Pregnancy Flashcards
20% of pregnant women get some form of pruritus
True
Which topical steroids are safe in pregnancy?
Hydrocortisone or hydrocortisone acetate 0.5%, 1% (Cortic-DS, Sigamcort, Dermaid/Dermaid soft cream)
Clobetasone butyrate 0.05%
(Eumovate)
Betamethasone valerate 0.02%
(Antroquoril, Cortival1/5, Celstone-M, Betnovate 1/5)
Betamethasone dipropionate 0.05%
(Eleuphrat, Diprosone, DipOV)
Which antihistamines are safe in pregnancy?
Polaramine (Dexchlorpheniramine) 2mg QDS
Avil (Pheniramine) 45.3mg per tablet start at ½ tab TDS and titrate – max is 3mg/kg/day
Periactin (Cyproheptadine) 4mg TDS up to max 20mg/day
Benadryl Original (diphenhydramine) –oral liquid only Aus
What are the Dermatoses of menopause/climacteric?
'Hot Flushing’ – heat symptom with visible flushing in 50% Keratoderma climactericum Atrophic vaginitis Lichen sclerosus Adverse efects of HRT
T/F
Autoimmune progesterone dermatitis gets worse in pregnancy
False
Often remits in pregnancy
What are the clinical features of Autoimmune progesterone dermatitis?
Onset is usually after taking progesterone containing meds for first time eg OCP
Can resemble pompholyx or eczema or urticarial dermatitis
Less commonly looks like; EM, urticaria, DH or causes anaphylaxis or pruritus alone
Can cause oral erosions
eruption regularly appears during the period - esp in 7-10 days prior to onset of menstruation when progesterone levels are highest (luteal phase)
How do you diagnose and manage Autoimmune progesterone dermatitis?
Hypersensitivity to progesterone may be confirmed by skin prick or oral challenge
or serology for anti-progesterone Abs in the serum
Often resistant to TCS and antihistamines
Can try oestrogen to inhibit ovulation
Tamoxifen
Danazol
Bilateral oophorectomy
T/F
melasma starts early in pregnancy
occurs during 2nd half of pregnancy in 70% of cases
esp dark skinned women
T/F
melasma usually persists after delivery
False
Usually resolves after delivery but can persist esp if darker skin type
T/F
acne and hirsuitism are normal in pregnancy
False
can be physiological but may indicate an underlying problem
must investigate as could result in masculinisation of a female foetus
E.g. androgen-secreting tumour, luteoma, lutein cyst, PCOS
If not due to tumour can recur in later pregnancies
But usually resolves in between pregnancies
Which pts always get striae distensae (striae gravidarum)
Pseudoxanthoma elasticum
T/F
Polymorphic eruption of pregnancy occurs late in pregnancy
True
PEP beofore you Pop!
Onset 3rd trimester (85%) but can begin postpartum (15%)
T/F
Polymorphic eruption of pregnancy often recurs in later pregs
False
Doesnt usually recur in later preg but if so it is less severe than the first time
What are the histo features of PEP?
Spongiosis (can be severe with vesicles) and dermal oedema
Perivascular lymphohistiocytic infiltrate
May be many eos (same as Pg) or neuts
DIF usually negative but may be equivocal
What test can be done to distinguish PEP from early Pg
IF usually sufficient
can do BP180 NC16a FISH
Pg almost always due to Abs targeting NC16a domain of BP180
But rarely cna be due to Abs to BP230
Is it safe to use non-sedating antihistamines in pregnancy?
Some sources say okay to use loratadine (B1) or cetirizine (B2) in 2nd/3rd trimester (Bolognia) but would need to make this an individual discussion
When does PEP resolve?
resolves over 4 weeks (average) post partum
Pemphigoid gestationis (Pg) is up to 1000x more common than PEP
False
up to 1000x less common
1:10,000 – 1:60,000 pregnancies
T/F
Impetigo herpetiformis is the old tame for Pg
False
herpes gestationis is the old name for Pemphigoid gestationis (Pg)
Impetigo herpetiformis is generalized pustular psoriasis occurring in pregnancy
T/F
Pruritus(prurigo) gravidarum is the old name for AEP
False
Pruritus(prurigo) gravidarum is the old name for Intrahepatic cholestasis of pregnancy
Prurigo of pregnancy is the old name for AEP
T/F Pemphigoid gestationis (Pg) is more common in oriental pts
False
v rare
affects caucasians and blacks
T/F
Pg more common if mother has HLAs – B8, DR3 or DR4
True
‘autoimmune haplotype’ - woman may have known AI disease
Pg more common if father has HLAs – DR3 or DR4
False
if father has HLA DR2
What is the cause of Pemphigoid gestationis (Pg)?
Thought to be mismatch between foetal (paternal-derived) and maternal HLAs which triggers immune response which cross reacts with skin antigens
Onset is after collagen 17 has been produced – 4 wks gestation
AutoAbs react with basement membrane of placenta from second trimester
T/F Pemphigoid gestationis (Pg) is associated with trophoblastic tumours (hydatiform mole, choriocarcinoma)
True
What is the target antigen in Pg?
BP180 (BPAg2) - esp NC16A domain of BP180
and sometimes BP230
T/F
Most cases of Pemphigoid gestationis (Pg) occur in a first pregnancy
False
50% in 1st preg
T/F Pemphigoid gestationis (Pg) which recurs is more severe in subsequent pregnancies
False
more or less severe
But earlier onset in subsequent pregnancies
T/F Pemphigoid gestationis (Pg) can start anytime from 4 weeks gestation until 5 weeks postpartum
True
usually 2nd or 3rd trimester
T/F Pemphigoid gestationis (Pg) spares the palms and soles
False
But PEP usually spares face, palms and soles
What are the histo and IF findings of Pg?
spongiosis and papillary dermal oedema + some foci of eosinophilic spongiosis and a mixed infiltrate
Subepidermal bullae containing many eos
(split level is through lamina lucida)
DIF;
Always BMZ linear deposition of C3 in active disease
May also see IgG (25-30%) but usually not seen even though it is there (the IgG fixes the C3)
What are the salt split skin findings of Pg?
Abs bind to epidermal side (roof) of salt split skin
T/F
indirect IF is of no use in Pg
False
IgG1 can be detected by ELISA
Can see C3 which binds to BMZ
T/F
25% of cases of pg flare at delivery (even within hours)
False
75% flare
T/F
Pg resolves quickly after delivery
False
Pg lasts on average 6 month duration
75% flare at delivery even though often settles a bit before then
Can last years
What are risk factors for prolonged course of Pg?
Mom;
Multiparity (previous affected pregnancies)
Older age
Mucosal involvement
T/F
OCP (of any kind) is contraindicated in (post delivery) mum who has active Pg
True
may trigger severe flare
But if disease has resolved pt can use OCP for contraception – but some people advise never to take OCP if pt has had Pg as can trigger recurrence
T/F Pemphigoid gestationis (Pg) can flare w/ menstruation
True
What are effects of Pemphigoid gestationis (Pg) on the pregnancy and infant?
Premature delivery
Risk of low birth weight/ small for dates (esp if severe Pg)
5-10% develop neonatal pemphigoid
Foetal prognosis worse if
- Early onset disease (earlier in pregnancy)
- More blistering
High risk pregnancy need to deliver in unit with SCBU
When does neonatal Pg present and how long does it last?
Presents in 1st 3 days of life, resolves in 1st 3 weeks
T/F
all cases of Pg need systemic Rx
False
about 20% are mild enough to treat only with potent or very potent TCS and antihistamines
T/F
CsA is first line in mod-severe Pg
False
prednisolone 1st line - start at 0.5mg/kg/day and titrate
Plasmapheresis second
Can also use CsA or IVIg or Dapsone during pregnancy
May need pred still but use others as sparers
deliver baby only if very severe and Rx failure++
After preg can use AZA, Cyclophos, sulfapyridine, rituximab, doxy + nicotinamide
T/F
Its safe to continue the same treatment for Pg postpartum
False
depends if breast feeding or not
Both steroids and antihistamines get into breast milk and can affect infant
Tetracyclines and nicotinamide have been successful in non-breastfeeding women
Other immunsuppressants have been used postpartum – cyclophosphamide, IVIg, rituximab
What is the 1,2,3,4 or Pg?
1 – IgG1
2 – BPAg2 (BP180, NC16A domain) and father HLA DR2
3 – C3 and HLA DR3 and neonatal pemphigoid 1st 3 days to 3 wks
4 – HLA DR4
T/F
In AEP the woman always has atopic eczema or atopic diathesis in self or family
True
20% have known eczema
T/F
Intrahepatic cholestasis of pregnancy is the most common pruritic disorder in pregnant women
False
AEP most common – 1 in 5-20 pregnancies
ICP affects up to 1 in 20 pregnancies
What is the aetiology of AEP?
Thought to be triggered by immune changes of pregnancy – switch to dominant humoral and Th2 cytokine response with relative lack of cell mediated immune function and reduced Th1 cytokine production
T/F
AEP usually starts in 3rd trimester
False
Onset often in 1st trimester
before 3rd trimester in 75% of cases
T/F
The papular type of AEP is less common than the eczematous type
True
1/3 are P-type
2/3 are E-type
T/F
IgE is often raised in AEP
True
raised in 70%
T/F
UVB is very useful for AEP
True first try; General measures like eczema – emollient, soap-free wash etc TCS Antihistamine Can use topical 10% urea or 1% menthol
T/F
Intrahepatic cholestasis of pregnancy (ICP) has a significnat genetic predisposition
True
50% have family history
T/F
Intrahepatic cholestasis of pregnancy (ICP) is more symptomatic if there is more cholestasis
False
always mild cholestasis but severe tich
T/F
Intrahepatic cholestasis of pregnancy (ICP) starts in the 2nd or 3rd trimester
True
T/F
ICP is due to reduced excretion of bile acids
Likely due to poor function of liver bile transporter proteins which cannot cope with additional requirements of pregnancy due to effects of raised Oe and P
True
T/F
Bile acids cross placenta
True
can affect foetal cardiac muscle
risk of abnormal foetal heart rate so must diagnose and manage appropriately
T/F
Serum bile acids are normal in ICP
False
Total serum acids are elevated (>11 µmol/L)
What are the biochemical findings in ICP?
Total serum acids are elevated (>11 µmol/L)
Can be deranged LFTs
- esp high ALP
- may be high transaminases
T/F
Raised ALP is always pathological in pregnancy
False
often high in pregnancy
may be higher than usual in ICP
What are the clinical features of ICP?
Itching often starts on palms and soles
No primary skin lesions but signs of scratching on abdo, buttocks, arms and legs
Can be excoriations up to prurigo nodules
May be mild jaundice (10%)
Mum can sometimes get fat malabsorption causing steatorrhoea and vitamin K deficiency (which increases risk of intra and post partum bleeding) esp if significant intra and extra hepatic cholestasis
What are risks to the foetus in ICP?
ICPS Intrapartum foetal distress Cardiac - abnormal foetal heart rate Premature delivery - significant risk Stillbirth
T/F
maternal bile acid level correlates with foetal risk
True
The higher the maternal bile acids, the higher the foetal risk
T/F
ICP often recurs in later pregnancies but not with OCP
False
Can recur in later pregnancies (45-70%) or w/ OCP (often)
T/F
Recurrent attacks of ICP increase risk of gall stones
True
jaundice during attacks also increases risk of gallstones
What is management of ICP?
ICP in the UK
U - ursodeoxycholic acid
K - vitamin K if INR high
Check LFTs and viral serology (Hep B, C, CMV, HIV)
If jaundiced check INR (PT) and give IM vit K if needed
Make sure obstetrician involved and baby closely monitored
Treatment w/ ursodeoxycholic acid can reduce itch and improve LFTs – safe but can cause some mild diarrhoea - 1g or 15mg/kg daily; Use after 1st trimester under obstetrician guidance (NB usually dont use cholestyramine)
What is Microchimerism?
Presence of small numbers of foetal cells in maternal circulation which persists
May set up a GvHD like response and trigger autoimmune disease but unclear if any real adverse effects
T/F
generalized pustular psoriasis occurring in pregnancy usually starts in 1st trimester
False
Onset usually in last trimester and persists until delivery
T/F
generalized pustular psoriasis occurring in pregnancy may recur in subsequent pregnancies or with OCP
True
What is treatment ladder for generalized pustular psoriasis occurring in pregnancy?
Supportive cares, electrolyte monitoring
TCS only if not too severe
nbUVB
Steroids - pred 30-40mg/day
cyclosporine - May need high doses; up to 9-12mg/kg/d
deliver baby if late in preg or mum very unwell - threatening maternal life
Infliximab has been
T/F
Hypercalcaemia is a features of generalized pustular psoriasis occurring in pregnancy
False
Hypocalcaemia
can cause tetany and GI upset
