A 24-year-old woman, gravida 1 para 0, at 35 weeks gestation comes to the office for a routine prenatal visit. The patient has dichorionic diamniotic twins and has had no complications during the pregnancy. Fetal movement is normal for each twin. Over the past week, the patient developed a pruritic rash on the abdomen. The pruritus has become progressively more severe and is preventing her from sleeping. She has no chronic medical conditions. Vital signs are normal. The fetal heart rate for both twins is 150/min. Fundal height is 38 cm. Physical examination is seen in the exhibit. No other lesions are visualized. Which of the following is the most appropriate treatment for this patient?

Question

A 24-year-old woman, gravida 1 para 0, at 35 weeks gestation comes to the office for a routine prenatal visit.  The patient has dichorionic diamniotic twins and has had no complications during the pregnancy.  Fetal movement is normal for each twin.  Over the past week, the patient developed a pruritic rash on the abdomen.  The pruritus has become progressively more severe and is preventing her from sleeping.  She has no chronic medical conditions.  Vital signs are normal.  The fetal heart rate for both twins is 150/min.  Fundal height is 38 cm.  Physical examination is seen in the exhibit.  No other lesions are visualized.  Which of the following is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_da24_6e10_bc81_bf63d7b77b7b_MD0003_00 This patient has polymorphic eruption of pregnancy (PEP) (also known as pruritic urticarial papules and plaques of pregnancy [PUPPP]), a common inflammatory disorder that develops during the third trimester of pregnancy or immediately postpartum. PEP occurs when overstretching of the skin causes underlying connective tissue damage, which exposes dermal antigens and causes an inflammatory response. Chronic inflammation results in a pruritic, erythematous papular rash that is limited to the abdominal striae. The PEP rash may develop a centrifugal spread but typically spares the umbilicus, face, hands, and feet. PEP PEP is diagnosed clinically and is common in nulliparous women or those with multiple gestations. It does not require additional obstetric management as it is not associated with adverse maternal-fetal outcomes. Therefore, management is control of pruritic symptoms; treatment typically includes antihistamines and topical corticosteroids. PEP typically resolves spontaneously immediately postpartum. (Choice A) Oral antibiotics (eg, cephalexin) are used in the treatment of cellulitis. In contrast to this patient with PEP, those with cellulitis have a unilateral rash that extends beyond the abdominal striae and is often accompanied by warmth, tenderness, redness, or fever. (Choice B) Antiviral agents (eg, valacyclovir) are indicated in the management of herpes zoster, which can present with an erythematous papular rash confined to the abdomen. Herpes zoster typically is a unilateral rash (following a dermatomal pattern) that spreads beyond the abdominal striae, and lesions evolve into vesicles and bullae. (Choice D) Topical retinoids are indicated in the treatment of melasma, a common rash during pregnancy. However, melasma typically presents as a hyperpigmented rash on sun-exposed areas such as the face (commonly as a malar rash that spares the nasolabial folds). In addition, retinoids are teratogenic and contraindicated during pregnancy. (Choice E) Ursodeoxycholic acid is used in patients with intrahepatic cholestasis of pregnancy, which typically presents with pruritus during the third trimester. Patients typically have pruritus worst on the hands and feet and have no associated rash. Educational objective: Polymorphic eruption of pregnancy (PEP) develops in the third trimester as a pruritic, erythematous papular rash that is limited to the abdominal striae and spares the umbilicus. PEP is not associated with adverse maternal-fetal outcomes and resolves spontaneously postpartum. Treatment is with topical corticosteroids. References: Pruritus in pregnancy and its management. (http://www.ncbi.nlm.nih.gov/pubmed/29929597) Polymorphic eruption of pregnancy: review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/27960565) Dermatological diseases associated with pregnancy: pemphigoid gestationis, polymorphic eruption of pregnancy, intrahepatic cholestasis of pregnancy, and atopic eruption of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26609305)

A 24-Year-Old Woman, Gravida 1 Para 0, at 35 Weeks