing evidence indicates that maternal hypotension and hypoxemia represent the main threats to fetal wellbeing. Epinephrine hesitancy remains common in clinical practice. New insights into mast cell disorders, hereditary alpha-tryptasemia, and MRGPRX2-mediated reactions are refining risk stratification and expanding understanding of severe and perioperative anaphylaxis. Recent epidemiological studies also highlight the predominance of drug-related and cesarean-associated triggers and support the implementation of multidisciplinary care pathways, allergy evaluation, and targeted prevention strategies.

Maternal anaphylaxis should be viewed as a time-critical obstetric emergency in which prompt recognition and immediate epinephrine administration are essential to optimize maternal and fetal outcomes. Future progress will depend on pregnancy-adapted diagnostic approaches, improved risk identification, systematic prevention efforts, and coordinated multidisciplinary management across obstetric, anesthetic, emergency, and allergy services.