A study of pregnancy specific dermatoses and their effect on the outcome of pregnancy

INTRODUCTION

Pregnancy is a complex state and interactions of multiple factors including genetic, hormonal and immunologic changes occurring during pregnancy result in various skin changes.¹ Interactions of hormonal factors with the immune system play a significant role in the pathogenesis of skin diseases specific to pregnancy.² The timing of many pregnancy specific dermatoses may be correlated to hormonal changes that occur during pregnancy. Physiological skin changes are common during pregnancy in addition to cutaneous diseases specific to pregnancy. It is important to differentiate physiologic changes from specific dermatoses as the latter can be pruritic or painful to the mother and may pose significant risk to mother, her fetus or both.

Ambros-Rudolph et al has classified specific pregnancy dermatosis as (1) pemphigoid gestationis (2) polymorphic eruption of pregnancy (3) intrahepatic cholestasis of pregnancy and (4) atopic eruption of pregnancy.³

There have been many studies focussing on a particular dermatosis or other occurring in pregnancy. The studies available show wide variations in the incidence of specific dermatoses of pregnancy. Studies related to this topic are few in this part of the state.

The concerns of the patient having any of the dermatological disorders may range from cosmetic appearance to it’s potential effects on the fetus in terms of morbidity and mortality. Some of the dermatoses may influence pregnancy and fetal health which can be countered effectively if diagnosed early. So a study was undertaken to know the incidence and type of pregnancy dermatoses and its influence on obstetric outcome if any.

The study was conducted with the aim to determine the proportion of pregnancy related dermatoses among antenatal women presenting to the outpatient department or referred from Obstetrics and Gynaecology department, to study the factors influencing pregnancy dermatoses and to study the effect of pregnancy dermatoses in the development of the baby if any.

METHODS

After getting sanction from ethical committee, all antenatal women attending the outpatient department with dermatological complaints and those cases referred from Obstetrics and Gynaecology department were taken up for the study. The study was conducted at Govt. Medical college hospital, Kottayam in central Kerala during April 2013 to October 2014.

A total of 175 antenatal women were studied irrespective of duration of pregnancy and gravidity. Detailed history and physical and cutaneous examinations were done. In all cases, blood, urine examinations, screening with VDRL and ELISA for HIV were done. In all cases with pruritus, LFT and serum bile acids were done. All cases were followed up to know their pregnancy outcome including sex of the baby, birth weight and mode of delivery etc.

Patients who were not willing to participate in the study and those who could not be followed up till delivery were excluded from the study.

RESULTS

A total of 175 antenatal women were included in the study. Of these, 95 were primi gravida (54.3%) and the rest 80 (45.7%) were multi gravida as shown in Table 1.

Mean age of the patients was 27.3 years with a standard deviation of 4.8. Their age ranged from 19 years to 42 years. Maximum patients belonged to 21-30 age group. Most of the patients presented in the third trimester as shown in Figure 1.

Mean weight of patients was 60.5 kg with a standard deviation of 9.019. Body weight ranged from 43 kg to 105 kg. Physiological changes of pregnancy were present in 165 cases (94.3%). Of the various physiological changes, hyper pigmentation was the commonest being present in 158 (90.3%) cases. Most of them (97%) were in the third or second trimester.

Pregnancy specific dermatoses

Mean age of patients with pregnancy dermatoses was 27.1. Maximum number of cases was observed below 30 years. There was no association between age and occurrence of pregnancy dermatoses. Most common of the specific pregnancy dermatoses noted was PUPPP.

There was a statistically significant higher incidence of pregnancy specific dermatoses in third trimester (p= 0.03). No cases of pregnancy specific dermatosis occurred in first trimester as in Figure 2. All cases of PUPPP presented in the third trimester. There was a higher incidence of ICP and AEP in the third trimester as in Table 3.

As presented in Table 3, there was a statistically significant higher incidence of specific pregnancy dermatoses (42/66) among primi gravida in the study (p= 0.03). There was statistically significant higher incidence of PUPPP among primi. There was no association between gravidity and other pregnancy specific dermatoses.

There was a significant association between PUPPP and higher maternal body weight. There was no association between other specific pregnancy dermatoses and body weight as given in Table 4.

There was a higher incidence of PUPPP in twin pregnancies which was statistically significant (p= 0.036). No other pregnancy specific dermatosis showed statistically significant higher incidence among twin pregnancies as shown in Table 5. As given in Table 6, mean birth weight of babies whose mothers had PUPPP was found to be high which was statistically significant.

We found higher incidence of PUPPP among mothers who had gestational diabetes mellitus (GDM). This was found to be statistically significant. Other specific dermatoses had no significant association as in Table 7.

PUPPP was found to be more common among mothers who had male babies. Other specific pregnancy dermatoses had no such association as presented in Table 8. Table 9 shows that there was no association between presence of specific dermatoses and mode of delivery.

DISCUSSION

Pregnancy is a unique physiological state characterised by metabolic, immunologic and hormonal readjustments, many of which bring changes in skin and mucus membranes. In addition to these, a host of rare pruritic dermatoses are specific to pregnancy.

During the 18 month study from April 2013 to October 2014, 175 antenatal women were taken up for the study. They were followed up to know the pregnancy outcome also.

Parity and age

Primis outnumbered multiparas in this study (54.3% against 45.7%) which is in agreement with other studies also.⁴ The mean age in this study 27.3 years which is higher compared to other studies by Kumari et al and Muzzafir et al.^5,6 This could be due to relatively earlier age at marriage in other states compared to our state.

Majority of patients were in second and third trimester as in other studies by Kumari et al and Shivakumar et al.^5,7

Physiological changes

Hyperpigmentation was the commonest physiological change (90.3%) as in other studies by Rathore et al, Kumari et al and Muzzafir et al.^4-6

Specific dermatoses of pregnancy

We observed specific pregnancy dermatoses in 66 (38.3%) patients. Raj et al had only 1.5% cases and Kumari et al had 3.6%.^5,8 Higher percentage in this study is due to the fact that ours being a tertiary care teaching hospital, more cases are referred from periphery. No association was noted between age and occurrence of pregnancy dermatoses in this study.

PUPPP was the most common type of specific pregnancy dermatosis seen. This is in agreement with many other studies.⁵

Trimester distribution

All cases of pregnancy dermatoses occurred in the second and third trimester. Most other Indian studies also had similar findings.^7,8 Vaughan Jones et al found that 49% of specific dermatoses occurred during third trimester.⁹ This is because of the maximum hormonal change occurring in the third trimester. In this study, all cases of PUPPP occurred in the third trimester. Ambros-Rudolph et al found that 98% cases of PUPPP occurred in third trimester.³ This is attributed to the excessive abdominal stretching resulting in collagen and elastic fibre damage with subsequent conversion of non-antigenic molecules to antigenic ones, acting as a trigger for the inflammatory skin changes.^10-12 PUPPP was more common among primi gravid in this study i.e. 72%. Study by Ambros-Rudolph et al also had 73% primis.³ This is because of the lax abdominal wall in multi gravida resulting in less stretching.

PUPPP was found to be more common in women with more body weight (>60 kg) and in twin pregnancy. This is also due to the excessive abdominal stretching. The same explanation can be given for the increased incidence in mothers whose babies have more birth weight.

In GDM, the body weight of the mother and baby will be higher, resulting in excessive abdominal stretching and PUPPP.

A higher incidence of PUPPP was seen in mothers with male babies. Other studies also show a higher occurrence of PUPPP in mothers with male foetuses.^9,13 This is due to the migration of fetal cells to maternal skin, leading to skin eruption because pregnancy is associated with peripheral blood chimerism, particularly during third trimester.¹⁴ Why this occurs more with male fetus is speculative.

No adverse outcome occurred in patients and their off springs in our study. This could be due to the better obstetric care in this tertiary care centre.

CONCLUSION

Study was conducted on 175 patients between April 2013 and October 2014. Most common age group was 21-30 years. Most common physiological change was hyper pigmentation. Specific pregnancy dermatoses were observed in 66 (38.3%) cases. 94% of pregnancy dermatoses occurred in third trimester. Most common specific dermatosis in the study was PUPPP. 64% of patients with specific dermatoses were primi gravida. All cases of PUPPP occurred in third trimester. There was a higher incidence of PUPPP among mothers with more body weight, in twin pregnancy and gestational diabetes mellitus. PUPPP was also more common in mothers whose babies were male and with more birth weight. None of the specific dermatoses produced adverse outcome of pregnancy.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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