вход по аккаунту


Pruritus in Pregnancy - Family Medicine Resident Presentations

код для вставкиСкачать
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
• 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
• Risk factors: hepatitis C virus associated with
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 пѓ 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
– 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 пѓ worsening coagulopathy
• Recurrence in subsequent pregnancies:
пѓ 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
• May last for weeks to months after delivery
with variable recurrence in subsequent
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
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
• Synonyms:
– gestational pemphigoid
– Herpes gestationis
Pathophysiology of PG
• Production of autoantibody with potential
crossreactivity between placental tissue &
• 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
Pemphigoid Gestationis
Treatment of PG
• Suppressing blister formation and relieving
• Prednisone, 20-40mg/d, higher doses may be
required, tapering to lowest effective dose.
• Refractive cases: cyclophosphamide, pyridoxine,
dapsone, cyclosprine, gold, methotrexate, and
• No available controlled trials
• Follow up: risk for development of Grave’s dz.
• 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 ICPпѓ bile acids.
• If pemphigoid gestationis is suspected, skin
biopsies are needed.
– Antepartum fetal monitoring may be indicated.
• Goal of treatment otherwise is symptom
• 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.
• “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
Размер файла
582 Кб
Пожаловаться на содержимое документа