Term
| Describe rash and onset for pruritic urticarial papules and plaques of pregnancy (PUPPS) |
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Definition
Third trimester or postpartum
Primigravidas
Resolution postpartum
Association with multiple gestation
No recurrence in future pregnancies
Polymorphous eruption starts in the abdominal striae and shows periumbilical sparing |
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Term
Describe rash and onset of pruritic folliculitis of pregnancy |
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Definition
Presents with itching and papular acne like rash usually on back, shoulders and chest, sometimes arms and abdomen
Second or third trimester
Resolution postpartum
recurrence in future pregnancies unlikely |
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Term
| Pruritus gravidarum rash and onset |
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Definition
| No rash; occurs in first trimester |
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Term
| Prurigo of pregnancy rash and onset |
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Definition
Second or third trimester
Resolution postpartum
+ recurrence in future pregnancies
Grouped excoriated papules over the extensor extremities and occasionally abdomen |
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Term
| Pemphigoid gestationis (herpes gestationis) rash and onset |
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Definition
Vesicles and bullae; occurs in second and third trimesters
Second or third trimester or postpartum
Flare at delivery (75%)
Resolution postpartum
+++ recurrence in future pregnancies |
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Term
| Risk factors for cholestasis of pregnancy |
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Definition
- ethnicity (Rebekah says women from Chile and Sweden, but maybe based on lower dietary intake of selenium or better reporting in those countries)
- twin gestation (estrogen/progesterone component)
- assisted reproductive technology (even controlled for twins)
- hep C
- AMA (?)
- family history of biliary disease (strong genetic component)
- preeclampsia
- previous cholestatsis.
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Term
| Presenting symptoms for cholestasis |
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Definition
| itching without rash with onset in pregnancy (especially in palms and soles of feet) PLUS some signs of liver dysfunction in labs. (Almost) always starts after 20 weeks. Usually has onset in 3rd trimester. |
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Term
| Differential diagnosis for cholestasis |
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Definition
prurigo gestationis, PUPPP, pruritic folliculitis of pregnancy (all gestational) OR any other derm disorder like eczema, hives, etc.
OR
Underlying liver disease, hepatitis, biliary obstruction, fatty liver of pregnancy, lymphoma, leukemia |
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Term
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Definition
Itching without rash plus abnormal liver labs.
ALT/AST elevated plus
Total bile acids elevated 10-40 = mild, >40 severe |
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Term
| Diagnostic tests done in management of cholestasis |
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Definition
If ALT/AST come back elevated do Hep panel
Antenatal testing: NST/AFI if you think cholestasis likely
-In cholestasis patients studies show that they do not make any difference but still standard of care
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Term
| Theraputic management of cholestasis |
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Definition
hydrocortisone 1% creme (maybe 2.5%)
Aveno baths
Benadryl 25-50mg PO Q4-6H prn (50 mg at night for sleep)
Consider: Actigall 300mg BID if sx persist or elevated lab values
Consider: Milk thistle or Guar Gum |
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Term
| Education mangement of cholestasis |
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Definition
| FM counts/awareness, resolution after pregnancy, s/sx PTL |
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Term
| What is the minimum gestational age for induction with cholestasis? |
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Definition
Would always wait until 36 weeks to deliver. Delivering before 36 weeks is more risky than waiting, even with extremely elevated bile salts.
Between 36-37 weeks may do amnio for lung maturity if dates aren’t good. Most likely will wait until 37 weeks. |
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Term
| What is the likelihood of recurrence with cholestasis? |
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Definition
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Term
| What are two hypotheses for PUPPS cause? |
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Definition
1. Stretching may cause damage to connective tissue, which results in exposure of antigens that trigger an inflammatory response
2. Another possibility is that it represents an immunologic response to circulating fetal antigens. As an example, one study demonstrated fetal DNA in maternal skin lesions
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Term
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Definition
- Topical corticosteroids as initial therapy for relief of symptoms
- Nonsedating oral antihistamines are an acceptable alternative
- Systemic glucocorticoids (eg,prednisone 0.5 mg/kg per day) are occasionally required because of extreme pruritus
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Term
| Clinical implications of cholestasis |
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Definition
- 1-5% risk of IUFD
- risk of PTL
- Meconium staining,(25-60%)
- fetal distress (22-33%)
- PPH,(20%)
- Recurrence in subsequent pregnancies(60-70%)
- may increase risk of gallstones.
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Term
| How often do you do antenatal testing for cholestasis? |
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Definition
| Weekly ANT starting at 32 wks or the onset of diagnosis if > than 32 wks. |
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Term
| Management plan for pemphigold gestationis |
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Definition
| Patients with mild PG may respond well to oral antihistamines and systemic oral corticosteroids, whereas patients with more severe symptoms may need oral corticosteroids. |
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Term
| Management plan for puritic folliculitis of pregnancy |
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Definition
- Diagnostic: none
- Theraputic:
- Symptomatic: calamine lotion, aveno baths, loose fitting clothing
- Pharmacologic: 5-10% benzoyl peroxide and topical corticosteroids
- Consult: only if needed to r/o other dermatologic conditions
- Education: Will resolve after pregnancy, Recurrence in subsequent pregnancies unlikely, No maternal or fetal complications
- Follow-up: routine
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Term
| Impetigo Herpetiformis s/s |
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Definition
- round, arched or polycyclic patches covered with small painful pustules in a herpetiform pattern. Most commonly appears on the thighs and groin, but rash may coalesce and spread to trunk and extremities, mucous membranes may be involved BUT face, hands and feet are not affected. Pruritus is generally absent.
- systemic sxs: N/V, diarrhea, fever, chills, and lymphadenopathy.
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Term
| Impetigo Herpetiformis treatment |
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Definition
| systemic corticosteroids- prednisone 15 to 30 mg to as high as 50-60 mg daily followed by a slow taper. ; antibiotics for secondarily infected lesions. Typically dissolves after delivery, although may recur in subsequent pregnancies. |
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Term
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Definition
| The most frequent initial symptoms are nausea or vomiting (approximately 75 percent of patients), abdominal pain (particularly epigastric, 50 percent), anorexia, and jaundice. About one-half of patients have signs of preeclampsia at presentation or at some time during the course of illness |
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