A 36-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the office for a prenatal visit. The patient is a landscape designer and has noticed skin changes over the past few weeks because she has spent more time in the sun. She has progressive darkening of the face, particularly over the nasal bridge and cheeks, and increasing freckles on the upper and lower extremities. The patient also has increased hair on the upper lip and itching over the stretch marks on the abdomen and chest. On examination, there is hyperpigmentation over the cheeks and nasal bridge that spares the nasolabial folds. The upper lip has multiple dark terminal hairs. The abdomen is gravid and nontender with multiple erythematous papules within the striae on the abdomen and chest. The chest also has multiple blanching, 1- to 2-cm spider angiomas. There is a black-tan nevus with irregular borders on the lower extremity and multiple freckles on bilateral extremities. The remainder of the examination is unremarkable. Which of the following findings is most concerning in this patient?

Question

A 36-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the office for a prenatal visit.  The patient is a landscape designer and has noticed skin changes over the past few weeks because she has spent more time in the sun.  She has progressive darkening of the face, particularly over the nasal bridge and cheeks, and increasing freckles on the upper and lower extremities.  The patient also has increased hair on the upper lip and itching over the stretch marks on the abdomen and chest.  On examination, there is hyperpigmentation over the cheeks and nasal bridge that spares the nasolabial folds.  The upper lip has multiple dark terminal hairs.  The abdomen is gravid and nontender with multiple erythematous papules within the striae on the abdomen and chest.  The chest also has multiple blanching, 1- to 2-cm spider angiomas.  There is a black-tan nevus with irregular borders on the lower extremity and multiple freckles on bilateral extremities.  The remainder of the examination is unremarkable.  Which of the following findings is most concerning in this patient?

Quizplus · Accepted Answer

11ec25c8_da55_1a5e_bc81_65c36a59f07e_MD0003_00 Pregnancy induces multiple maternal changes, including in the skin, hair, and nails, due to fluctuations in estrogen and progesterone. Most of these changes are benign and reversible. However, pathologic changes in pregnancy can also occur; therefore, all changing skin lesions should be assessed for possible malignancy. This patient with prolonged sun exposure has the ugly duckling sign, a variegated (ie, different colors) nevus (eg, black-tan) with irregular borders distinctly different from the other melanocytic nevi (freckles). The ugly duckling sign is concerning for possible melanoma. Increased pigmentation is normal in pregnancy, but color variation is abnormal and requires additional evaluation with biopsy regardless of pregnancy status. Additional indications for biopsy include a change in shape (asymmetry), size, or border regularity. (Choice A) Centrofacial hyperpigmentation that spares the nasolabial folds is due to melasma, a common benign condition in pregnancy. This is likely induced by estrogen and progesterone effects on melanocytes, causing increased melanin accumulation. It typically fades postpartum, although some hyperpigmentation may persist. (Choice B) Polymorphic eruption of pregnancy (also known as pruritic urticarial papules and plaques of pregnancy [PUPPP]) may be triggered by the skin stretching over the enlarging gravid uterus that causes inflammation and pruritus within abdominal striae. It is a benign self-limited condition that resolves postpartum. (Choice C) Increasing upper lip hair in pregnancy is due to increased circulating androgens (placental and ovarian), causing thickened terminal hair growth. In addition, scalp hair spends more time in the anagen growth phase, causing decreased hair loss. Hair loss occurs postpartum due to a large proportion of hair in the resting telogen phase (ie, telogen effluvium); however, terminal hairs may be permanent. (Choice D) Spider angiomas are benign, erythematous lesions that blanch with pressure. They occur frequently in pregnancy due to increased estrogen levels that cause increased blood vessel vascularity; they typically resolve postpartum. Spider angiomas Educational objective: Variegated nevi, particularly those that change (eg, color, shape), require evaluation and biopsy in pregnant and nonpregnant women due to the possibility of melanoma.

A 36-Year-Old Woman, Gravida 1 Para 0, at 30 Weeks