What is Pruritus in Pregnancy?
Pruritus, or itchiness, often occurs when the skin becomes damaged or dry. When the protective layer of the skin is harmed, it can cause water to be lost from the top layer of skin, and this triggers nerves that make you itch. Scratching can further harm the protective skin layer, leading to more itchy feelings. Creams or lotions applied directly to the skin are commonly used treatments, and as we better understand the reasons behind itchiness, new itch-relief therapies are being found.
Pregnancy is a time of significant changes in the body, including hormone levels, which can lead to various alterations in the skin. Over 90% of pregnant women experience some sort of skin changes. Among these, feeling itchy is very common. However, we don’t fully understand why this itchiness occurs. Some skin disorders affect specific parts of the body – for instance, itchiness in the genital area is a common symptom during pregnancy.
It’s important to understand that itchiness during pregnancy could be due to either changes related to pregnancy or to other unrelated causes. Discerning between these is crucial because itchiness during pregnancy may sometimes be the first sign of an underlying problem which could negatively affect both the mother and the baby, leading to increased risk of illness and, in some cases, even the threat of death.
What Causes Pruritus in Pregnancy?
During pregnancy, various changes in the body including increased pressure due to the growing abdomen, and swelling may all result in itching or “pruritus”. Pregnant women’s bodies also undergo hormonal changes which can affect the immune system and lead to increased itching.
Itches during pregnancy can be due to many reasons like skin conditions that only appear during pregnancy and disappear after birth or issues that are not directly related to pregnancy. One reason could be an increase in certain hormones during pregnancy which affects the production of a certain type of immunity protein called IgE and the release of certain elements that contribute to the itching problem.
There are conditions that cause itching in pregnancy which are not directly related to pregnancy. These include various illnesses such as kidney, liver, and thyroid problems, anemia due to lack of iron, diabetes, parasitic infestations, certain mental health disorders, and systemic infections such as hepatitis or HIV. However, the most common cause of generalized itch is dry skin.
Some other common causes of itching during pregnancy include atopic dermatitis, which is an ongoing inflammatory skin disease that causes skin irritation and itching when in contact with irritants. Prurigo nodularis, a chronic skin disease that results in extremely itchy nodular skin lesions that trigger constant itching and scratching, and psoriasis, a skin disease that causes itching and is identified by patches of red, thick, and scaling skin. There’s also notalgia paresthetica, a condition characterized by persistent itching on the back. Other causes include pigmented contact dermatitis, pityrosporum folliculitis, parapsoriasis, neurodermatitis, and primitive cutaneous amyloidosis.
Itching in the vulva or the vagina, although it can increase during pregnancy, is usually not specifically related to pregnancy and has multiple causes, including certain skin conditions, or vulvovaginal candidiasis, a common infection caused by the yeast Candida albicans. Certain parasites, sexually transmitted, can also lead to itching.
Skin diseases that affect the skin of the vulva, can also cause itching. Rarely, these skin conditions are seen during pregnancy and they are either an inflammatory skin condition called Lichen Sclerosis, or an autoimmune disorder known as Lichen Planus. Another condition, Lichen Simplex Chronicus, can make a cycle of itching and scratching.
In some cases, the cause of itching might not be identified and is this scenario is termed as pruritus of unknown origin, which affects a significant percentage of pregnant women.
There are also certain skin conditions that are specific to pregnancy and have itching as one of their symptoms. They include pemphigoid gestationis, intrahepatic cholestasis of pregnancy, polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pustular psoriasis of pregnancy.
Intrahepatic cholestasis of pregnancy (ICP) refers to severe itching caused by problems in the liver. The itching usually begins in the late second or early third trimester but can be as early as 8 weeks of gestation.
Atopic Eruption of Pregnancy (AEP) is a cause of itching in pregnancy and is the most common skin disease seen during pregnancy. This condition usually starts early in pregnancy and causes very itchy, grouped skin eruptions mainly on the arms or legs.
Another common cause of itching in pregnancy is Polymorphic Eruption of Pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy (PUPPP), which generally starts in the last trimester or even after delivery, and is associated with severe itching.
Pustular Psoriasis of Pregnancy is a rare form of psoriasis that usually occurs in the third trimester of pregnancy and can cause mild itching. Pemphigoid gestationis (PG) is a rare condition that can also cause severe itchiness during pregnancy due to an autoimmune process. This condition usually gets better as the pregnancy progresses, but it may recur in future pregnancies.
Risk Factors and Frequency for Pruritus in Pregnancy
Between 23% and 38% of pregnant women experience itching, and for 2% of these women, it can become severe. It can be an early sign of a condition related to pregnancy. The source of itchiness for about 11.8% to 76.4% of these women comes from skin conditions associated with pregnancy. Usually, itching starts around the 27th week of pregnancy or just after.
- The itchiest spots tend to be the abdomen, chest, hands, feet, and lower legs, in that order.
- It’s less common for the itching to affect the private area.
- Itching usually gets worse in the evening and can interfere with sleep for some women.
- Humidity, heat, and dry air can make the itching worse.
We still don’t know exactly how many pregnant women experience itching, but it’s probable that it’s even more common than current statistics suggest.
Signs and Symptoms of Pruritus in Pregnancy
Itching is an annoying feeling that makes you want to scratch. When pregnant women experience itching, doctors will go over detailed medical and travel history, check for skin conditions associated with the itching, identify the location and timing of the itch, and any treatments they have tried. This information helps in identifying the cause and deciding on an effective treatment. Different techniques can assess itching, and labs might be helpful, based on what the doctor thinks could be causing the itch.
In ICP (Intrahepatic cholestasis of pregnancy), a condition where the normal flow of bile in the gallbladder is affected, the itching doesn’t lead to visible skin issues. If there are any primary skin issues, ICP is ruled out. The only signs usually seen are marks or wounds from scratching due to itching.
Itching in the female genital area caused by a yeast infection is usually accompanied by a burning sensation and, in some cases, painful urination and sexual intercourse. Upon examining, doctors could find abnormalities such as vaginal discharge, skin redness, small pus-filled bumps, or skin sores. A chronic skin condition called Lichen simplex chronicus can result in redness, flaking, firm plaques, and scratch marks in the female genital area. In case of a parasitic infection like scabies, the doctor might observe burrows in the skin of the genital area. In case of pubic lice, the lice and their eggs could be visible.
Testing for Pruritus in Pregnancy
Itching during pregnancy may or may not be accompanied by noticeable changes to the skin. If such changes are present, it usually signals a skin-related disease. Other skin changes such as skin abrasions, thickening, and darkening, are typically the result of scratching and long-term rubbing. To evaluate the itching during pregnancy, doctors consider various factors such as the specific location of the itching or skin lesions, timing of when the itching started, things that make the itching worse or better, and the appearance of the skin lesions.
Initial tests might include checking liver functions, complete blood count, basic metabolic panel (a blood test that measures different chemicals in the blood), thyroid-stimulating hormone (to check thyroid health), and bile acids (which helps digest fat) levels in the blood. Depending on these initial test results, further tests may be needed. These can include protein electrophoresis (a test to analyze specific proteins in the blood), HIV testing, testing stool for worms and parasites, and testing for hepatitis (a disease that harms the liver).
Itching without any changes in the skin may suggest other conditions such as cholestasis of pregnancy (a liver disorder that can occur late in pregnancy), psychological factors or nerves-related issues. Other causes may include conditions such as paresthetica (a sensory nerve disorder), after-effects of shingles, stroke, vulvodynia (pain in the vulva), and itching on the forearm.
Treatment Options for Pruritus in Pregnancy
The goal of treatment should be to alleviate symptoms and prevent any potential harm to the baby. Minor symptoms can be managed with reassurance, education, psychological strategies, lotions to stop itchiness, and mild steroid creams. Patients should be advised to avoid stress and irritating clothing.
Itchiness associated with the skin barrier is treated initially with topical therapies. This includes creams and lotions that maintain skin moisture, corticosteroid creams, ointments, local anesthetics, and oral and topical antihistamines, which are used to reduce itching and allergy symptoms. In some cases, a mix of topical (applied to the skin) and systemic (affecting the whole body) therapies may be required to stop the itch-scratch cycle. However, the choice and duration of treatment greatly depend on the individual patient and the underlying cause of the itching.
Topical steroids are usually considered safe during pregnancy, but stronger steroids might cause issues like restricted baby growth, skin thinning, and increased stretch marks. So, it is advised to start with mild- to moderate-potency steroids for topical application. If stronger steroids are needed to control itchiness, they should be used for a limited duration and should not be applied on areas with thin skin.
Topical azoles are safe to use during pregnancy to treat yeast and fungal infections. Studies have shown that these creams, such as clotrimycin and miconazole, do not increase the rate of complications in the pregnancy. Among the oral antifungal agents, terbinafine is considered the safest during pregnancy, but low-dose fluconazole can also be taken safely. However, it is generally preferred to use topical antifungal agents during pregnancy.
The safety of medications used to treat itchiness during pregnancy is not fully understood, but first-generation antihistamines, which help to reduce itchiness, are considered safe during pregnancy. Other drugs, such as cholestyramine and oral corticosteroids, may also be used, especially for stubborn itchiness.
Polymorphic Eruption of Pregnancy (PEP), Atopic Eruption of Pregnancy (AEP), and Pemphigoid Gestationis (PG) are different conditions that could cause itchiness during pregnancy. These are usually treated with low- to mid-potency steroids applied on the inflamed areas, milder soaps, moisturizing creams, and oral antihistamines. For some cases, ultraviolet phototherapy or oral corticosteroids may be used if the itchiness is not reduced by other treatments.
In the case of Intrahepatic Cholestasis of Pregnancy (ICP), a condition that causes itchiness and can affect liver function in pregnant women, treatment typically begins with oral ursodeoxycholic acid. This medication helps to relieve itchiness and also lowers serum liver levels. If used safely, this treatment can reduce the chances of stillbirth and preterm birth rates – an additional benefit of the medicine. If the symptoms persist, Rifampicin is another medication safely used in the last stage of pregnancy to treat ICP.
ICP increases the risks of complications for the baby, including preterm birth, neonatal depression, and stillbirth. However, the risks for the mother are small. To decrease the risk of complications, the American College of Obstetricians and Gynecologists recommends regular check-ups with the doctor right from the time of diagnosis until the child is delivered. The right time for delivery is established according to the levels of total bile acids in the serum of the mother.
What else can Pruritus in Pregnancy be?
During pregnancy, various skin conditions may occur. A few of these include:
- Polymorphic eruption of pregnancy (PEP): This is a common skin condition affecting 1 in 200 to 250 pregnant women, particularly common among those who are first-time mothers, expectant mothers of more than one baby, and those who are obese. Typically showing up in the third trimester, it’s characterized by intensely itchy, hives-like bumps and patches which appear on the belly, but spare the palms, soles, belly button and face.
- Atopic eruption of pregnancy (AEP): Included in this category are prurigo of pregnancy, pruritic folliculitis of pregnancy, and eczema of pregnancy. It is actually the most common skin issue seen during pregnancy.
- Pemphigoid gestationis: This used to be called herpes gestationis.
- Pustular psoriasis of pregnancy (PPP).
There are also skin conditions that do not present any primary skin abnormalities such as:
- Psychogenic disorders
- Systemic diseases
- Neurologic conditions
- Renal abnormalities
- Liver abnormalities
- Endocrine disorders, like thyroid and diabetes
- Iron deficiency anemia
- Cancer
- Rheumatic disease
- Drug reactions
- Systemic infections, such as HIV
- Dry skin or xerosis
- Intrahepatic cholestasis of pregnancy
What to expect with Pruritus in Pregnancy
Patients should be advised that their symptoms, especially itching caused by skin conditions related to pregnancy, will typically resolve quickly after they have given birth. The fact that these conditions are usually temporary is an important factor to keep in mind.
In the case of skin conditions not specific to pregnancy, the recovery outlook can vary, depending on the cause of the itching.
For a condition known as Intrahepatic Cholestasis of Pregnancy (ICP), a liver disease that occurs during pregnancy, both the mother’s and baby’s recovery outlook is typically very good. This condition is usually managed by keeping a closer eye on the baby’s health, treating the mother with medications to reduce bile acids, which cause the itchiness, and considering early delivery based on doctor’s advice.
Possible Complications When Diagnosed with Pruritus in Pregnancy
Pruritus or itching during pregnancy can lead to different complications for the mother and the unborn child, mainly due to a condition known as Intrahepatic Cholestasis of Pregnancy (ICP).
For the mother, these complications can involve problems with nutrient absorption and sometimes bleeding after giving birth. These issues stem from reduced vitamin K levels due to liver abnormalities. Some research also suggests that those affected may have an increased chance of developing gallbladder disease, including gallstones.
Complications for the unborn child with ICP can include premature birth, insufficient oxygen supply inside the womb, a condition where the amniotic fluid is stained by meconium (baby’s first stool), and low birth weight. High levels of bile acids, especially more than 100 micromol/L, have been linked to an increased risk of adverse events in the fetus. It is believed that these complications happen due to a lack of oxygen supply to the placenta and the harmful effects of high levels of bile acids on the fetal heart. However, full understanding of how ICP leads to these negative outcomes is still limited.
Possible Complications:
- Nutrient absorption issues in mother
- Postpartum bleeding in mother
- Possible gallbladder disease in mother
- Premature birth
- Insufficient oxygen supply in the womb
- Meconium-stained amniotic fluid
- Low birth weight
- Increased risk with high bile acid levels
Preventing Pruritus in Pregnancy
Patients need to avoid scratching as much as possible to prevent additional skin injuries and open sores. If the symptoms become too difficult to manage or cause a lot of discomfort, they should get in touch with their healthcare provider. Sticking to the treatment prescribed by the doctor is very important, and patients should feel comforted knowing that the outlook for their condition is generally good.
