Pruritus in Pregnancy Carol Mendez, MD Albert Einstein College of Medicine Montefiore Medical Center Department of Family and Social Medicine April 29, 2010 Pruritus in Pregnancy • Normal skin changes: linea nigra, melasma, striae distensae. • Unrelated to pregnancy: flare of preexisting dermatosis • Without rash – Intrahepatic cholestasis of pregnancy • With rash – Related to pregnancy • Early onset, trunk & limbs involved: atopic eruption • Late onset, predominant abdominal involvement – Polymorphic eruption of pregnancy – Pemphigoid gestationis Intrahepatic Cholestasis of Pregnancy • Occurs in 3rd TM • Incidence 1 in 100 to 150 pregnancies, #2 cause of jaundice in pregnancy • Pruritus without primary lesions • Only secondary excoriations/prurigo nodularis • Elevated total serum bile acid levels • Prematurity, fetal distress, stillbirths • Spontaneous resolution after delivery • Synonym: pruritus gravidarum Causes and Pathogenesis • Unclear • Probably increased hepatic sensitivity to estrogen • Risk factors: hepatitis C virus associated with ICP Clinical Picture-ICP • Symptoms are worst at night • Trunk, Palms and Soles • Jaundice, clay colored stools, dark urine – 20%-50% of patients • Steatorrhea can lead to vit. K malabsorption and prolongation of PT risk of hemorrhage. • LAB: mild-moderate elevation of transaminases, marked elevation in alkaline phosphatase • Bile acid levels 10-100x normal Fetal risks with ICP • Distress, still birth and preterm delivery • Neonatal respiratory distress syndrome • Placental anoxia from vasoconstriction of placental chorionic veins from toxic bile acids and meconium. • Can be reduced by tx and delivery b/t 36-38 weeks with favorable lung maturity and cervix. Treatment of ICP • Mild: symptom relief with emollients and topical antipruritics. – Systemic antihistamines are not useful – Ursodeoxycholic acid (UDCA)-naturally occuring hydrophilic bile acid that enhances excretion of hydrophobic bile acids, other hepatotoxic compounds, and sulfated progesterone metabolites. • Controls pruritus and serologic abnormalities • Works faster than cholestyramine, safe for mother and fetus • May result in decreased fetal mortality associated with ICP – Plasmapheresis – Cholestyramine may be effective up to 50% • May precipitate vit K worsening coagulopathy Prognosis • Recurrence in subsequent pregnancies: 60% to 70% • Use of oral contraceptives • Resolves within the first month after delivery Early onset-trunk and limbs involved Atopic Eruption of Pregnancy • • • • • Very common, incidence 1 in 300 to 450 20% exacerbated atopic dermatitis 80% firm manifestation Lab: elevated IgE levels No maternal or fetal risk Cause of AEP • Unknown • Reported cases of increased IgE • Cholestasis Clinical Course-AEP • Onset during 2nd and 3rd TM • Discrete, excoriated papules, predominnately on extensor surfaces and occasionally on abdomen. • May last for weeks to months after delivery with variable recurrence in subsequent pregnancies. Treatment of AEP • Topical corticosteroids • Ultraviolet B light therapy • Benzoyl Peroxide Late onset-3rd TM Predominant Abdominal Involvement • Polymorphic Eruption of Pregnancy (Pruritic Urticarial Papules and Plaques of Pregnancy) – Abdominal striae sparing umbilicus – No fetal risk • Pemphigoid Gestationis – Vesiculo-bullous eruption on urticated erythema – Periumbilical involvement – Small for dates babies Polymorphic Eruption of Pregnancy (PUPPP) • • • • • • • Papular urticarial eruption Mostly in primiparous women Begins within abd. striae, sparing umbilicus Resolves spontaneously & rapidly postpartum No maternal or fetal risk Rarely recurs Incidence is 1 in 120 to 240 pregnancies Causes of PEP/PUPPP • Association with multiple gestation • Rapid, late stretching of abdominal skin Clinical presentation- PEP • Late 3rd TM and immediate postpartum period • Intensely pruritic erythematous papules, 1-3 mm, quickly coalescing into urticarial plaques. • Tiny vesicles, 2mm, may occur in the plaques, but bullae are absent. • Begin in abd. striae and spread in days to abdomen, buttocks, thighs, upper inner arms, and lower back. • Spearing periumbilical area, face, breasts, palms, and soles. No mucus membrane lesions. PUPP Striae Treatment of PEP/PUPPP • Potent topical corticosteroids, tapered off after 1 week of therapy. • Severe cases: prednisone 10-40mg/d • Oral antihistamines generally ineffective. • Resolution 7-10 days after delivery • Majority of women don’t have a recurrence. Pemphigoid Gestationis • Incidence is 1 in 50,000 • Intensely pruritic vesiculobullous eruptions on urticated erythema with periumbilical involvement • Late 3rd TM or immediate postpartum period. • Lesions begin within or adjacent to umbilicus. • Increased risk of small for gestational age births, risk of prematurity and 5% of babies have urticarial, vesicular, or bullous lesions-resolve spontaneously. • Dx: 2 skin biopsies for histology and direct immunofluorescence • Synonyms: – gestational pemphigoid – Herpes gestationis Pathophysiology of PG • Production of autoantibody with potential crossreactivity between placental tissue & skin. • 100% incidence of anti-human leukocyte antigen (HLA) antibodies • Subepidermal blisters on H&E stain • Immunofluorescence microscopy: linear C3 depositions along dermal-epidermal junction Clinical Course-PG • Abrupt onset of intensely pruritic urticarial lesions on the trunk progressing in generalized fashion spreading along face, mucous membranes, palms, and soles. • A flare at delivery in 75% of cases. • Recurs with subsequent pregnancies, menstruation, and use of oral contraceptive. • Complete resolution in weeks to months postpartum. Pemphigoid Gestationis Treatment of PG • Suppressing blister formation and relieving pruritus. • Prednisone, 20-40mg/d, higher doses may be required, tapering to lowest effective dose. • Refractive cases: cyclophosphamide, pyridoxine, dapsone, cyclosprine, gold, methotrexate, and plasmapheresis. • No available controlled trials • Follow up: risk for development of Grave’s dz. Conclusion • Pruritus in pregnancy can be due to a flare of conditions before conception or related to pregnancy specific dermatoses. • Generalized pruritus without a rash should prompt an evaluation for ICPbile acids. • If pemphigoid gestationis is suspected, skin biopsies are needed. – Antepartum fetal monitoring may be indicated. • Goal of treatment otherwise is symptom relief. Reference • Olin, Stephen T. “Dermatoses of Pregnancy.” Family Medicine Obstetrics. Ed. Stephen D. Ratcliffe, et al. 3rd ed. Philadelphia, PA: Mosby Elsevier, 2008. 317-321. Print. • Woff, Klaus and Richard Allen Johnson. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. New York: McGraw Hill, 2009. Print. • “Cholestasis of Pregnancy.” DynaMed. 01 Mar. 2010. Web 24 Apr. 2010 • Pictures are from UpToDate online 18.1, “Dermatoses of Pregnancy”. Web 29 Apr. 2010