From the Guidelines
The most appropriate treatment for this patient is ursodeoxycholic acid (UDCA) at a starting dose of 10-15 mg/kg per day, which can be divided into 2 or 3 daily doses, to alleviate pruritus and potentially improve perinatal outcomes. The patient's presentation with a pruritic rash on the abdomen and abdominal striae at 35 weeks gestation with dichorionic diamniotic twins is suggestive of intrahepatic cholestasis of pregnancy (ICP). According to the Society for Maternal-Fetal Medicine consult series #53, UDCA is the most commonly used treatment for ICP and is recommended as the first-line agent for the treatment of maternal symptoms of ICP [ 1 ]. UDCA has been shown to improve maternal symptoms, including pruritus, and laboratory abnormalities, with no known adverse effects on the fetus [ 1 ]. While the data on whether UDCA improves perinatal outcomes are less conclusive, a meta-analysis of 12 randomized trials reported that patients with ICP who received UDCA had a reduced risk for preterm birth, fetal distress, and neonatal intensive care unit admission [ 1 ].
Key points to consider in the treatment of ICP include:
- UDCA is the preferred treatment for ICP due to its effectiveness in relieving pruritus and improving laboratory abnormalities [ 1 ]
- The typical starting dose for UDCA treatment is 10-15 mg/kg per day, which can be divided into 2 or 3 daily doses [ 1 ]
- Alternative drugs, such as S-adenosyl-methionine and cholestyramine, can be considered for patients who cannot take UDCA or who have continued symptoms on the maximum dosage [ 1 ]
- Antihistamines, such as diphenhydramine or hydroxyzine, may be used for pruritus, but their benefit is limited [ 1 ]
In this patient's case, UDCA is the most appropriate treatment due to its effectiveness in alleviating pruritus and potentially improving perinatal outcomes, with a recommended starting dose of 10-15 mg/kg per day [ 1 ].
From the Research
Treatment Options for Pruritic Rash
The patient's symptoms of a pruritic rash on the abdomen and abdominal striae at 35 weeks gestation with dichorionic diamniotic twins can be treated with topical corticosteroids, as they are considered safe for use in pregnant women 2, 3, 4.
Topical Corticosteroid Application
The application of topical corticosteroids should be done correctly to minimize the risk of adverse effects. The fingertip unit method can be used to teach patients how to apply the medication, with one fingertip unit covering approximately 2% body surface area on an adult 2.
Potential Side Effects
Prolonged use of topical corticosteroids can lead to adverse effects such as atrophy, striae, rosacea, telangiectasias, purpura, and other cutaneous and systemic reactions 2, 4.
Diagnosis of Contact Dermatitis
If the pruritic rash is suspected to be contact dermatitis, the diagnosis can be confirmed by determining whether the problem resolves with avoidance of the causative substance 5.
Treatment of Contact Dermatitis
Localized acute allergic contact dermatitis lesions can be treated with mid- or high-potency topical steroids, such as triamcinolone 0.1% or clobetasol 0.05% 5.
Key Considerations
- Topical corticosteroids are safe for use in pregnant women 2, 3, 4.
- Correct application of topical corticosteroids is critical to successful use 2.
- Prolonged use of topical corticosteroids can lead to adverse effects 2, 4.
- Diagnosis of contact dermatitis can be confirmed by avoidance of the causative substance 5.
- Treatment of contact dermatitis depends on the severity and extent of the lesions 5.