Pregnancy

Question 1

20% of pregnant women get some form of pruritus

Answer 1

True

Question 2

Which topical steroids are safe in pregnancy?

Answer 2

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)

Question 3

Which antihistamines are safe in pregnancy?

Answer 3

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

Question 4

What are the Dermatoses of menopause/climacteric?

Answer 4

'Hot Flushing’ – heat symptom with visible flushing in 50%
Keratoderma climactericum
Atrophic vaginitis
Lichen sclerosus 
Adverse efects of HRT

Question 5

T/F

Autoimmune progesterone dermatitis gets worse in pregnancy

Answer 5

False

Often remits in pregnancy

Question 6

What are the clinical features of Autoimmune progesterone dermatitis?

Answer 6

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)

Question 7

How do you diagnose and manage Autoimmune progesterone dermatitis?

Answer 7

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

Question 8

T/F

melasma starts early in pregnancy

Answer 8

occurs during 2nd half of pregnancy in 70% of cases

esp dark skinned women

Question 9

T/F

melasma usually persists after delivery

Answer 9

False

Usually resolves after delivery but can persist esp if darker skin type

Question 10

T/F

acne and hirsuitism are normal in pregnancy

Answer 10

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

Question 11

Which pts always get striae distensae (striae gravidarum)

Answer 11

Pseudoxanthoma elasticum

Question 12

T/F

Polymorphic eruption of pregnancy occurs late in pregnancy

Answer 12

True
PEP beofore you Pop!
Onset 3rd trimester (85%) but can begin postpartum (15%)

Question 13

T/F

Polymorphic eruption of pregnancy often recurs in later pregs

Answer 13

False

Doesnt usually recur in later preg but if so it is less severe than the first time

Question 14

What are the histo features of PEP?

Answer 14

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

Question 15

What test can be done to distinguish PEP from early Pg

Answer 15

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

Question 16

Is it safe to use non-sedating antihistamines in pregnancy?

Answer 16

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

Question 17

When does PEP resolve?

Answer 17

resolves over 4 weeks (average) post partum

Question 18

Pemphigoid gestationis (Pg) is up to 1000x more common than PEP

Answer 18

False
up to 1000x less common
1:10,000 – 1:60,000 pregnancies

Question 19

T/F

Impetigo herpetiformis is the old tame for Pg

Answer 19

False
herpes gestationis is the old name for Pemphigoid gestationis (Pg)
Impetigo herpetiformis is generalized pustular psoriasis occurring in pregnancy

Question 20

T/F

Pruritus(prurigo) gravidarum is the old name for AEP

Answer 20

False
Pruritus(prurigo) gravidarum is the old name for Intrahepatic cholestasis of pregnancy
Prurigo of pregnancy is the old name for AEP

Question 21

T/F
Pemphigoid gestationis (Pg) is more common in oriental pts

Answer 21

False
v rare
affects caucasians and blacks

Question 22

T/F

Pg more common if mother has HLAs – B8, DR3 or DR4

Answer 22

True

‘autoimmune haplotype’ - woman may have known AI disease

Question 23

Pg more common if father has HLAs – DR3 or DR4

Answer 23

False

if father has HLA DR2

Question 24

What is the cause of Pemphigoid gestationis (Pg)?

Answer 24

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

Question 25

``` T/F Pemphigoid gestationis (Pg) is associated with trophoblastic tumours (hydatiform mole, choriocarcinoma) ```

Answer 25

True

Question 26

What is the target antigen in Pg?

Answer 26

BP180 (BPAg2) - esp NC16A domain of BP180 | and sometimes BP230

Question 27

T/F | Most cases of Pemphigoid gestationis (Pg) occur in a first pregnancy

Answer 27

False | 50% in 1st preg

Question 28

``` T/F Pemphigoid gestationis (Pg) which recurs is more severe in subsequent pregnancies ```

Answer 28

False more or less severe But earlier onset in subsequent pregnancies

Question 29

``` T/F Pemphigoid gestationis (Pg) can start anytime from 4 weeks gestation until 5 weeks postpartum ```

Answer 29

True | usually 2nd or 3rd trimester

Question 30

``` T/F Pemphigoid gestationis (Pg) spares the palms and soles ```

Answer 30

False | But PEP usually spares face, palms and soles

Question 31

What are the histo and IF findings of Pg?

Answer 31

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)

Question 32

What are the salt split skin findings of Pg?

Answer 32

Abs bind to epidermal side (roof) of salt split skin

Question 33

T/F | indirect IF is of no use in Pg

Answer 33

False IgG1 can be detected by ELISA Can see C3 which binds to BMZ

Question 34

T/F | 25% of cases of pg flare at delivery (even within hours)

Answer 34

False | 75% flare

Question 35

T/F | Pg resolves quickly after delivery

Answer 35

False Pg lasts on average 6 month duration 75% flare at delivery even though often settles a bit before then Can last years

Question 36

What are risk factors for prolonged course of Pg?

Answer 36

Mom; Multiparity (previous affected pregnancies) Older age Mucosal involvement

Question 37

T/F | OCP (of any kind) is contraindicated in (post delivery) mum who has active Pg

Answer 37

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

Question 38

``` T/F Pemphigoid gestationis (Pg) can flare w/ menstruation ```

Answer 38

True

Question 39

What are effects of Pemphigoid gestationis (Pg) on the pregnancy and infant?

Answer 39

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

Question 40

When does neonatal Pg present and how long does it last?

Answer 40

Presents in 1st 3 days of life, resolves in 1st 3 weeks

Question 41

T/F | all cases of Pg need systemic Rx

Answer 41

False | about 20% are mild enough to treat only with potent or very potent TCS and antihistamines

Question 42

T/F | CsA is first line in mod-severe Pg

Answer 42

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

Question 43

T/F | Its safe to continue the same treatment for Pg postpartum

Answer 43

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

Question 44

What is the 1,2,3,4 or Pg?

Answer 44

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

Question 45

T/F | In AEP the woman always has atopic eczema or atopic diathesis in self or family

Answer 45

True | 20% have known eczema

Question 46

T/F | Intrahepatic cholestasis of pregnancy is the most common pruritic disorder in pregnant women

Answer 46

False AEP most common – 1 in 5-20 pregnancies ICP affects up to 1 in 20 pregnancies

Question 47

What is the aetiology of AEP?

Answer 47

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

Question 48

T/F | AEP usually starts in 3rd trimester

Answer 48

False Onset often in 1st trimester before 3rd trimester in 75% of cases

Question 49

T/F | The papular type of AEP is less common than the eczematous type

Answer 49

True 1/3 are P-type 2/3 are E-type

Question 50

T/F | IgE is often raised in AEP

Answer 50

True | raised in 70%

Question 51

T/F | UVB is very useful for AEP

Answer 51

``` True first try; General measures like eczema – emollient, soap-free wash etc TCS Antihistamine Can use topical 10% urea or 1% menthol ```

Question 52

T/F | Intrahepatic cholestasis of pregnancy (ICP) has a significnat genetic predisposition

Answer 52

True | 50% have family history

Question 53

T/F | Intrahepatic cholestasis of pregnancy (ICP) is more symptomatic if there is more cholestasis

Answer 53

False | always mild cholestasis but severe tich

Question 54

T/F | Intrahepatic cholestasis of pregnancy (ICP) starts in the 2nd or 3rd trimester

Answer 54

True

Question 55

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

Answer 55

True

Question 56

T/F | Bile acids cross placenta

Answer 56

True can affect foetal cardiac muscle risk of abnormal foetal heart rate so must diagnose and manage appropriately

Question 57

T/F | Serum bile acids are normal in ICP

Answer 57

False | Total serum acids are elevated (>11 µmol/L)

Question 58

What are the biochemical findings in ICP?

Answer 58

Total serum acids are elevated (>11 µmol/L) Can be deranged LFTs - esp high ALP - may be high transaminases

Question 59

T/F | Raised ALP is always pathological in pregnancy

Answer 59

False often high in pregnancy may be higher than usual in ICP

Question 60

What are the clinical features of ICP?

Answer 60

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

Question 61

What are risks to the foetus in ICP?

Answer 61

``` ICPS Intrapartum foetal distress Cardiac - abnormal foetal heart rate Premature delivery - significant risk Stillbirth ```

Question 62

T/F | maternal bile acid level correlates with foetal risk

Answer 62

True | The higher the maternal bile acids, the higher the foetal risk

Question 63

T/F | ICP often recurs in later pregnancies but not with OCP

Answer 63

False | Can recur in later pregnancies (45-70%) or w/ OCP (often)

Question 64

T/F | Recurrent attacks of ICP increase risk of gall stones

Answer 64

True | jaundice during attacks also increases risk of gallstones

Question 65

What is management of ICP?

Answer 65

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)

Question 66

What is Microchimerism?

Answer 66

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

Question 67

T/F | generalized pustular psoriasis occurring in pregnancy usually starts in 1st trimester

Answer 67

False | Onset usually in last trimester and persists until delivery

Question 68

T/F | generalized pustular psoriasis occurring in pregnancy may recur in subsequent pregnancies or with OCP

Answer 68

True

Question 69

What is treatment ladder for generalized pustular psoriasis occurring in pregnancy?

Answer 69

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

Question 70

T/F | Hypercalcaemia is a features of generalized pustular psoriasis occurring in pregnancy

Answer 70

False Hypocalcaemia can cause tetany and GI upset