Pruritic Skin Lesions in Pregnancy

Prurigo in Pregnancy

26 y/o G1P0 at 28 WGA with h/o atopy presents with erythematous papules and nodules on extensor surfaces of the extremities.

• Obtain CMP, total/direct bilirubin, bile acid level, and prothrombin time to rule out alternative etiologies

• Hydrocortisone valerate 0.2% ointment (group 4 corticosteroid) and loratadine 10 mg daily for symptom control

• Pt counseled that condition does not adversely affect pregnancy outcome

Polymorphic Eruption of Pregnancy (Previously PUPPP)

26 y/o G1P0 at 28+ WGA presents with intensely pruritic rash. Rash first appeared on abdomen along striae lines. Urticarial plaques and papules present on exam.

• Obtain CMP, total/direct bilirubin, bile acid level, and prothrombin time to rule out alternative etiologies

• Consider lesion biopsy if concerned for pemphigoid gestationis or pustular psoriasis

• Hydrocortisone valerate 0.2% ointment (group 4 corticosteroid) and loratadine 10 mg daily for symptom control

• Patient counseled that condition does not adversely affect pregnancy outcome

Intrahepatic Cholestasis of Pregnancy

26 y/o G1P0 at 28 WGA with h/o gallstones presents with pruritus. Pruritus is worse at night and most severely affects the palms and soles. Jaundice, excoriations, and prurigo nodules on exam.

• Labs

  • Obtain CMP, total/direct bilirubin, prothrombin time

  • Serum bile acid levels > 16 mcg/mL indicate increased risk for adverse fetal outcomes

• Medications

  • Start loratadine 10 mg daily for pruritus

  • Consider ursodiol [Actigall] 300 mg BID for

• Consults

  • Refer to Maternal Fetal Medicine for evaluation

  • 34 WGA: Start twice weekly monitoring with NST on Mondays and and modified BPP (NST + single deepest pocket) on Thursdays

  • Schedule for induction of labor at 37 WGA

• Patient counseled that

  • Condition increases risk for premature delivery and intrauterine fetal demise

  • Pruritus generally resolves after delivery

  • Liver function will be retested 6-8 weeks after delivery

Notes

• Rare condition

• Onset is generally occurs during the second or third trimester

• The rash present is secondary to excoriation and not associated with increased bile acid levels