Pruritis in pregnancy

1. PRURITIS IN PREGNANCY
PREPARED BY-
Ankit mandal
INTERN
MODERATOR
Dr. Indra yadav
Department of obstetrics and gynaecology
KU-BMCTH

2. PRURITIS RELATED TO PREGNANCY
• Intrahepatic cholestasis of pregnancy /obstetric
cholestasis (ICP)
• Pruritic urticarial papules and plaques of
pregnancy(PUPPP)
• Atopic eruption of pregnancy
• Pemphigoid gestations

3. Unrelated to pregnancy
• Scabies
• Urticaria
• Drug eruptions
• Allergy
• Psoriasis
• Insect bites

5. INTRAHEPATIC CHOLESTASIS OF
PREGNANCY/OBSTETRIC CHOLESTASIS
• Incidence ranges from o.1% to 15.6% in South
Asia.
• No primary skin lesion
• characterized by pruritus, icterus in the absence
of a skin rash
• Resolve after child birth

6. ETIOPATHOGENESIS

7. • Exact Cause is unknown
• Estrogen impairs the synthesis, metabolism, transport of bile
acids, causing downsteam dysfunction of bile acids
homeostasis.
• Progesteron causes inhibition of cholecystokinin mediated
action on Gallbladder
• Decreased contractility of gallbladder leads to bile stasis.
• Bile pigments binds in subcutaneous layer, irritates the nerve
ending

8. • Genetic mutation of hepatocellular transport system eg-
mutation of ABCB4 gene assosciated with progressive
familial intrahepatic cholestasis
• Bile acids are cleared incompletely and accumulate in
plasma .
• Increase myometrial contractilily and enhanced sensitivity
to oxytocin- Preterm labour

9. • Marked Vasoconstriction in the
placental chorionic veins resulting
foetal death.
• Particularly taurocholic acid, toxic to
cardiomyocytic cell leads to cardiac
arrhythmias- Death

10. CLINICAL PRESENTATION
• Pruritis develops in late pregnancy, sudden in onset
• Starts on palms and soles later generalised
• Sleep disturbances, pruritis worse at night
• Skin changes- excoriation from scratching
• Jaundice is rare
• LFT may dearrange after several weeks of development of pruritis.

11. • Hyperbilirubinemia results from retention of conjugated
pigment , but total plasma concentration rarely exceeds 4 to 5
mg/dl.
• Mild : bile acids > 14mmol/L
• Moderate : bile acids > 40mmol/L
• Severe : bile acids > 100mmol/L
• Increasing fetal risks are directly associated with increasing
maternal serum bile acids (Glantz et al, 2004).
• Alkaline phosphatase - elevated more than in normal
pregnancy.
Investigations

12. DISORDER ONSET AST(IU/L) BILIRUBIN
(MG/DL)
PT
CHOLESTASIS LATE NL-200 1-5 NL
FATTY LIVER LATE 200-800 4-10 ↑
PREECLAMPSIA MID-LATE NL-300 1-4 NL
HEPATITIS VARIABLE 2000+ 5-20 ↑↑

13. • Serum Aminotransferase are normal to moderately elevated but
seldom exceeds 4 to 5 mg/dl.
• Sonography done to exclude cholelithiasis and billiary
obstruction.
• No altered blood pressure or proteinurea rule out preeclamptic
liver disease .
• Low serum aminotransferase levels with cholestasis rule out
acute viral hepatitis.

14. MANAGEMENT
• Counseling - Risk to the foetus
• Surveillance -liver function test
-Prothrombin time
• Foetal wellbeing - Cardiaotocography
- USG - growth , liquor volume,
umbilical artery doppler blood flow

15. PHARMACOLOGICAL TREATMENT
a) Topical emollients –
calamine lotion .
b) Antihistamines - Chlorpheniramine 4mg TDS)
Promathazine (phanergan) 25mg at night
• Cholestyramine is effective but it causes decreased
absorption of fat soluble vitamins.

16. • Ursodeoxycholic acid is effective for both pruritis and
feotal outcome -ACOG
• Ursodeoxycholic Acid (UDCA) can reduce serum bile
acids and helps relieve pruritus.
• Starting dose: Ursodeoxycholic Acid 300mg TDS
Maximum dose: Ursodeoxycholic Acid 600mg QDS
Orally
• Increase UDCA weekly following blood tests (LFTs, bile
acids) if bile acids not responding OR >40mmol/L.

17. • Rifampicin can be added when UDCA is at maximum
dose and patient is not responding (bile acids >
40mmol/L despite UDCA).
• Do not start if ALT >200IU/L.
• Works synergistically with UDCA to help reduce serum
bile acid levels – UDCA must therefore be continued
• Due to limited evidence for use, rifampicin is
considered a last line agent for the management of
refractory cases of obstetric cholestasis.

18. CHOLESTASIS AND PREGNANCY
OUTCOMES-
• Neonatal complication occurred in 1/3rd of pregnancies -
i.e respiratory distress, fetal distress, meconium stained
liquor.
• Abnormal amount of bile acids may cause fetal cardiac
arrest
-Gorelik and collegue

19. • Perinatal mortality rates were slightly increased but
infant death was limited to mother having total bile acid
level ≥40 µmol/L.
- Glantz and collegues
• Delivery by labour induction to avoid stillbirth.
• Advise active management of 3rd stage of labour due to
higher risk of postpartum haemorrhage.
• Elective early delivery was offered at 37-38 weeks of
gestation

20. POSTNATAL MANAGEMENT
• Intramuscular Vitamin K is recommended for neonates.
• LFTs and bile acids checked in 6 weeks at her postnatal check
up.
• Counselling patient, itching should resolve, and bile acids
and LFTs should return to normal within 6 weeks.
•
• Use of oestrogen-containing contraception pill may result in
recurrence of cholestasis.

21. • Recurrence risk of 45-90% in subsequent pregnancies, and the
increased incidence of 35% in family members (Geenes, 2014;
RCOG, 2011).
• Decreased prothrombin production, leading to a prolongation of
the prothrombin time.
• Increase Rate Of Cesarean section.
• Increase Risk Of PPH

22. THANKYOU

23. PRURITIC URTICARIAL PAPULES
AND PLAQUES OF PREGNANCY
(PUPPP)

24. PRURITIC URTICARIAL PAPULES AND
PLAQUES OF PREGNANCY (PUPPP)
• Intensly pruritic 1-2 mm erythematous Papules within the
striae
• Appears late in pregnancy
• Lesion initially form within striae but show Umbilical
sparing
• Self limiting , usually respond to oral antihistaminic, skin
emollients, topical steroids
• Good prognosis resolves after delivery without scarring.
• No recurrence

25. PHEMPHIGOID GESTATIONIS (PG)

26. PHEMPHIGOID GESTATIONIS (PG)
• Autoimmune (3%), occurs in1st pregnancy in 2nd/3rd
trimester
• Initially ,pruritic papules and urtricarial plaques followed
by vesicles and bulla
• Result of primary reaction between maternal IgG
directed against collagen xvii of basement membrane of
skin and amniotic epithelium

27. • Flare at time delivery and post partum
• Skin biopsy and serum Antibody assay for
confirmation
• Steroids & antihistamines
• IUGR, preterm
• 10%-cutaneous involve of newborn
• Post partum flare,
• Recurrence

28. ATOPIC ERUPTION OF GESTATION

29. ATOPIC ERUPTION OF GESTATION
• It comprises three condition;-
-Eczema in pregnancy: dry , thickened ,scaly red patches
involving flexor extremities
-Prurigo of pregnancy:5-10mm itchy,erythematous
papules found on extensor surface and trunk
-Pruritic folliculitis of pregnancy: small, erythematous
follicular papules

30. • All lesion resolve after delivery
• Diagnosis by exclusion
• Good prognosis,
• Low or moderate potent Corticosteroids +
antihistaminics

31. RCOG-
2022

32. TAKE HOME MESSAGE
• Good history taking is important to
rule out other causes of pruritis
• Systemic approach to include both
obstetric and non-obstetric causes
• Pruritis is common, may precede
abnormal LFT.

33. THANK-YOU

34. REFERENCES
• 25th edition Wiliams obstetrics , Mc Graw Hill
Publication.
• Zu Y, Yang J, Zhang C and Liu D (2021) The
Pathological Mechanisms of Estrogen-Induced
Cholestasis: Current Perspectives. Front. Pharmacol.
• RCOG Guideline 2022
• ACOG Guideline
• Google images