Chapter 21: Cutaneous Findings Related to Pregnancy

COMMON SKIN CHANGES RELATED TO PREGNANCY

• Hyperpigmentation of nipples, external genitalia

• Linea nigra: midline pigmentary demarcation line on abdomen

• Melasma: ill-defined pigmentation of cheeks, forehead

• Striae: start reddish, become whitish, redness may be improved faster by pulsed dye laser, but otherwise that and other treatments unproven to have long-term benefit

• Vascular lesions: varicosities, pyogenic granuloma

• Increased or changing nevi, melanoma: unclear if truly increased over controls

• Telogen effluvium typically starts 3 months after delivery

PRURITUS GRAVIDARUM

• This is itching without rash (up to 14% of all pregnancies)

• Potential intrahepatic cholestasis of pregnancy should be investigated in these patients, but this occurs in only 1 to 2% of all pregnancies, clinical jaundice in only 0.02% of pregnancies

• Elevated liver function tests and serum bile acid levels may occur

• Elevated glutathione S-transferase alpha (GSTA), a specific marker of hepatocellular integrity, identifies women with intrahepatic cholestasis and distinguishes them from those with benign pruritus gravidarum

• Reported increases in rates of premature delivery and perinatal mortality appear to be restricted to those in whom frank clinical jaundice develops

• Recurs in 50% of pregnancies

• Treatment: phenobarbital, cholestyramine, (ursodeoxycholic acid controversial but advocated by some)

PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY (PUPPP), POLYMORPHOUS ERUPTION OF PREGNANCY (PEP)

• The term PUPPP seems to be preferred in the United States and PEP in Europe (FIG. 21-1)

• Polymorphous eruption with papules, plaques, urticarial lesions

• The most common of the pregnancy rashes (0.6% of all pregnancies)

• Onset in abdominal striae is common, then commonly spreads to abdomen, buttocks, thighs

• Spongiosis may occur and cause confusion with pemphigoid gestationis, then immunofluorescence biopsy may be needed, since pemphigoid gestationis possibly may cause increased fetal morbidity or mortality, unlike PUPPP

• Intensely pruritic, like most of these pregnancy rashes

• Primagravids mostly, does not recur with subsequent pregnancies

• Increased incidence of twins, rapid maternal weight gain

• Usually third trimester

• Biopsy not very specific: perivascular lymphocytes with eosinophils, edema, sometimes with spongiosis or parakeratosis

PEMPHIGOID GESTATIONIS (HERPES GESTATIONIS)

• The term pemphigoid gestationis is preferred by many because "herpes gestationis" causes confusion with herpes virus infection and its implications (FIG. 21-2)

• Onset second or third trimester

• Papules, urticarial plaques, vesicles, bullae

• Often develops around umbilicus and extremities, later spreading to trunk, palms, and soles. Usually spares face and mucous membranes

• Autoimmune disease similar to bullous pemphigoid (but linear C3 more often seen at dermal-epidermal junction zone than IgG). In both diseases the linear band is found in the epidermal side (roof) of the subepidermal blister

• Increased HLA-DR3, DR4, B8

• Circulating IgG4 autoantibodies in the blood are called herpes gestationis factor, ...