Abstract
A primigravida in her 20s, with 38 weeks period of gestation, came to the emergency ward of obstetrics wing with complaints of extensive itching over the extremities. On local examination, there were multiple, discrete, hyperpigmented papules topped with depigmentation and excoriations on upper and lower extremities. These are of 0.5–1 cm in size and some have central crusts . On clinical findings and exclusion of other pathologies, it was diagnosed as prurigo of pregnancy. The patient had an uneventful follow-up period.
Keywords: Obstetrics, gynaecology and fertility; Skin; Primary care
Background
Prurigo of pregnancy (PP) affects one in 300 to one in 450 pregnancies.1 Studies conducted in India have revealed a greater incidence, frequently surpassing that of polymorphic eruption of pregnancy.1 It includes conditions such as early-onset prurigo and papular dermatitis of pregnancy as described by Spangler, as well as Besnier’s prurigo gestationis.2 It begins in the middle of pregnancy, between weeks 25 and 30 of gestation.3 There are no diagnostic laboratory abnormalities, and the histopathological results are non-specific. It has no adverse effects on the development of the fetus.4
Case presentation
A primigravida in her 20s, with 38 weeks period of gestation, presented with complaints of extensive itching over the extremities. There were no similar episodes in the past and no significant family history. On examination, her vitals were normal and there was no pallor or icterus. There were multiple, discrete, hyperpigmented papules topped with depigmentation and excoriations on upper and lower extremities measuring about 0.5–1 cm in diameter and some have crustations in the centre (figures 1 and 2). The liver function tests showed total bilirubin of 0.9 mg/dL, serum glutamic pyruvic transaminase (SGOT) of 22 U/L and serum glutamic pyruvic transaminase (SGPT) of 40 U/L. Hence, intrahepatic cholestasis of pregnancy, sclerosing cholangitis and primary biliary cirrhosis were ruled out. Discharge from the excoriations was taken and sent for culture and sensitivity which was found to be sterile, and hence, infections were ruled out. There were no rashes or pain on the stretch marks on belly, and hence, pruritic urticarial papules and plaques of pregnancy (PUPPP) were ruled out. Based on the clinical findings, patient was diagnosed as PP and treated with topical steroids, emollients and oral antihistamines that were administered for 2 weeks. Improvement in symptoms was seen after 1 week of treatment.
Figure 1.
A papules over the upper extremities.
Figure 2.
The central crusts in the papules of lower extremities.
Investigations
Blood investigations showed haemoglobin of 10.8 g/L, platelet count of 2.5 lakhs/ L and WBC count of 14 / L . Liver function tests showed total bilirubin of 0.9 mg/dL, SGOT of 22 U/L and SGPT of 40 U/L. Culture and sensitivity report was sterile.
Treatment
Topical steroids for local application was administered two times per day for 2 weeks
Emollients and oral antihistamines were administered two times per day for 2 weeks.
Outcome and follow-up
Patient was discharged on day 6, and symptoms were reduced. She came for follow-up care after a week and her skin lesions significantly subsided.
Discussion
Our case presented with multiple discrete papules of 0.5–1 cm in diameter over extremities and was associated with intense itching. The possible causes for this condition like cholestasis of pregnancy, atopic dermatitis, infections, PUPPP and sclerosing cholangitis were ruled out on the basis of clinical features, liver function tests and culture and sensitivity. On clinical basis and after ruling out other causes, it was finally diagnosed as PP. It is a very common condition seen in pregnant women and is not associated with any teratogenicity. Regular antenatal check-ups with vigilance are required in early diagnosis and treatment.
Patient’s perspective.
I was unaware throughout my pregnancy. For the first time at 38 weeks, I got to know the condition of my skin lesions. It brought a lot of anxiety, and I was worried about the pregnancy outcome and the future. I was counselled and supported by the medical team. Now I am aware of such conditions and want to be vigilant for my future pregnancy.
Learning points.
Prurigo of pregnancy is a non-specific condition which is diagnosed based on clinical findings and excluding the other pathologies.
By keen and thorough examination of the patient, diagnosis and management can be done early.
Patient counselling is crucial with regard to these skin problems.
Footnotes
Contributors: AB drafted the manuscript. RGY and AK helped in the preparation of the manuscript, and STR finalised the manuscript.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
Patient consent for publication
Consent obtained directly from patient(s).
References
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