Pruritus affects upto 20% of pregnant women. There are conditions unique to pregnancy that involve pruritus as a leading symptom. This is called dermotoses of pregnancy. May produce risk to mother and foetus. Approach to skin lesions in pregnancy: Pruritus related to pregnancy, Pruritus not related to pregnancy

1. Prof. Rokeya Begum
DIRECTOR
Surgiscope Fertility Centre
Laparoscopic & Hysteroscopic Surgeon
Pruritus in
pregnancy

2. Pruritus affects upto 20% of pregnant women.
May produce risk to
mother and foetus.

3. Pruritus related to pregnancy
Pruritus not related to pregnancy
Approach to skin lesions in pregnancy

4. There are conditions unique to
pregnancy that involve
pruritus as a leading symptom.
This is called dermotoses of
pregnancy.

5. Dermatoses of pregnancy
1. Intrahepatic cholestasis of
pregnancy/obstetric cholestasis(ICP).
2. Pemphigoid gestationis(PG).
3. Pruritic urticarial papules and plaques of
pregnancy(PUPPP).
4. Atopic eruption of pregnancy.

6. Pregnancy Related
• Atopic eruption of pregnancy
• Pruritic urticarial papules and
plaques of pregnancy (PUPPP)
• Pemphigoid gestationis
Unrelated to pregnancy
• Scabies
• Urticaria
• Drug eruptions
• allergy
Rash
• Obstetric Cholestasis
• Exacerbation of underlying
liver disease
No Rash
Approach to Pruritus

7. PUPPP
Pruritic urticarial papules and
plaques of pregnancy (PUPPP)
 Syn: PUPPP(4%)
 Papules within the striae
 Umbilical sparing
 Self limiting
 More common in primid.3rd
trimester
 Good prognosis
 M:F.3:1
 No recurrence

8. Atopic Eruption in Pregnancy
(AEP)
• Most common skin
condition (50%)
• Prurigo,pruritic folliculitis
in pregnancy
• Ig E levels
• Good prognosis,recurrence
50%
• Corticosteroids +
antihistamines
AEP

9. Phemphigoid Gestationis
(PG)
• Herpes gestationis
• Autoimmune (3%),2nd/3rd
trimester
• Skin biopsy for confirmation
• Flare at time delivery and post
partum
• Steroids & antihistamines
• IUGR,preterm
• 10%-cutaneous involve of
newborn
• Post partum flare,recurrence
PG

10. ICP

11. PUPPP
Prurutic lesions
wiithin striae-
progress to papules
Periumbilical
sparing
PG
Popules & plaques
abdomen
(umbilical)
Progress to
blisters
AEP
Common,develops
early ,History of
atopy,Eczematous
or papular lesions-
trunks
OC
Pruritis,no rash
Pregnancy Specific Dermatological Condition

12.  Fever
 Maculopapular
rash
 Cephalocaudal
Dengue

13. Contact dermatitis
Atopic dermatitis
Drug induced
Urticaria/
Dermographism
Dermographism

14. Appropriate doses of LMWH
Use booking weight
Iatrogenic

15. Erythematous
papules and
plaques with a
silver scale
40-60%
improve in
pregnancy
Psoriasis

16. Intrahepatic cholestasis of
pregnancy/obstetric cholestasis
This is a multifactorial condition of
pregnancy characterized by pruritus in
the absence of a skin rash with abnormal
liver function tests and both resolve after
birth.

17. Incidence
* Unique to pregnancy
* In UK 0.7 of all pregnant women.
* Worldwide 0.2-2%

18. Risk factors
 Asian
 Multifetal pregnancy
 Invitro fertilization
 Older women
 H/O gall stone
 Hepatitis C infection.
 Sisters of affected women.

19. Pathogenesis

20. Bile acid
Synthesis in hepatocyte from cholesterol
Cholic acid
Cholesterol
Chenodeoxy cholic acid
Glycocholic acid
Taurocholic acid
Emulsification of fat and fat
soluble vitamin
Glycocheno
deoxycholic acid
Taurocheno
deoxycholic acid
Lithocholic acid
Entero hepatic
Circular 95%
Deconjugation by
Bacteria
Secondary bile acid
Deoxycholic acid
Primary bile acid

21. Bile acid homeostasis
Bile acid are inherently toxic –
homeostasis is highly
regulated by gene encode a
receptor known as Farnesoid X
receptor(FXR)
Receptor
- down regulation of
synthesis
- uptake of bile acid
- upregulation of export.

22. Bile acid homeostasis is
disturbed in intrahepatic
cholestasis of pregnancy.

23. Sulfated progesterone metabolites are
partial agonists for FXR

Inhibiting the induction of its target genes.

Inhibit hepatic uptake of bile acid.

Efflux of bile acid
Reproductive hormone

24. Oestrogen
Reducing the expression and function of
several bile acid transport protein in the
liver including –
a)Bile acid efflux protein.
b) Bile salt export pump (BSEP)

25. Environmental factors
 Low Selenium intake
 Low Vit D
 Hepatitis C infection

26. Defect in excretion of
bile acid resulting
elevated bile acid level
in serum.

27. Symptoms
1. Second or Third trimester.
2. Sudden onset.
3. Severe pruritus.
4. Starts on palms and soles quickly generalised.
5. Pruritus persists throughout pregnancy and is worst at night.
6. Sleep disturbances
7. Constitutional symptoms of cholestasis-
a) dark urine
b) pale stool
c) right upper quadrant pain.
d) Jaundice is rare (<10% of pregnancy)

28. Diagnosis
1. Pruritus starting from palms and soles without rash.
2. Confirmed by measuring serum bile acid.
Normal level- up to 11 µmol/L
3. Alanine amino transferase and Aspartate amino
transferase – level increase

29. Bile acid measurement cannot done in Bangladesh.
Diagnosis based on-
a) Typical pruritus
b) Abnormal live function tests
c) Resolve after delivery-6 weeks.
4.Alkaline phosphatase
5. Gamma glutamyl transferase raised in 20%
6. bilirubin –raised in 10%

30. Other investigations
a) USG of liver to exclude gall stone. 13%
b) Gestational diabetes and hepatitis c virus has to be
excluded.
c) Coagulation profile
d) PET and acute fatty live.

31. Non pregnancy associated causes
of abnormal liver function tests-
May present for the first time in
pregnancy.
Viral hepatitis
Antoimmune hepatitis
Biliary obstruction
Drug induced live injury
Primary biliary cirohosis.

32. Suspected case
1. Viral marker – Hepatitis A, B, C, E CMV EBV
2. Auto anibody –
i. Anti smooth muscle antibody-chronic active
hepatitis
ii. Anti mitochondrial antibody – primary biliary
cirrhosis.

33. Perinatal outcome
1. Preterm birth-
- Spontaneous
- Iatrogenic
2. Meconium staining of amniotic fluid
3. Foetal distress
4. Sudden IUD

34. Preterm birth
Obstetricians should be aware (and should advise women) that
the incidence of premature birth, especially iatrogenic, is
increased.
Spontaneous
preterm birth
(range 4-12%)
Iatrogenic
preterm birth
(range 7–25%)

35. Cirlulating bile acid
Increase gut motility
Meconium stain liquor
Mechanism

36. Increase myometrial
contractilily and enhanced
sensitivity to oxytocin
Preterm labour

37. Bile acid
Particularly taurocholic acid
Toxic to cardiomyocytic cell
Cardiac arrhythmias
Death

38. Marked
Vasoconstriction in the
placental chorionic
veins causing event
resulting foetal death.

39. Management
1. Counselling - Risk to the foetus
2. Surveillance
-liver function test-
- Prothrombin time
- bile acid weekly

40. 3. Foetal well being
- CTG
- USG
- growth
- liquor volume
- umbilical artery doppler
blood flow.

41. 4. Pharmacological treatment-
a) Topical emollients
- calamine lotion and aqueous cream with
menthol.
b) Antihistamines-
- Chlorpheniramine (piriton 4mg TDS)
- Promathazine (phanergan) 25mg at night

42. Topical emollients
(calamine lotion and aqueous
cream with menthol).
Safe
but their efficacy
is unknown

43. c) Ursodeoxycholic acid (UDCA)
- Naturally occuring hydrophilic bile
acid.
- Improves pruritus and liver function.
- Lack of robust data concerning
protection against still birth and safety
to the foetus and neonate.

44. Doses
1000-1500mg/day in 2 to 3
divided doses.

45. Rifampicin – choleretic antibiotic
Improves symptoms

46. • Enhance bile acid detoxification as
well as bilirubin conjugation
by combination of rifampicin and
UDCA
• Reduce pruritus and enhance bile acid
excretion

47. Dexa methasone
* 10mg orally for 7 days and then stopping
over 3 days.
* The general concern about adverse foetal
and neonatal neurological effects of repeated
course of maternally administered dexa
methasone limit the potential use of
dexamethasone.

48. Vitamin K
• Increase fat excretion affects the
absorption of fat soluble vitamin includes
vitamin-K
• Prothrombin time is prolonged.
Water soluble formulation of vitamin K
10mg/day/orally start at 34 weeks of
pregnancy or at the time of diagnosis

49. Strategy for delivery
Elective early delivery was offered at 37-38
weeks of gestation. Severe ICP i,e total
serum bile acid level of more than 40 µmol/L
or high transaminase level

50. Mode of delivery
• Spontaneous
• Induction of labour result
in an increase rate of
emergency C/S.

51. Maternal morbidity
• Intense pruritus and Consequent sleep deprivation.
• Increase Rate Of CS.
• Increase Risk Of PPH.
• If cholestasis lasts for several wks, liver dysfunction may result in:
- Decreased vitamin K re-absorption or
-Decreased prothrombin production, leading
to a prolongation of the prothrombin time.

52. Postnatal followup
Symptoms and biochemical abnormalities resolve
rapidly following delivery.
LFTS checked 6 weekly after delivery.
Elevated level -referred to hepatologist.

53. - Recurrent in next pregnancy
- Exposure to reproductive
hormone like pill.

55. Take a good history
Systematically approach obstetric & non obstetric causes (autoimmune)
Common causes are AEP & PUPP
Pruritus is common,may precede abnormal LFT
If unsure-skin biopsy (HPE & direct immunofluorence)
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Take home message