Womens & Childrens Services Clinical Guidelines WACSClinProc1.

16 Title: Replaces: Description: Target Audience: Key Words: Rash in Pregnancy New Guideline Exposure and management of rash illness in pregnancy Midwives and medical officers, QVMU Pruritic urticarial papules and plaques of pregnancy, herpes gestationis, prurigo of pregnancy, cholestasis Parvovirus B19 and Rubella Exposure in Pregnancy WACSClinProc1.15 Varicella-Zoster Virus Exposure and Infection in Pregnancy and Newborn Period WACSClinProc1.5

Policy Supported:

Purpose: Definition: Dermatoses of pregnancy refer to skin eruptions that are confined to pregnancy and puerperal women. These include: Pruritic urticarial papules and plaques of pregnancy (PUPPS) Herpes gestationis Prurigo of pregnancy Cholestasis of pregnancy Polymorphic Eruption of Pregnancy (PEP) PEP was previously known as pruritic urticarial papules and plaques of pregnancy (PUPPS). PEP occurs in 1/160 to 1/300 pregnancies. It is more common in primigravida women and women with multiple gestation. The aetiology of PEP is unknown. It poses no increased risk of fetal or maternal morbidity. PEP presents as erythematous papules within striae. Abdominal striae are the most common initial site. The lesions then spread to the extremities and coalesce to form urticarial plaques (hives). The face, palms and soles are usually spared. White halos often surround the erythematous papules. Lesions may also be target-like, usually exhibiting three distinct rings/colour changes instead of a halo. All women have extreme pruritus. PEP usually begins late in the third trimester, but may develop postpartum. There are rare case reports of first and second trimester disease. Pruritus may worsen immediately after delivery, but generally resolves by 15 days postpartum. Moisturiser, topical steroids and antihistamines alleviate symptoms in most women. Systemic corticosteroids may be required for extreme pruritus. Herpes Gestationis Herpes gestationis refers to a blistering disease that is associated with pregnancy and increased fetal risk. The incidence is 1/1700 to 1/50 000 pregnancies.
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Herpes gestationis erupts during the second or third trimester or postpartum. Pruritus may precede the rash, which typically begins on the trunk as urticarial plaques or papules surrounding the umbilicus, vesicles may also be present. Lesions maybe seen on the palms and soles, but rarely on the face or mucous membranes. The eruption spreads rapidly and forms bullae. Skin biopsy maybe required for diagnosis. Topical steroids and antihistamines should be administered in early or mild cases, but are usually ineffective. Systemic steroids, such as prednisone (0.5mg/kg per day), control most cases. The fetus is at risk for growth restriction and prematurity. Mild placental insufficiency may result from an immune response between placental antigens and the antibody targeted against the skin antigen. Few newborns actually present with an eruption. Those with neonatal herpes gestationis have a mild course that resolves within weeks. Prurigo of Pregnancy The incidence of prurigo of pregnancy is 1 in 300 to 1 in 450 pregnancies. It usually begins in the second or third trimester. Clinical diagnostic criteria consist of erythematous, excoriated nodules, or papules on the extensor surfaces of the limbs and trunk. Lesions are grouped and may be crusted or appear eczematous. The lesions usually resolve in the immediate postpartum period, although it can persist for up to three months. The aetiology is unknown. Treatment is symptomatic; topical steroids and antihistamine.

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Attachments Attachment 1 Attachment 2

Dermatoses of Pregnancy Pictures References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 13 December 2007

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ATTACHMENT 1 Dermatoses of Pregnancy

Nelson-Piercy, C 2002, Handbook of Obstetric Medicine, 2

nd

ed, Dunitz, London.

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ATTACHMENT 2 REFERENCES Ahmadi, S & Powell, F 2005, Pruritic urticarial papules and plaques of pregnancy: Current status Journal of Dermatology, vol 46, pp. 55-60. Nelson-Piercy, C 2002, Handbook of Obstetric Medicine, 2nd ed, Dunitz, London. Pmeranz, M 2006, Dermatoses of pregnancy, UpToDate, Online: http://uptodateonline.com/utd/content/topic.do?topicKey=pregcomp/12600&selectedTitle=1 ~1318&source=search_result

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