Protocols

Subject: Pruritis in Pregnancy

Screening/Diagnosis:

Cause: Pruritic urticarial papules and plaques of pregnancy (PUPP)

Erythematous papules, especially within striae
Intense pruritus involving abdomen, especially striae, with spread to thighs,buttocks, breasts, and arms
More common in third trimester
Most common rash in pregnancy
More common in multiparous women
Not associated with poor pregnancy outcome
May respond to antihistamines and topical steroids
Dermatology evaluation not required

Prurigo of pregnancy (prurigo gestationis)

Grouped excoriated or crusted pruritic papules over the extensor surfaces of the extremities, and occasionally on the trunk and elsewhere
Can look like insect bites

Occurs in second half of pregnancy
Not associated with poor pregnancy outcome
May respond to antihistamines and topical steroids
Dermatology evaluation not required

Intrahepatic cholestasis of pregnancy

Trunk and extremity itching without rash
Develops in third trimester
Associated with poor pregnancy outcome
Check labs: bile salts, liver function
If suspected, refer to High Risk OB Clinic

Herpes gestationis or pemphigoid gestationis (is really bullous pemphigoid that arises during pregnancy

Vesicles and bullae (blisters) on abdomen and extremities in second half of pregnancy
Rare
May be associated with poor pregnancy outcome – requires referral to High Risk OB Clinic
Requires dermatology evaluation
Responsive to prednisone (dosage: 20 to 40 mg per day)

Impetigo herpetiformis (is really pustular psoriasis that arises during pregnancy)

Crops of pustules that start in skin folds and progress
Most likely to arise in the third trimester
Rare
May be associated with poor pregnancy outcome – requires referral to High Risk OB Clinic
Requires dermatology evaluation
Treated with steroids and other therapies

Other common pruritic conditions which can occur in pregnancy

Atopic dermatitis

Allergic contact dermatitis

Recommendations

Refer patients with blistering or pustular rashes and patients who have itching without rash

Nonspecific Management of pruritus in pregnancy:

Use skin lubricants liberally: petrolatum or lubricant cream at bedtime; alcohol-free, hypoallergenic lotions frequently during the day, i.e. Eucerin cream

Decrease frequency of bathing and use lukewarm water; after bathing, briefly pat skin dry and immediately apply skin lubricant.

Use mild, unscented, hypoallergenic soap two to three times per week (i.e. Dove); limit daily use of soap to groin and axillae (spare legs, arms, and torso).

Humidify dry indoor environment, especially in winter.

Choose clothing that does not irritate the skin, avoid clothing made of wool, smooth-textured cotton, or heat-retaining material (synthetic fabrics).

Avoid use of vasodilators (caffeine, alcohol, spices, hot water) and excessive sweating.

Avoid use of provocative topical medications, such as corticosteroids for prolonged periods (risk of skin atrophy) and topical anesthetics and antihistamines (may sensitize exposed skin and increase risk of allergic contact dermatitis).

Prevent complications of scratching by keeping fingernails short and clean, and by rubbing skin with the palms of the hands if urge to scratch is irresistible.

Treatments:

Standard topical antipruritic agents: For example - menthol and camphor (e.g. Sarna lotion), oatmeal baths (e.g., Aveeno), pramoxine (e.g., PrameGel), calamine lotion (Caladryl; use only on weeping lesions, not on dry skin), doxepin 5% cream (Zonalon).

Topical corticosteroids: use lowest effective strength (1% hydrocortisone cream) once to twice daily.

Systemic antipruritic agents (used in allergic and urticarial disease): benadryl 25 mg every 6-8 hours prn, zyrtec 10 mg a day, Claritin 10 mg a day (category B).

Reference:

Gabbe: Obstetrics: Normal and Problem Pregnancies, 5^th ed.

Prepared in conjunction with the

Division of Maternal-Fetal Medicine

Duke University Medical Center

Director

6/20/08 Date

The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.

These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions. We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.

The protocols remain the intellectual property of the Duke University Health System. They cannot be reproduced in whole or part without the expressed permission of the Health System.

These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia. Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.

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