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The spectrum of mucocutaneous manifestation during pregnancy: An observational study of 170 pregnant women visiting a tertiary care hospital


 Department of Dermatology, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India

Date of Submission08-Aug-2020
Date of Decision01-Jan-2021
Date of Acceptance01-Jan-2021

Correspondence Address:
Nachiket Palaskar,
Department of Dermatology, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune - 411 041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2589-8302.335113

  Abstract 


Background: Pregnancy is characterized by myriad of temporary alteration in endocrine, metabolic, and immunological factors. These alterations result in multiple mucocutaneous manifestations. The various skin changes may be either physiological or changes in preexisting skin diseases, or development of new pregnancy-specific dermatoses. Pregnancy-specific skin dermatoses include atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy, pemphigoid gestationalis, and intrahepatic cholestasis of pregnancy. Aims: The aim of the study was to study the frequency and pattern of mucocutaneous manifestations in pregnant women attending the tertiary care hospital. Settings and Design: A descriptive observational study. Subjects and Methods: A total number of 170 pregnant women attending antenatal outpatient department from October 2017 to March 2019 were included in the study. Detailed history, clinical examination, and relevant investigations were done. Patients not willing to give informed consent were only excluded from the study. Results: In this study, 58.23% (99) were primigravida and 41.77% (71) were multigravida. Most of the cases presented during third trimester (73%). In this study among the 170 pregnant women, the incidence of skin changes observed was 790 physiological entities, nonspecific dermatoses of pregnancy were 95, and 42 cases of specific dermatoses of pregnancy. The most common physiological changes noted were pigmentary changes 46.96% out of all physiological changes. All pregnant women showed pigmentary changes. Most common pigmentary change was linea nigra and melasma. Other changes were striae distensae 14.55%, vascular changes 10.37%, mucous membrane changes 5.19%, pruritus 17%, hair changes 1.51%, and nail changes 1.13%. Tinea corporis was most common infection 48.6% out of all infections, followed by candidal vaginitis 10.8%. Acne vulgaris was most common inflammatory disorder seen in 12.35%, followed by urticaria and psoriasis, seen in 7.05% and 1.76%, respectively. Polymorphic eruption of pregnancy and AEP was seen in 14.70% and 10%, respectively. No cases of intrahepatic cholestasis of pregnancy and pemphigoid gestationalis were noted. Conclusions: This study brings into focus prevalence of various mucocutaneous changes during pregnancy. Thorough knowledge about pregnancy dermatoses is essential to arrive at a specific diagnosis which is a mandate for counseling and management.

Keywords: Physiological changes, pregnancy modified dermatoses, specific dermatoses



How to cite this URL:
Bedi A, Khatu SS, Poulkar CB, Palaskar N, Chaudhari ND, Patokar AS. The spectrum of mucocutaneous manifestation during pregnancy: An observational study of 170 pregnant women visiting a tertiary care hospital. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=335113




  Introduction Top


Pregnancy results in cutaneous changes in more than 90% of women.[1] During pregnancy profound, immunologic, metabolic, endocrine, and vascular changes occur, which make the pregnant woman susceptible to changes of the skin and appendages, both physiological and pathological changes.[2] Cutaneous manifestations can be grouped into three broad categories, physiological cutaneous changes related to pregnancy; diseases modified by pregnancy; and specific dermatoses of pregnancy.[3] Skin manifestations occur due to the production of a number of proteins and steroid hormones by the fetoplacental unit and also by the maternal pituitary, thyroid, and adrenal glands.[4] Estrogen is produced by ovaries and later by placenta; it activates and regulates production of other key hormones. Estrogen plays a major role in various cutaneous manifestations during pregnancy. The cutaneous changes due to estrogen are also seen in oral contraceptive use and in liver diseases due to inadequate estrogen metabolism. These conditions are generally benign but can cause substantial anxiety in affected patients. Similarly, the concerns of the patient may range from cosmetic appearance, to the chance of recurrence of the particular problem during a subsequent pregnancy, to its potential effects on the fetus in terms of morbidity and mortality.[5] Although most of these skin dermatoses are benign and resolve in postpartum period, a few can risk fetal life and require antenatal surveillance.[6] Some dermatoses such as intrahepatic cholestasis of pregnancy and pemphigoid gestationalis can lead to adverse health outcome including prematurity, fetal distress, or even stillbirth. Most of the dermatoses of pregnancy can be treated conservatively, but a few require intervention in the form of termination of pregnancy. Therefore, understanding the frequency and pattern of occurrence of dermatological conditions would help in early identification and prompt treatment. It is essential for improving maternal and fetal outcome and to minimize their morbidity.


  Subjects and Methods Top


Aim

Descriptive observational study was to find out frequency and pattern of mucocutaneous manifestations in pregnant women of all age groups, irrespective of duration of pregnancy, attending the tertiary care hospital.

Objective

  • To study the prevalence of mucocutaneous manifestation in pregnant women attending the tertiary care hospital
  • changes in pregnant women attending the tertiary care hospital.



  Materials and Methods Top


Study population

Data were collected from all pregnant women with skin manifestations attending a tertiary care hospital.

Method of collection of data

In this descriptive observational study, data were collected from October 2017 to March 2019 over a period of 18 months. The sample size of 170 patients was selected using purposive sampling technique.

Study pro forma

A special pro forma was used to record the name, age, occupation, address (rural/urban), and detailed history including the present, past, obstetrical, and personal history was noted. Each patient was examined in detail. The clinical examination was conducted over the patients including general physical examination, obstetrics examination, and cutaneous examination including mucosa, hairs, and nails. Per speculum examination was done, whenever required after informed and written consent. Vinegar (acetic acid) solution test,  Pap smear More Details test, and human papilloma virus (HPV)-DNA tests were performed to confirm the diagnosis of HPV infection in suspected cases. All patients received appropriate treatment.

Inclusion criteria

  • All pregnant women with mucocutaneous manifestations of all age groups and irrespective of duration of pregnancy, attending tertiary care hospital
  • Skin and/or mucosal ailments either preexisting or recently developed in pregnancy
  • Patients who had given informed consent.


Exclusion criteria

  • Patients not willing to participate in the study.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


  Results Top


A total of 170 pregnant women were recruited in our study. Of these, 99 (58.23%) were primigravida and 71 (41.77%) were multigravidas. Their age range was 18–36 years with a mean of 24 years. Most of the cases presented in the third trimester (73%).

Earliest gestational age at which cutaneous changes were noted was 6 weeks and as late as 38 weeks [Table 1].
Table 1: Gestational age

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Pregnancy dermatoses were divided into three categories:

  • Physiological skin changes
  • Skin diseases affected by pregnancy
  • Specific dermatoses of pregnancy.


In this study, out of 170 pregnant women, the incidence of skin changes observed were 790 physiological entities, 95 nonspecific dermatoses of pregnancy, and 42 cases of specific dermatoses of pregnancy. The physiological changes are the most common skin changes in pregnancy [Figure 1].
Figure 1: Incidence of cutaneous manifestations in pregnancy

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The most common physiological changes noted were pigmentary changes 371 (46.96% of all physiological changes), followed by striae distensae 115 (14.55%) developing on the lower abdomen, thighs, breast, and buttocks, followed by vascular changes 82 (10.37%), mucous membrane changes 41 (5.19%), and pruritus in 141 (17%). Other changes such as miliaria, acanthosis nigricans, and molluscum fibrosum gravidarum were 2.39%. Hair and nail changes were 1.51% and 1.13%, respectively [Table 2].
Table 2: Spectrum of physiological changes in skin and appendages

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All pregnant women showed pigmentary changes. Pigmentary changes were more common in primigravida than multigravida. The most common pigmentary change was linea nigra and melasma [Figure 2].
Figure 2: Pigmentary changes among primigravida and multigravida

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Vascular changes include pitting edema of feet (62) 75.6%, palmar erythema (10) 12.19%, telangiectasia (3) 3.65%, purpura (2) 2.43%, and varicosities (5) 6% [Table 3].
Table 3: Vascular changes in pregnancy

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Various infections seen during pregnancy were bacterial, fungal, viral, and arthropod infections. Fungal infection was most commonly seen in this study. Fifty-four cases had tinea corporis infection (48.6% of all infections reported). Second most common fungal infection was candidal vaginitis in 12 cases (10.8% of all infections reported). Most common viral infection was due to HPV seen in seven cases (6.3% of all infections reported) [Table 4].
Table 4: Percentage of various infections during pregnancy

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Acne vulgaris was most common inflammatory disorder seen in 21 cases (12.35%), followed by urticaria and psoriasis, seen in 12 cases (7.05%) and three cases (1.76%), respectively [Table 5].
Table 5: Various inflammatory disorders

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Out of the total specific dermatoses of pregnancy cases, polymorphic eruption of pregnancy and atopic eruption of pregnancy (AEP) were seen in 25 cases (14.70%) and 17 cases (10%), respectively. No cases of intrahepatic cholestasis of pregnancy and pemphigoid gestationalis were noted [Figure 3].
Figure 3: Incidence of specific dermatoses of pregnancy

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Out of 42 cases of specific dermatoses seen during the pregnancy, polymorphic eruptions of pregnancy were noted in 25 patients and AEP was noted in 17 patients. Out of these 25 patients, 22 mothers were found to be primigravid. Specific dermatoses were majorly seen in the third trimester of pregnancy among the affected mothers. Only one case of polymorphic eruption of pregnancy was seen in second trimester [Table 6].
Table 6: Gravida distribution of specific dermatoses of pregnancy

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  Discussion Top


Pregnancy is a period throughout which women undergo significant skin changes. Virtually, all body systems are affected including the skin. Most changes during pregnancy are due to hormonal and/or mechanical alterations. The concerns of the patient having any of the disorders may range from cosmetic appearance, to the chance of recurrence of the particular problem during a subsequent pregnancy. In the present study, 790 physiological changes were seen. It was most common cutaneous manifestations in pregnancy observed, followed by 95 coincidental dermatological disorders affected in pregnancy and 42 specific dermatoses of pregnancy.

Physiological skin changes in pregnancy were the most common skin changes in pregnancy as mentioned in other studies by Kumari et al., Sharath Kumar et al., and Hassan et al. In this study, the physiological changes were seen in all cases. The most common physiological changes noted were pigmentary changes (46.96% {371}) out of all physiological changes. In this study, linea nigra [Figure 4] was seen in 70% making it most common pigmentary change. In a study done by Hassan et al., linea Nigra was seen in 80%.[7] In both studies done by Kumari et al. and Sharath Kumar et al., pigmentary changes were seen in all cases, and linea nigra was seen in 91.4% and 87% cases, respectively.[1],[8] Striae distensae contributes 14.55% out of all physiological changes (115). It develops over the lower abdomen, thighs, breast, and buttocks. Other physiological changes seen in this study were 10.37% vascular changes (82), 5.19% mucosal membrane changes (41), and 17% pruritus (141). Other changes such as miliaria, acanthosis nigricans, and molluscum fibrosum gravidarum were noted in 2.39%. Hair and nail changes were 1.51% and 1.13%, respectively.
Figure 4: 34 weeks of gestation, gravida 1 presented with striae gravidarum and linea nigra

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One pregnant woman may have one or more than one physiological skin changes associated with pregnancy. The sites of increased pigmentation were seen in combination. The sites noted were neck, axilla, and genital region in 49 cases, whereas 52 cases showed pigmentation over neck, axilla, inner thigh, and perineal regions. This pattern of hyperpigmentation was probably due to regional differences in the number of melanocytes in the skin and stimulating effect of estrogen and progesterone on the melanocytic-stimulating hormone.

In vascular changes, 75.6% lesions (62) included pitting edema of feet, 12.19% lesions (10) included palmar erythema, 3.65% lesions included telangiectasia, 2.43% lesions included purpura, whereas 6% of lesions included varicosities. In a study by Winton and Lewis, nonpitting edema of legs, eyelids, face, and hands was present in about 50% of women during the third trimester.[9] Vascular changes result from distention, proliferation of vessels, and regress postpartum. The edema decreases during the day and is thought to be due to secondary sodium and water retention in conjunction with increased capillary permeability. In our study, seven cases complained of hirsutism and two cases reported androgenic alopecia. A mild to moderate rise in incidence of hirsutism and hypertrichosis during pregnancy is common. It usually resolves after delivery. There is an increased proportion of anagen growing hairs due to estrogen and androgen stimulation in the second half of pregnancy.[4] In our study, 1.32% (9) were nail changes. In a study done by Kumari et al.[1], 0.66% were nail changes. Nail changes such as subungual hyperkeratosis were seen in (four cases) 44.44% and increased brittleness in (five cases) 55.55%. Nail growth is generally increased during pregnancy. Nails become more brittle and softer. Distal onycholysis and subungual hyperkeratosis may occur. Beau's lines develop after delivery.[10]

The most common infection encountered in the present study was fungal infection, particularly tinea corporis infection [Figure 5]. Nearly 48.6% cases (54) of tinea corporis were seen in the present study. In several studies, candida vaginitis was the most common infection observed and up to 50% of neonates born to infected mothers are positive for candida.[8] Among the infections, the most common cause of white discharge per vagina was candidiasis in a study done by Shivakumar et al. 21.78%, which was not similar to this study.[11] In the present study, out of all infections, only 10.8% (12) were of candidal vaginitis. The most common sexual-transmitted disease associated was condyloma acuminatum caused due to HPV. In our study also, most common cause of viral infection was HPV 6.3% (7). Vinegar (acetic acid) solution test and PAP smear test were performed to confirm diagnosis of HPV infection in suspected cases. In a study done by Shivakumar et al., condyloma acuiminata were seen in 4.70% of cases, these findings are similar to this study.[11]
Figure 5: 24 weeks of gestation, gravida 3 presented with tinea corporis

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Pregnancy has a variable effect on psoriasis. Occasionally, a sudden eruption of acute pustular psoriasis can occur. Patients typically improve because of changes in immunity, although in 10%–20% of women psoriasis can worsen and they require a more complex treatment. Generalized pustular psoriasis can present in pregnancy, often requiring systemic treatment. The term “impetigo herpetiformis” has been used to describe a severe variant of generalized pustular psoriasis occurring in pregnant women. Recurrence in subsequent pregnancies is characteristic with earlier onset and increased severity.[12] In this study, only 1.76% cases (3) of psoriasis were noted. In the present study, out of three cases, two were palmoplantar psoriasis and one was chronic plaque psoriasis. There was no change in the activity of disease during pregnancy. Panicker et al. in his study reported 1% of cases (6). Majority of psoriasis cases were of palmoplantar psoriasis in Panicker et al. study. These findings were similar to this study.[13]

Acne vulgaris often improves in early pregnancy but worsens in the third trimester as maternal androgen level increase. In this study, 12.35% cases (21) of acne were noted, whereas in a study done by Sharath Kumar et al., 13% cases (32) were seen. Findings of this study were similar to a study done by Sharath Kumar et al.[8] In the present study, most of the cases were seen during the third trimester, but there was no change of activity during pregnancy. The increase activity of sebaceous glands could be the causative factors for the disease. Other condition which worsens during pregnancy is rosacea due to marked increase in estrogen levels. Increased eccrine glands function lead to miliaria, hyperhidrosis, dyshidrotic eczema, and decreased apocrine gland function lead to improvement in hidradenitis suppurativa, Fox-Fordyce disease.[14] Urticaria presents commonly during pregnancy and can mimic other pregnancy dermatoses, particularly pemphigoid gestationalis or polymorphic eruption of pregnancy. In this study, 7.05% cases (12) of urticaria were noted, whereas in a study done by Sharath Kumar et al., 2% of cases were seen. Findings of this study were not similar to study done by Sharath Kumar et al.[8]

Specific dermatoses of pregnancy represent a heterogeneous group of ill-defined pruritic skin diseases unique to pregnancy. Ambros–Rudolph proposed a simplified clinical classification of specific dermatoses of pregnancy.[15] This classification basically subdivided the specific dermatoses of pregnancy into the following four groups: pemphigoid gestationalis, polymorphic eruption of pregnancy, AEP, and intrahepatic cholestasis of pregnancy.[16] Pruritic urticarial papules and plaque of pregnancy (PUPPP) has a marked pruritic component and the onset of pruritus coincides with the skin lesions which are seen as polymorphous, erythematous, nonfollicular papules, and plaques. The eruption begins over the abdomen, commonly involving striae gravidarum with sparing of the periumbilical region. The incidence of specific dermatoses of pregnancy was 24.72% in the present study. Among 42 cases of specific dermatoses of pregnancy, 37 cases were seen in primigravida and five cases were seen in multigravida. PUPPP was the most common pruritic dermatoses in pregnancy seen in this study. The total number of cases of PUPPP in this study was 25 (14.70%) and a total number of cases of AEP were 17 (10%) [Figure 6]. Of the 25 cases of PUPPP, 24 cases were observed in the third trimester and one case of PUPPP was observed in the second trimester. All 17 cases of AEP were observed in the third trimester. None of the cases of specific dermatoses of pregnancy were observed in the first trimester. Specific dermatoses in a study by Shivakumar et al. and Kumari et al. were 9.41% and 14.9%, respectively. These findings were not similar to this study.[1],[11]
Figure 6: 30 weeks of gestation, gravida 1 presented with atopic eruption of pregnancy

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While polymorphic and atopic eruptions of pregnancy are distressing only to the mother because of pruritus. Pemphigoid gestationalis may be associated with prematurity and small-for-date babies and intrahepatic cholestasis of pregnancy poses an increased risk for fetal distress, prematurity, and stillbirth. Timely treatment of common specific dermatoses such as AEP and polymorphic eruption of pregnancy prevents morbidity during the antenatal period. Corticosteroids and antihistamines control pemphigoid gestationalis, polymorphic, and atopic eruptions of pregnancy, while intrahepatic cholestasis of pregnancy should be treated with ursodeoxycholic acid.[17]

Pregnancy causes changes in the immune system that result in an increase in autoimmune disease and reduction in cell-mediated immunity. Pemphigoid gestationalis, pemphigus vulgaris, and systemic lupus erythematosus can all lead to neonatal involvement from passive transfer of maternal antibodies across the placenta. Pemphigoid gestationalis is a rare autoimmune bullous disease that can cause reduced fetal growth and prematurity.[18] None of these autoimmune diseases were noted in this study.

This study brings into focus prevalence of various cutaneous changes during pregnancy. A detailed history and physical examination are important for the diagnosis and treatment of dermatoses of pregnancy that will direct the most appropriate laboratory evaluation and careful management in an effort to minimize maternal and fetal morbidity.

Limitations

We suggest that larger sample size will provide more accurate results. Another major limitation in the present study is location in a rural setting where myths and folklore around resulting in antenatal women not consenting to biopsies and detailed expensive investigations for what they consider a mere minor limitation on the road to motherhood.

Conclusions:

This study brings into focus prevalence of various mucocutaneous changes during pregnancy. Thorough knowledge about pregnancy dermatoses is essential to arrive at a specific diagnosis which is a mandate for counseling and management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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