Pruritus in Pregnancy

Dr. Zafar Iqbal Malghani
MBBS, FCPS (Medicine)
District Physician DHQ Layyah
Email: zafarmalghani@gmail.com

“One day, I was sitting in my office in routine, examining and prescribing medicine to the patients when a young pregnant lady, in her late second trimester, swiftly entered the office, itching her palms, arms and legs. She complained that doctors were failed treating her illness. Even she complained that skin specialists had no solution of it. She told that she had the same illness during her last pregnancy.”

Pruritus in pregnancy or pruritus gravidarum (PG) refers to sudden onset of generalized pruritus with no evidence of any primary skin lesion during pregnancy, especially in second and third trimester of pregnancy. It affects 1-8% of the women during pregnancy, and sometimes, it may suffer up to 20 % of the pregnant women [1-3]. It is also called obstetric cholestasis, idiopathic jaundice of pregnancy, and intrahepatic cholestasis of pregnancy (ICP) [4].

Features

• Generalized itching usually starts during late second trimester and early third trimester. However, it may start as early as eight week of gestation.

• PG peaks in the last month pregnancy and also occurs in the subsequent pregnancies.

• Usually PG starts as severe itching of palms and soles then quickly spread to abdomen, chest and the extremities.

• Most often, irritation and restlessness affect the sleep of the sufferer as PG is worse at night.

• PG may present with jaundice, dark urine, clay-coloured stools and skin excoriations [5].

Causes

The cause of pruritus gravidarum is still unknown. However, it is thought that it occurs due to hepatic bile flow disruption during pregnancy [5]. Disruption of bile flow leads to pregnancy induced intrahepatic cholestasis, triggered by hormones especially estrogen. Therefore, serum level of bile acids rises to toxic levels, leading to severe pruritus.

Diagnosis

Most often, diagnosis is based on the characteristic symptom of itching starting from palms and soles (usually without rash) without any primary skin lesion. Total serum bile acid levels are reported above 11.0 μmol/L. Liver transaminase levels (e.g. aspartate aminotransferase, alanine aminotransferase) may also be raised. Jaundice and raised blood bilirubin may be noted. Abdominal ultrasonography and serologic tests may also be advised to rule out other causes of pruritus such as gall stones and viral hepatitis. Also, steatorrhea and vitamin K deficiency may be noted.

Treatment

No specific treatment is available. However, the aim of the treatment is to reduce bile acid levels in serum.

1. Ursodeoxycholic acid (Triptor) is considered as treatment of choice as it offers the following benefits:Improves maternal pruritus

• Decreases liver transaminase
• Reduces bile acids levels
• May reduce the rate of adverse fetal outcomes
• The dose of ursodeoxycholic acid is 15mg/kg daily divided in two doses until delivery [5].

2. Antihistamines (Rigix, Neosedil) may be used as they reduce itching during pregnancy. Dose of Rigix is 10mg once at night time.
3. Soothing baths and Emollients reduce itching. Avoid lotions containing calamine as it dries the skin and may exacerbate pruritus.
4. Peppermint oil and oil prepared from a plant called Rocket (Eruca sativa, Taramira in Urdu) are also used for pruritus in pregnancy as alternative medicine in Asia. These oils have anti-inflammatory properties and provide symptomatic relief [6,7].
5. Cholestyramine (4g orally thrice a day), a resin, reduces serum bile acid levels by absorbing bile from large gut. However, it should be avoided as it causes constipation and vitamin K deficiency which may happen to occur with pruritus gravidarum.
6. Elective delivery is recommended around 36-38 weeks in severe cases.

Prognosis

Prognosis of pruritus gravidarum is good. Pruritus subsides soon after delivery in days or weeks; however, it may occur in subsequent pregnancies. Use of hormonal contraceptives may prone the affectees to pruritus. So, estrogen-containing contraceptive pills are contraindicated in those women who suffered from PG. Jaundice and vitamin K deficiency puts the pregnant women at increased risk of intra- and postpartum hemorrhage. Other risks of pruritus gravidarum include preterm labour, meconium in the amniotic fluid, fetal distress and fetal demise.

References

1. Peharda V, Gruber F, Kastelan M, Brajac I, Cabrijan L. Pruritus an important symptom of internal diseases. Dermatovenerologica 2000;9:108-11.
2. Wong RC, Ellis CN. Physiologic skin changes in pregnancy. J Am Acad Dermatol 1984;10(6):929-40.
3. Rook A, Wilkinson DS, Ebling FJ, editors. Textbook of dermatology. 3rd ed. Oxford, Engl: Blackwell Scientific Publications 1979. p.213.
4. GP Notebook. Pruritus gravidarum. Available from: <http://www.gpnotebook.co.uk/simplepage.cfm?ID=-2147090414> [accessed on 11 Sep 2014].
5. Bergman H, Melamed N, Koren G. Pruritus in pregnancy. Can Fam Physician 2013;59(12): 1290-4.
6. Amjadi MA, Mojab F, Kamranpour SB. The effect of peppermint oil on symptomatic treatment of pruritus in pregnant women. Iran J Pharm Res 2012;11(4):1073-7.
7. Padulosi S, Pignone D. Rocket: a Mediterranean crop for the world. IPGRI 1996; 1-101. Available from: <ftp://ftp.cgiar.org/ipgri/Publications/pdf/234.PDF> [Accessed on 11 Sep 2014].

Author:
Dr. Zafar Iqbal Malghani
MBBS, FCPS (Medicine)
District Physician DHQ Layyah
Email: zafarmalghani@gmail.com

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Keywords: Pruritus in pregnancy, Pruritus gravidarum, Cause, Diagnosis, Treatment, Prognosis, Ursodeoxycholic acid, Antihistamines, Emollients, Rocket oil, Peppermint oil