 |
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
- Peharda
V, Gruber F, Kastelan M, Brajac I, Cabrijan L. Pruritus an important symptom of
internal diseases. Dermatovenerologica 2000;9:108-11.
- Wong RC,
Ellis CN. Physiologic skin changes in pregnancy. J Am Acad
Dermatol 1984;10(6):929-40.
- Rook A,
Wilkinson DS, Ebling FJ, editors. Textbook of dermatology. 3rd ed.
Oxford, Engl: Blackwell Scientific Publications 1979. p.213.
- GP
Notebook. Pruritus gravidarum. Available from: <http://www.gpnotebook.co.uk/simplepage.cfm?ID=-2147090414>
[accessed on 11 Sep 2014].
- Bergman
H, Melamed N, Koren G. Pruritus in pregnancy. Can Fam Physician 2013;59(12):
1290-4.
- 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.
- 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
Keywords: Pruritus in pregnancy,
Pruritus gravidarum, Cause, Diagnosis, Treatment, Prognosis, Ursodeoxycholic acid, Antihistamines,
Emollients, Rocket oil, Peppermint oil
