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Skin Diseases in Pregnancy

  • Normal skin changes associated with pregnancy are darkening of linea alba (linea nigra), melasma (see Section 13), and striae distensae (Fig. 15-1).

  • Pruritus occurring in pregnancy may be due to a flare of preexisting dermatosis or a pregnancy-specific dermatosis.

  • Pregnancy-specific dermatoses associated with fetal risk are cholestasis in pregnancy, pustular psoriasis of pregnancy (impetigo herpetiformis), and pemphigoid gestationis.

  • Pregnancy-specific dermatoses not associated with fetal risk are polymorphic eruption of pregnancy and prurigo gestationis.

  • An algorithm of an approach to a pregnant patient with a pruritus is shown in Fig. 15-2.

Figure 15-1.

Striae distensae in a pregnant woman (36 weeks of gestation).

Figure 15-2.

Algorithm of approach to a pregnant patient with pruritus. AEP, atopic eruption of pregnancy; PEP, polymorphic eruption of pregnancy; PG, pemphigoid gestationis; CP, cholestasis of pregnancy.

Cholestasis of Pregnancy (CP)

ICD-9: 646.7 ○ ICD-10: K83.1 Image not available.

  • Occurs in the third trimester.

  • Leading symptoms: pruritus, either localized (palms) or generalized. Most severe during the night.

  • Cutaneous lesions invariably absent, but excoriations in severe cases.

  • Elevation of serum bile acids.

  • Fetal risks include prematurity, intrapartal distress, and fetal death.

  • Treatment: ursodeoxycholic acid, plasmapheresis.

Pemphigoid Gestationis

ICD-9: 646.8 ○ ICD-10: O26.4 Image not available.

  • Pemphigoid gestationis is a pruritic polymorphic inflammatory dermatosis of pregnancy and the postpartum period. It is an autoimmune process with circulating complement-fixing IgG antibodies in the serum. The condition is described in Section 6.

Polymorphic Eruption of Pregnancy (PEP)

ICD-9: 709.8 ○ ICD-10: 99.740 Image not available.

  • PEP is a distinct pruritic eruption of pregnancy that usually begins in the third trimester, most often in primigravidae (76%). Common, estimated to be 1 in 120–240 pregnancies.

  • There is no increased risk of fetal morbidity or mortality.

  • The etiology and pathogenesis are not understood.

  • Average time of onset is 36 weeks of gestation, usually 1–2 weeks before delivery. However, symptoms and signs can start in the postpartum period.

  • Severe pruritus develops on the abdomen, often in the striae distensae. Skin lesions consist of erythematous papules, 1–3 mm, quickly coalescing into urticarial plaques (Fig. 15-3) with polycyclic shape and arrangement; blanched halos around the periphery of lesions. Target lesions. Tiny vesicles, 2 mm, but bullae are absent. Although pruritus is the chief symptom, excoriations are infrequent. Affected are the abdomen, buttocks, thighs (Fig. 15-3), upper inner arms, and lower back.

  • The face, breasts, palms, and soles are rarely involved. The periumbilical area is usually spared. There are no mucous membrane lesions.

  • Differential diagnosis includes all pruritic abdominal rashes in pregnancy (Fig. 15-2), drug reaction, allergic contact dermatitis, and metabolic pruritus.

  • Laboratory findings...

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