Risk factors for development of PEP include rapid weight gain, multiple gestation pregnancy, nulliparous, and primigravid.2 It usually self-resolves in the postpartum period and does not recur with subsequent pregnancies.
Curbside Consults delivers expert perspectives from physicians outside of the OB/GYN specialty to provide insight into various health issues affecting pregnant women. This new section is the brainchild of Editorial Advisory Board member Christine Isaacs, MD.
A 28-year-old primigravid patient presents for her routine prenatal visit. She is 36 weeks pregnant and complains that the stretch marks on her abdomen have become extremely itchy, red, and bumpy. She has no other obstetric complaints. Vital signs and fetal monitoring are within normal limits.
On physical exam you see this (Figure 1):
This scenario describes polymorphic eruption of pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy (PUPPP). Clinically, this presents as an abrupt onset of pruritic urticarial papules and plaques, targets, and vesicles within and around abdominal striae distensae, trunk, buttocks, and thighs. It typically spares the umbilicus, palms, and soles. There are no associated maternal or fetal morbidities.
Risk factors for development of PEP include rapid weight gain, multiple gestation pregnancy, nulliparous, and primigravid.2 It usually self-resolves in the postpartum period and does not recur with subsequent pregnancies.
A 30-year-old primigravid patient at 37 weeks of pregnancy comes in complaining of itchy hives and blisters that suddenly developed on her abdomen and thighs. She denies fever, malaise, or any other systemic symptoms.
On physical exam you see this (Figure 2):
This scenario describes pemphigoid gestationis, also known as herpes gestationis, which typically presents in late pregnancy or the postpartum period as an abrupt onset of PUPP that progress to tense vesicles and bullae on an erythematous base. Of note, these lesions involve the umbilicus or are immediately adjacent to it and spread to extremities, including palms and soles. Fetal risks include prematurity and small for gestational age.5 Maternal risks include Graves disease.5 Early-onset disease correlates with disease severity. This usually self-resolves during the postpartum period but can recur in subsequent pregnancies.
Herpes gestationis typically presents in late pregnancy or the postpartum period.
A 21-year-old woman at 12 weeks of pregnancy presents with a complaint of new itchy bumps that started a week ago on her face and neck, under her arms, under her breasts, and on her arms and legs. She reveals she has never had a rash like this but did have eczema as a child. She does not complain about any other symptoms. Vital signs and fetal monitoring are within normal limits.
On physical exam you see the following (Figure 3):
This scenario describes atopic eruption of pregnancy, which is the most common rash seen in pregnancy. Onset is typically before the second or third trimester. It is a spectrum of conditions that includes prurigo of pregnancy, eczema of pregnancy, and pruritic folliculitis of pregnancy.
Clinically, it presents as excoriated papules or nodules, eczematous papules and plaques, or monomorphic follicular-based papules on the abdomen, flexural areas, and extremities. It typically occurs in patients with a history of atopic dermatitis but could be of new onset. It is due to an immune system shift from a T-helper (Th)1-predominant to a Th2-predominant system during pregnancy.
Patients who already have this imbalance due to atopic dermatitis experience flares. It is self-limited and there are no maternal or fetal risks.
A 22-year-old gravida 2 para 1 woman at 33 weeks of pregnancy presents with the complaint that she has been itchy all over her body for the past 3 days. She states that itching prevents her from sleeping at night and she experienced something similar during her first pregnancy but not as intensely. She reports that her first child was born at 35 weeks. Physical exam shows normal-appearing skin without any rash or secondary lesions
This scenario describes intrahepatic cholestasis of pregnancy, which is characterized by extreme pruritus in absence of rash, followed by secondary excoriation and prurigo papules and nodules. There is no long-term morbidity to the mother, but fetal risks include premature birth, meconium staining of amniotic fluid, abnormal fetal heart rate, and stillbirth.8 This condition is self-limited, with itching resolving days after delivery. It recurs with subsequent pregnancies.
A 25-year-old woman at 30 weeks of pregnancy presents with complaint of new-onset rash located in her axilla and groin, as well as malaise and fever. She states that she has never had a rash like this.
On physical exam you note the following (Figure 4):
This scenario presents a case of impetigo herpetiformis, also known as generalized pustular psoriasis of pregnancy. This presents in the third trimester of pregnancy as eczematous scaly plaques surrounded by 1- to 3-mm pustules in flexural areas, which then extend to the trunk and extremities.
Patients usually have no prior history of psoriasis. Maternal risk includes seizures, tetany, delirium, and cardiac arrhythmias secondary to hypocalcemia.10 Fetal risk includes placental insufficiency.10 The condition typically self-resolves in the postpartum period, and it recurs with earlier onset and a more severe course in subsequent pregnancies.
A 36-year-old woman at 29 weeks of pregnancy presents with a complaint of a bleeding bump on her lip. She does not recall any trauma to her lip and states the lesion started growing slowly over the past month. She has not attempted any home remedies and complains of no other symptoms. Her physical exam and fetal monitoring are within normal limits.
In physical exam you see the following (Figure 5):
This case scenario describes a pyogenic granuloma, also known as pregnancy granuloma, which is a vascular lesion composed of multiple capillary hemangiomas. Its development is associated with increasing hormonal levels in pregnancy, as well as trauma.12
It presents as a dome-shaped, painful, hemorrhagic papule usually on the gingiva, but it can also occur on the lips and other bodily sites. Their presence can cause pain, anxiety, difficulty eating, and, though rarely, life-threatening hemorrhage if poorly controlled.
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References
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