Evaluation and Management of Pruritus in a Pregnant Woman Affecting Face and Hands
Immediately order serum bile acids and liver function tests (AST, ALT, bilirubin) to rule out intrahepatic cholestasis of pregnancy (ICP), as this condition carries significant risk of stillbirth and requires urgent treatment with ursodeoxycholic acid and timed delivery. 1
Diagnostic Approach
Critical First Step: Rule Out ICP
- ICP is diagnosed when serum bile acids exceed 10 μmol/L in the setting of pruritus, typically presenting in the second or third trimester 1
- The classic presentation is intense pruritus affecting palms and soles (hands and feet are often worst-affected areas) without a primary rash, though the face can also be involved 2, 1, 3
- Pruritus that is worse at night and severe enough to disrupt sleep is highly suggestive of ICP 1
- If initial bile acid levels are normal but clinical suspicion remains high, repeat testing after 1-2 weeks as levels can rise later in pregnancy 1
Key Distinguishing Features
- Pruritus WITHOUT a visible rash = ICP until proven otherwise 1, 4
- Pruritus WITH a visible rash suggests other pregnancy-specific dermatoses (atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis) 5, 4
- Most ICP cases present with mild to moderately elevated AST/ALT and total bilirubin <6 mg/dL 1
Management Algorithm Based on Diagnosis
If ICP is Confirmed (Bile Acids >10 μmol/L)
First-Line Treatment:
- Initiate ursodeoxycholic acid (UDCA) 10-15 mg/kg/day in divided doses immediately 1
- UDCA improves pruritus, serum bile acid levels, liver transaminases, and meta-analyses demonstrate decreased adverse outcomes including preterm birth and stillbirth 1
Second-Line Treatment:
- Add cholestyramine if UDCA alone is insufficient for pruritus control 1
- Monitor prothrombin time regularly due to vitamin K deficiency risk with cholestyramine 1
Third-Line Treatment:
- Rifampicin can be attempted for refractory pruritus 2, 1
- Starting dose 150 mg twice daily, can increase to 600 mg twice daily 2
- Monitor for hepatotoxicity and inform patient about color changes to secretions 2
Delivery Timing (Critical for Fetal Safety):
- Bile acids ≥100 μmol/L: Deliver at 36 0/7 weeks due to substantially increased stillbirth risk 1
- Bile acids <100 μmol/L: Deliver between 36 0/7 and 39 0/7 weeks 1
- Administer antenatal corticosteroids if delivering before 37 0/7 weeks 1
If ICP is Excluded (Normal Bile Acids and Liver Tests)
Consider Other Pregnancy-Specific Dermatoses:
- Atopic eruption of pregnancy: Most common, presents with eczematous lesions, can occur any trimester 5, 6
- Polymorphic eruption of pregnancy: Urticarial papules and plaques starting in striae distensae, sparing umbilicus, typically third trimester 5, 3
- Pemphigoid gestationis: Rare, presents with periumbilical vesicles and bullae, carries risk of prematurity 2, 5, 3
Treatment for Non-ICP Dermatoses:
- Emollients and moderate-potency topical corticosteroids for atopic eruption and polymorphic eruption 7
- Chlorpheniramine is the preferred antihistamine due to long safety record in pregnancy 7
- Avoid hydroxyzine in early pregnancy 7
- Systemic corticosteroids (prednisolone) for pemphigoid gestationis, as prednisolone is 90% inactivated by the placenta 2
Critical Pitfalls to Avoid
- Never delay bile acid testing in a pregnant woman with new-onset pruritus, as stillbirth can occur suddenly without warning signs in ICP 1
- Never delay delivery beyond 36 weeks in confirmed ICP with bile acids ≥100 μmol/L, as stillbirth risk increases substantially 1
- Do not perform preterm delivery based on clinical suspicion alone without laboratory confirmation of elevated bile acids 1
- Do not miss vitamin K deficiency in patients on cholestyramine; monitor PT regularly 1
- If pruritus persists beyond 6 weeks postpartum, pursue further evaluation for underlying chronic liver disease (primary biliary cholangitis, primary sclerosing cholangitis) 1, 8