What is the initial workup and treatment for a pregnant patient presenting with urticaria (hives)?

From the Guidelines

The initial workup for a pregnant patient with urticaria should include a thorough history and physical examination to identify potential triggers, while treatment focuses on safe antihistamines. The goal is to minimize morbidity, mortality, and improve quality of life for both the mother and the fetus. When evaluating a pregnant patient with urticaria, it is essential to consider the potential risks and benefits of various treatments.

• A thorough history and physical examination are crucial to identify potential triggers and guide treatment.
• First-line therapy includes oral cetirizine (10mg daily) or loratadine (10mg daily), both pregnancy category B medications with established safety profiles 1.
• For severe or refractory cases, diphenhydramine (25-50mg every 4-6 hours) can be used short-term, though it may cause drowsiness.
• Topical calamine lotion or cool compresses provide symptomatic relief.
• Avoidance of identified triggers is essential.
• Severe cases with angioedema, respiratory distress, or hypotension require immediate emergency care with epinephrine.
• Laboratory testing is generally unnecessary unless there are concerns for systemic disease.
• Corticosteroids (prednisone 40-60mg daily with taper) should be reserved for severe, persistent cases unresponsive to antihistamines, using the lowest effective dose for the shortest duration. It is also important to note that allergen immunotherapy is usually not initiated during pregnancy due to risks associated with systemic reactions and their treatment, but maintenance doses can be continued during pregnancy if the patient is already receiving immunotherapy 1. Regular follow-up is important to monitor symptoms and medication effectiveness, with referral to an allergist or dermatologist for persistent urticaria lasting beyond 6 weeks.

From the Research

Initial Workup for Hives in Pregnancy

• The initial workup for a pregnant patient presenting with urticaria (hives) should consider the potential effects of pregnancy on the course of chronic inflammatory conditions, including urticaria 2.
• A thorough medical history should be taken to identify potential triggers or underlying causes of urticaria, such as infections, drugs, or foods 3.
• Physical examination and laboratory tests may be performed to exclude differential diagnoses and identify underlying causes or triggers 4.

Treatment of Hives in Pregnancy

• The international EAACI/GA2LEN/EuroGuiDerm/APAAACI guideline for urticaria recommends adopting the same management strategy in pregnant and lactating patients, starting with standard doses of second-generation (non-sedative) H1 antihistamines 2.
• The dose of antihistamines may be increased up to 4-fold in case of no response, and omalizumab may be added in antihistamine-refractory patients 2.
• Second-generation H1 antihistamines, such as olopatadine, fexofenadine, bilastine, rupatadine, and levocetirizine, have been shown to be effective in treating chronic spontaneous urticaria (CSU) 5.
• Continuous daily therapy with antihistamines may be more effective than taking them only when symptoms return (PRN) in maintaining or improving quality of life in patients with CSU 6.

Considerations in Pregnancy

• Pregnancy-associated changes in the immune system may affect the course of urticaria, and the hormonal changes during pregnancy can modulate the course of chronic inflammatory conditions 2.
• The safety and efficacy of urticaria treatments during pregnancy are not well established, and further research is needed to provide evidence-based guidance on the management of urticaria during pregnancy and lactation 2.