From the Guidelines
The recommended workup for pruritus in pregnancy begins with a thorough history and physical examination to distinguish between physiologic pruritus and pathologic conditions, as emphasized by the Society for Maternal-Fetal Medicine 1.
Initial Evaluation
The initial evaluation should include:
- A detailed history to assess the onset, extent, severity, aggravating and alleviating factors, timing, medical history, medications, allergies, and medical or family history of atopy 1
- A physical examination to assess for the presence of rashes, excoriations, papules, plaques, or bullae, as well as dark urine and jaundice 1
Laboratory Tests
Initial laboratory tests should include:
- Liver function tests (AST, ALT, bilirubin, alkaline phosphatase, and bile acids) to rule out intrahepatic cholestasis of pregnancy 1
- Complete blood count to check for polycythemia vera
- Thyroid function tests
- Renal function tests
Additional Testing
For persistent or severe pruritus with elevated bile acids, additional testing may include:
- Hepatitis serology
- Abdominal ultrasound
- Autoimmune markers
Management
Management depends on the underlying cause, with:
- Topical treatments like emollients, calamine lotion, or low-potency corticosteroids for mild cases
- Ursodeoxycholic acid (10-15 mg/kg/day) as the primary treatment for cholestasis, as recommended by the American Gastroenterological Association 1 and the European Association for the Study of the Liver 1
- Antihistamines such as diphenhydramine (25-50 mg every 4-6 hours) or cetirizine (10 mg daily) for symptomatic relief
Referral and Monitoring
Severe cases may require referral to dermatology or hepatology, and early diagnosis is crucial as conditions like cholestasis of pregnancy can increase risks of adverse fetal outcomes and may require additional fetal monitoring and consideration of earlier delivery 1.
From the Research
Diagnostic Approach
The recommended workup for pruritus in pregnancy involves a comprehensive diagnostic approach to identify the underlying cause of the symptom. This includes:
- A thorough medical history to identify any pre-existing conditions or previous pregnancies with similar symptoms 2
- Physical examination to look for any skin lesions or other signs of dermatological conditions 2
- Laboratory tests, such as liver function tests, to rule out any underlying liver disease or other conditions that may be causing the pruritus 3
Specific Conditions
Pruritus in pregnancy can be a symptom of various conditions, including:
- Intrahepatic cholestasis of pregnancy (ICP), a condition characterized by elevated bile acid levels and pruritus, typically affecting the palms and soles 3
- Atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis, and other pregnancy-specific pruritic diseases 2
Diagnostic Criteria for ICP
The diagnosis of ICP is based on:
- Symptoms of pruritus, typically affecting the palms and soles 3
- Elevated bile acid levels 3
- Other liver function tests, such as alanine aminotransferase and aspartate aminotransferase, may also be elevated 3
- Other causes of liver dysfunction should be ruled out 3
Treatment and Management
The treatment and management of pruritus in pregnancy depend on the underlying cause of the symptom. For ICP, treatment with ursodeoxycholic acid has been shown to improve maternal pruritus symptoms and biochemical tests 3, 4, 5, 6. However, the effect of ursodeoxycholic acid on fetal outcomes is still unclear, and delivery may be considered at 37 weeks' gestation due to the increased risk of stillbirth in the setting of ICP 3.