105: Skin Changes in Pregnancy Flashcards
What are the most common pigmentary disturbances observed during pregnancy?
The most common pigmentary disturbances during pregnancy include hyperpigmentation, darkening of the linea alba, and melasma.
What is the most common structural change that occurs during pregnancy?
The most common structural change during pregnancy is striae distensae, also known as striae gravidarum or colloquially as stretch marks.
What are the strongest predictors of developing striae distensae during pregnancy?
The strongest predictors of developing striae distensae include:
1. Family history
2. Personal history
3. Race
What is the most common vascular lesion to develop during pregnancy?
The most common vascular lesion to develop during pregnancy is spider angiomas.
What should be done if a pigmented lesion in a pregnant woman undergoes changes in morphology or symptoms?
Any pigmented lesion in a pregnant woman that undergoes changes in morphology (size, color, or shape) or symptoms (begins to itch, bleed, or scale) should be considered for histopathologic review.
Is melasma reversible during pregnancy?
Melasma is generally considered reversible, while linea nigra often persists postpartum.
A pregnant woman presents with blotchy facial hyperpigmentation. What is the condition, and does it typically resolve postpartum?
The condition is melasma. It may regress postpartum, but it often persists.
What does pruritus during pregnancy indicate?
It may be physiologic or herald a flare of a preexisting dermatosis or onset of a specific dermatosis of pregnancy.
What are the clinical features of Pemphigoid Gestationis?
Pemphigoid Gestationis is characterized by:
- Intensely pruritic vesiculobullous eruption on the trunk and extremities.
- Begins during the second or third trimester.
What is the management approach for Pustular Psoriasis of Pregnancy?
Management includes:
1. Topical treatments such as wet dressings and corticosteroids (rarely effective alone).
2. NBUVB + topical steroids: successful in rare cases.
3. Systemic corticosteroids: previously the mainstay of therapy.
4. Cyclopsorine & Infliximab: now considered first-line therapy (Cyclopsorine 5-10 mg/kg daily).
5. Monitoring of fluid status and electrolytes is essential due to potential imbalances.
What are the potential complications associated with Pemphigoid Gestationis?
Pemphigoid Gestationis can lead to:
- Premature delivery and low birth weight (LBW).
- Maternal disease severity correlates with these outcomes.
What distinguishes Pustular Psoriasis of Pregnancy from Generalized Pustular Psoriasis?
Key distinctions include:
Pustular Psoriasis of Pregnancy
- Absence of positive family history
- Abrupt resolution at delivery
- Tendency to recur only during subsequent pregnancies
- Not triggered by infection or drug discontinuation
Generalized Pustular Psoriasis
- Positive family history possible
- Symptoms may persist or recur
- More frequent recurrences
- Can be triggered by infections or drugs
A pregnant patient presents with intensely pruritic urticarial lesions on erythematous skin during the second trimester. What is the most likely diagnosis, and what diagnostic test would confirm it?
The most likely diagnosis is Pemphigoid Gestationis (PG). The diagnostic test to confirm it is Direct Immunofluorescence (DIF), which shows linear deposition of C3 at the dermoepidermal junction.
A patient in her third trimester develops erythematous patches with subcorneal pustules originating in flexural areas. What is the diagnosis, and what is the cardinal feature of this condition?
The diagnosis is Pustular Psoriasis of Pregnancy. The cardinal feature is the rapid resolution of symptoms after delivery.
A patient with Pustular Psoriasis of Pregnancy is prescribed cyclosporine. What is the recommended dosage range for this medication?
The recommended dosage range for cyclosporine in Pustular Psoriasis of Pregnancy is 5-10 mg/kg daily.
A patient with Pemphigoid Gestationis (PG) undergoes DIF testing. What specific finding confirms the diagnosis?
DIF testing shows linear deposition of C3 at the dermoepidermal junction, which is pathognomonic for Pemphigoid Gestationis (PG).
A patient with Pustular Psoriasis of Pregnancy is treated with infliximab. What precaution should be taken for the newborn?
For the newborn, live vaccines should be delayed if the mother was treated with infliximab.
A patient with Pemphigoid Gestationis (PG) experiences a postpartum flare. What hormonal factors may contribute to this exacerbation?
Postpartum flares of Pemphigoid Gestationis (PG) may be exacerbated by oral contraceptives and hormonal changes during the menstrual cycle.
A patient with Pustular Psoriasis of Pregnancy develops hypocalcemia. What life-threatening complications can arise from severe hypocalcemia?
Life-threatening complications from severe hypocalcemia include tetany, delirium, and convulsions.
A patient with Pemphigoid Gestationis (PG) has circulating autoantibodies. What diagnostic test can be used to detect these antibodies?
ELISA or Indirect Immunofluorescence (IIF) can be used to detect circulating autoantibodies in Pemphigoid Gestationis (PG).
A patient with ICP has elevated bile acid levels. What fetal monitoring is essential to manage this condition?
FHR - decelerations in fetal heart rate may be the earliest sign of fetal hypoxemia.
A patient with Pustular Psoriasis of Pregnancy is treated with cyclosporine. What other first-line therapy is available for this condition?
Another first-line therapy for Pustular Psoriasis of Pregnancy is infliximab, a TNF-α blocking agent.
A newborn baby of a patient with Pemphigoid Gestationis (PG) develops bullous lesions postpartum. What is the cause of these lesions in the newborn?
The bullous lesions in the newborn are caused by passive placental transfer of the anti–BMZ antibody.
What is the typical presentation of pemphigoid gestationis during pregnancy?
Intensely pruritic, vesiculobullous eruption on the trunk and extremities, beginning in the second or third trimester.
What is the characteristic feature of pustular psoriasis of pregnancy?
Erythematous patches with subcorneal pustules, typically occurring in the third trimester.
What are the most feared complications of pustular psoriasis of pregnancy?
Placental insufficiency and consequent stillbirth or neonatal death.
What is the cardinal feature of pustular psoriasis of pregnancy after delivery?
Rapid resolution of symptoms after delivery.
What laboratory findings are commonly associated with pustular psoriasis of pregnancy?
Leukocytosis, neutrophilia, elevated ESR, hypoferric anemia, and hypoalbuminemia.
What is the recommended treatment for severe cases of pustular psoriasis of pregnancy?
Cyclopsorine and infliximab are considered first-line therapies.
What is the role of systemic corticosteroids in the management of pustular psoriasis of pregnancy?
Previously the mainstay of therapy, but now less favored due to potential adverse effects.
What is the importance of monitoring fluid status and electrolytes in cases of pustular psoriasis of pregnancy?
To ensure rapid correction of imbalances and prevent complications.
What are the clinical features and potential complications associated with Pemphigoid Gestationis during pregnancy?
Pemphigoid Gestationis is characterized by:
- Intensely pruritic, vesiculobullous eruption occurring in mid-to-late pregnancy and the immediate postpartum period.
- Abrupt appearance of severely pruritic urticarial lesions on normal or erythematous skin.
- Increased incidence of SGA births and premature delivery.
How does Pustular Psoriasis of Pregnancy differ from Generalized Pustular Psoriasis in terms of clinical presentation and management?
Pustular Psoriasis of Pregnancy is characterized by:
- Occurrence during the 1st or 3rd trimester of an otherwise uneventful pregnancy.
- Erythematous patches with subcorneal pustules, often sparing the face, palms, and soles.
What is intrahepatic cholestasis of pregnancy (ICP) and its common features?
Intrahepatic cholestasis of pregnancy (ICP) is a rare, reversible cholestasis that occurs in late pregnancy, characterized by:
- Pruritus: Moderate-to-severe itching, often localized to palms and soles or generalized.
What are the potential fetal risks associated with intrahepatic cholestasis of pregnancy (ICP)?
The potential fetal risks associated with intrahepatic cholestasis of pregnancy (ICP) include:
- Increased rates of prematurity
- Fetal distress
- Fetal death
What is the recommended treatment for intrahepatic cholestasis of pregnancy (ICP)?
The recommended treatment for intrahepatic cholestasis of pregnancy (ICP) includes:
1. Ursodeoxycholic acid (UDCA): A naturally occurring hydrophilic bile acid that reduces maternal symptoms and fetal risk.
What are the hallmark symptoms and biochemical abnormalities of intrahepatic cholestasis of pregnancy (ICP)?
The hallmark symptoms and biochemical abnormalities of intrahepatic cholestasis of pregnancy (ICP) typically include:
- Symptoms: Pruritus, often severe, especially at night.
A patient in her third trimester develops severe pruritus localized to the palms and soles, with no primary skin lesions. What condition should be suspected, and what is the hallmark of its resolution?
Intrahepatic Cholestasis of Pregnancy (ICP) should be suspected. The hallmark of its resolution is that symptoms and abnormalities typically resolve within 2 to 4 weeks of delivery.
What is intrahepatic cholestasis of pregnancy (ICP)?
A rare, reversible cholestasis that occurs in late pregnancy when serum concentrations of estrogen reach their peak.
What are common symptoms of ICP?
Moderate-to-severe pruritus, which may be localized to the palms and soles or generalized, often accompanied by fatigue, nausea, vomiting, or anorexia.
What is the significance of elevated serum bile acids in ICP?
Elevation in serum bile acids is the single most sensitive indicator of ICP, with total serum bile acid levels greater than 11 μM/L being consistent with ICP.
What is the recommended treatment for ICP?
Ursodeoxycholic acid (UDCA) is the treatment of choice, as it reduces maternal symptoms and fetal risk.
What is the recurrence rate of ICP in subsequent pregnancies?
ICP recurs during subsequent pregnancies in an estimated 45% to 70% of patients.
What is the typical management approach for ICP?
An interdisciplinary approach characterized by intense fetal surveillance is essential to the management of ICP.
What is the relationship between pruritus and jaundice in ICP?
Pruritus generally precedes the onset of clinical jaundice by 1 to 4 weeks in ICP patients.
What are the common laboratory findings in ICP?
Mild perturbations in liver function tests, including elevated transaminases and alkaline phosphatase, are commonly found.
What is the impact of ICP on maternal outcomes?
Maternal outcomes are generally favorable, although women with severe cases are predisposed to postpartum hemorrhage secondary to vitamin K depletion.
What are the common clinical features of ICP and how do they relate to bile acid concentrations?
Common features of ICP include:
- Serum total bile acid concentrations >11 μM
- Cholic acid-to-chenodeoxycholic acid ratio >1.5 or cholic acid proportion of total bile acids >42%
- Glycine-to-taurine conjugates of bile acids ratio <1 or glycocholic acid concentration >2 μM (N range: 0.6 to 1.5 μM)
Degree of pruritus and disease severity generally correlate with bile acid concentrations.
What is the role of Ursodeoxycholic acid (UDCA) in the management of ICP?
Ursodeoxycholic acid (UDCA) plays a significant role in managing ICP by:
- Reducing maternal symptoms and fetal risk
- Exerting a hepatoprotective effect through augmentation of hydrophobic bile acid excretion
- Decreasing bile acid levels in colostrum, cord blood, and amniotic fluid
- Being well tolerated at doses between 450 mg and 1200 mg daily
- Showing superior efficacy over dexamethasone or cholestyramine in controlling clinical and liver function abnormalities that define ICP.
How does the timing of pruritus onset in ICP relate to the development of jaundice?
In ICP, pruritus typically begins during the:
- 1st trimester (10%)
- 2nd trimester (25%)
Pruritus generally precedes the onset of jaundice, dark urine, or lightly colored stools by 1 to 4 weeks.
What is the typical onset period for Polymorphic Eruption of Pregnancy (PEP)?
The typical onset for PEP is during the last trimester of pregnancy, with a mean onset at 35 weeks, although it can occur earlier in pregnancy and in the immediate postpartum period.
What are the common clinical features of Atopic Eruption of Pregnancy (AEP)?
Common clinical features of AEP include:
1. Eczematous (AEP, E-type) and papular (AEP, P-type) eruptions.
2. A classic eczematous eruption on flexural surfaces and the face.
3. Discrete, pruritic, excoriated papules with a predilection for extensor surfaces.
4. Onset is typically prior to the third trimester.
What is the management approach for Polymorphic Eruption of Pregnancy (PEP)?
Management for PEP typically includes:
- Topical corticosteroids and/or oral antihistamines for symptom relief.
- A brief course of oral corticosteroids may be required in refractory cases.
- Reassurance regarding the self-limited nature of PEP can help alleviate anxiety.
What distinguishes Atopic Eruption of Pregnancy (AEP) from other pregnancy dermatoses?
AEP is distinguished by:
- Early onset in pregnancy (before the third trimester).
- A personal and/or family history of atopy.
- The presence of eczematous lesions and a higher likelihood of recurrence in subsequent pregnancies.
What is the prognosis for Polymorphic Eruption of Pregnancy (PEP)?
The prognosis for PEP is generally good, with spontaneous remission typically occurring within days of delivery. Recurrences in subsequent pregnancies are unusual, and fetal and maternal prognoses are unaltered.
What are the risk factors associated with Atopic Eruption of Pregnancy (AEP)?
Risk factors for AEP include:
- A personal and/or family history of atopy.
- Previous distinct entities such as prurigo of pregnancy and pruritic folliculitis of pregnancy.
What is the typical duration of symptoms for Polymorphic Eruption of Pregnancy (PEP)?
The typical duration of symptoms is brief, averaging 6 weeks.
What is the typical treatment for Atopic Eruption of Pregnancy (AEP)?
The most common treatment includes emollients and midpotency topical corticosteroids.
What is the typical histopathologic finding in Polymorphic Eruption of Pregnancy (PEP)?
The typical histopathologic finding is eosinophilic spongiosis.
What is the relationship between Atopic Eruption of Pregnancy and future atopic conditions in infants?
In a mother with a known history of atopy, the infant will be at increased risk for atopic dermatitis.
What are the common features of lesions in Atopic Eruption of Pregnancy?
Lesions are discrete, pruritic, excoriated papules with a predilection for extensor surfaces, and may include minor features of eczema.
What is the typical location for Atopic Eruption of Pregnancy (AEP)?
Begins on the abdomen, classically within the striae gravidarum, with periumbilical sparing.
What is the characteristic pruritus associated with Atopic Eruption of Pregnancy (AEP)?
Intense and localized to involved skin, often disturbing sleep.
How does Atopic Eruption of Pregnancy (AEP) spread?
Rapidly spreads to thighs, buttocks, breasts, and arms; involvement of palms and soles is exceptional.
What are the treatment goals for Atopic Eruption of Pregnancy (AEP)?
Ameliorate pruritus and manage symptoms.
What are the first-line treatments for Atopic Eruption of Pregnancy (AEP)?
Emollients, midpotency topical corticosteroids, and antihistamines.
What additional treatment may be helpful for truncal and follicular lesions in AEP?
Benzoyl peroxide may be helpful for truncal and follicular lesions.
When is UVB therapy indicated in Atopic Eruption of Pregnancy (AEP)?
UVB therapy is indicated for severe cases.
What is the prognosis for Atopic Eruption of Pregnancy (AEP)?
Maternal and fetal prognoses are excellent, even in severe cases.
How does the onset of Atopic Eruption of Pregnancy (AEP) differ from Polymorphic Eruption of Pregnancy (PEP)?
AEP typically occurs prior to the third trimester, while PEP typically occurs in the last trimester.
What types of lesions are associated with Atopic Eruption of Pregnancy (AEP)?
Classic eczematous eruption on flexural surfaces and face, with papular lesions that may resemble prurigo of pregnancy.
What is a significant risk factor for Atopic Eruption of Pregnancy (AEP)?
Personal and/or family history of atopy.
What is the first-line treatment for pustular psoriasis of pregnancy?
Cyclosporine is the first-line treatment for pustular psoriasis of pregnancy.
What is the mean onset week for pruritus gravidarum?
The mean onset for pruritus gravidarum is 35 weeks.
What are common features of intrahepatic cholestasis of pregnancy (ICP)?
Common features of ICP include elevated serum bile acid concentrations.
What is the gold standard for diagnosing pruritic urticarial papules and plaques of pregnancy (PUPPP)?
The gold standard for diagnosis of PUPPP is a clinical examination and history.
What is the typical distribution of lesions in intrahepatic cholestasis of pregnancy?
Lesions are generalized, including palms and soles.
When does pustular psoriasis of pregnancy usually begin?
Pustular psoriasis of pregnancy usually begins in the third trimester.
What is the relationship between season and the incidence of intrahepatic cholestasis of pregnancy?
ICP has a higher incidence in the summer season.
What are two conditions that typically spare the palms and soles?
Polymorphic Eruption of Pregnancy (PEP) and Pustular Psoriasis of Pregnancy.
What is the diagnosis for intensely pruritic lesions on the abdomen that spare the periumbilical area?
The diagnosis is Polymorphic Eruption of Pregnancy (PEP). The mean onset is 35 weeks.
What is pathognomonic for pemphigoid gestationis?
DIF with linear C3 and IgG.
What is the hallmark of intrahepatic cholestasis of pregnancy (ICP)?
Symptoms and biochemical abnormalities typically resolve within 2 to 4 weeks of delivery.
What is a cardinal feature of pruritus gravidarum?
Rapid resolution of symptoms after delivery.
What is a common feature of intrahepatic cholestasis of pregnancy?
Severe pruritus, especially at night.
What is the common name for Nurse’s late onset prurigo of pregnancy?
Pruritus gravidarum.
What are the fetal risks associated with intrahepatic cholestasis of pregnancy?
Preterm delivery, fetal distress, and fetal death.
The highest rate of intrahepatic cholestasis of pregnancy is found in which country?
Chile.
What lab parameter is particularly sensitive for diagnosing intrahepatic cholestasis of pregnancy?
Bile acid concentrations.
What are the common pigmentary disturbances observed during pregnancy?
Common pigmentary disturbances include hyperpigmentation, secondary areolae, linea nigra, and melasma.
What structural changes occur in the skin during pregnancy?
Striae distensae (striae gravidarum) and molluscum fibrosum gravidarum (acrochordons).
What is pemphigoid gestationis?
An immunologically mediated, intensely pruritic, vesiculobullous eruption occurring in mid- to late pregnancy.
What are the differential diagnoses for pustular psoriasis of pregnancy?
Pustular drug eruption, pemphigoid gestationis, pemphigus vulgaris, dermatitis herpetiformis, subcorneal pustular dermatosis.
What are the most likely conditions to consider for polymorphic eruption of pregnancy?
Pemphigoid gestationis, atopic eruption of pregnancy, contact dermatitis.
What are the key physiologic skin changes that occur during pregnancy?
Hyperpigmentation, secondary areolae, linea nigra, melasma, hirsutism, thickening of scalp hair.
