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Pruritus in Pregnancy

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1. Effect of plasmapheresis on cholestatic pruritus and autotaxin activity during pregnancy. Full Text available with Trip Pro

Effect of plasmapheresis on cholestatic pruritus and autotaxin activity during pregnancy. 30614557 2019 02 14 1527-3350 2019 Jan 07 Hepatology (Baltimore, Md.) Hepatology Effect of Plasmapheresis on Cholestatic Pruritus and Autotaxin Activity During Pregnancy. 10.1002/hep.30496 Heerkens Marieke M Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands. Dedden Suzanne S Department of Gynaecology, Maastricht

2019 Hepatology

2. Pruritus vulvae: Scenario: Management of pruritus vulvae

dermatoses [ ]. How should I manage hormonal changes which cause pruritus vulvae? Manage pruritus vulvae appropriately, depending on the underlying cause: Atrophic vaginitis — see the CKS topic on . Pregnancy — see the CKS topic on . Basis for recommendation The evidence to support the management of hormonal changes is discussed within the relevant CKS topic. How should I manage gastrointestinal disease or urinary incontinence which is causing pruritus vulvae? Manage pruritus vulvae appropriately (...) Pruritus vulvae: Scenario: Management of pruritus vulvae Scenario: Management | Management | Pruritus vulvae | CKS | NICE Search CKS… Menu Scenario: Management Pruritus vulvae: Scenario: Management of pruritus vulvae Last revised in May 2017 Scenario: Management of pruritus vulvae From birth onwards (Female). How should I manage pruritus vulvae with a known cause? A comprehensive discussion of the management of specific causes of pruritus vulvae is beyond the scope of this topic. A brief

2017 NICE Clinical Knowledge Summaries

3. Prevalence and Relevance of Pruritus in Pregnancy Full Text available with Trip Pro

Prevalence and Relevance of Pruritus in Pregnancy Pregnant women are at greater risk to suffer from chronic pruritus, but data on this symptom in this group is very limited. The aim of this study was to investigate the prevalence, clinical characteristics, and the importance of pruritus in pregnant women. A total of 292 consecutive pregnant women at the 33.0 ± 6.1 weeks of gestation (WoG) were recruited into this prospective, cross-sectional study. All patients underwent thorough anamnesis (...) and detailed physical examination with the special emphasis on pruritus. Pruritus was assessed according to Visual Analogue Scale (VAS). Quality of life was measured with the Dermatology Life Quality Index (DLQI). The point prevalence of pruritus was 20.2% (n = 59), while pruritus prevalence during the entire pregnancy was 38.0% (n = 111). Pruritus started on average at the 27.2 ± 7.6 WoG; it was significantly more common among women in third trimester. The mean VAS was 4.8 (±2.4) points. The DLQI scoring

2017 BioMed research international

4. Pruritus

: experts in the field from Europe. More than 30% are European Academy of Dermatology and Venereology (EADV) members 3 Abbreviations and explanations AD Atopic dermatitis AEP Atopic eruption of pregnancy CGRP Calcitonin gene-related peptide CKD Chronic kidney disease CNS Central nervous system CNPG Chronic nodular prurigo CP Chronic pruritus (longer than 6 weeks) CPG Chronic prurigo CSU Chronic spontaneous urticaria DIF Direct immunofluorescence ICP Intrahepatic cholestasis of pregnancy IFSI (...) International Forum on the Study of Itch IIF Indirect immunofluorescence IL Interleukin Itch Synonym of pruritus NRS Numerical rating scale NSAID Non-steroidal anti-inflammatory drugs PAR Proteinase-activated receptor PBC Primary biliary cirrhosis PEP Polymorphic eruption of pregnancy PG Pemphigoid gestationis Pruritus A skin sensation that elicits the urge to scratch PUO Pruritus of undetermined origin PTH Parathyroid hormone PV Polycythaemia vera RCT Randomised controlled trials SSRI Selective serotonin

2019 European Dermatology Forum

5. Pruritus vulvae: What are the possible causes of pruritus vulvae?

prolactin levels can have an antagonistic effect on oestrogen production, and may result in low oestrogen levels. This can lead to vaginal dryness, itching, burning, and irritation. Pregnancy Increased hormone levels in pregnancy are associated with increased physiological vaginal discharge, and an increased risk of candidal vulvovaginitis, both of which cause vulvular pruritus. This information is based on expert opinion in narrative reviews Overview of vulvar pruritus through the life cycle (...) Pruritus vulvae: What are the possible causes of pruritus vulvae? Causes | Diagnosis | Pruritus vulvae | CKS | NICE Search CKS… Menu Causes Pruritus vulvae: What are the possible causes of pruritus vulvae? Last revised in May 2017 What are the possible causes of pruritus vulvae? Which dermatological conditions can cause pruritus vulvae? Contact dermatitis is the most common cause of pruritus vulvae — it is an inflammatory reaction with itch as the main symptom. Lichenification

2016 NICE Clinical Knowledge Summaries

6. Pharmacological interventions for treating intrahepatic cholestasis of pregnancy. (Abstract)

if SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, Salvia, Yinchenghao decoction, Danxioling and Yiganling, or Yiganling alone or in combination are effective in treating women with intrahepatic cholestasis of pregnancy.When compared with placebo, UDCA administered to women with ICP probably shows a reduction in pruritus. However the size of the effect is small and for most pregnant women and clinicians, the reduction may fall below the minimum clinically worthwhile effect (...) Pharmacological interventions for treating intrahepatic cholestasis of pregnancy. Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that can develop in pregnancy. It occurs when there is a build-up of bile acids in the maternal blood. It has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is poorly understood, therapies have been largely empiric. As ICP is an uncommon condition (incidence less than 2% a year), many trials have been small

2020 Cochrane

7. Pruritus ani: Which topical preparation should I prescribe or recommend?

lead to skin atrophy, contact dermatitis, and skin sensitization). See the CKS topic on for detailed information on prescribing topical corticosteroids. No topical preparations are licensed for use during pregnancy or breastfeeding. However, the potential risk of harms to the pregnant woman and/or the fetus or infant is likely to be less with simple, soothing products than with those containing corticosteroid (which are generally not recommended by the manufacturers for use during pregnancy due (...) Pruritus ani: Which topical preparation should I prescribe or recommend? Topical treatments | Prescribing information | Pruritus ani | CKS | NICE Search CKS… Menu Topical treatments Pruritus ani: Which topical preparation should I prescribe or recommend? Last revised in July 2016 Which topical preparation should I prescribe or recommend? If the perianal skin is excoriated, consider prescribing a soothing cream or ointment, such as one containing bismuth subgallate or zinc oxide. Some

2018 NICE Clinical Knowledge Summaries

8. Pruritus ani: Chlorphenamine

(as they are more susceptible to adverse effects). Pregnant or breastfeeding women: The manufacturer of chlorphenamine advises avoiding its use during pregnancy. However, the UK Teratology Information Service (UKTIS) bumps patient information leaflets on chlorphenamine states that there is currently no evidence that chlorphenamine is harmful to a fetus. However, because only a small number of pregnant women have been studied, it is not possible to say for certain that it is completely safe. When deciding (...) Pruritus ani: Chlorphenamine Chlorphenamine | Prescribing information | Pruritus ani | CKS | NICE Search CKS… Menu Chlorphenamine Pruritus ani: Chlorphenamine Last revised in July 2016 Chlorphenamine What dose of chlorphenamine should I prescribe? The recommended oral doses of chlorphenamine are: Children aged 1 month–2 years: 1 mg twice daily. Children aged 2–6 years: 1 mg every 4–6 hours (maximum of 6 mg daily). Children aged 6–12 years: 2 mg every 4–6 hours (maximum of 12 mg daily

2018 NICE Clinical Knowledge Summaries

9. British Association of Dermatologists? guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis

variables are that iron overload is asso- ciated with both liver in?ltration 35 (see section 7.7) and Table 2 Causes of generalized pruritus without rash Pruritic skin diseases before rash Disorders of iron metabolism Uraemia Hepatic disease (especially cholestasis) Malignancy Haematological disorders Infection Endocrine disease Neurological disorders Psychological and emotional factors Adverse drug reactions Heart failure Pregnancy Pruritus of elderly skin Pruritus of unknown origin (GPUO) © 2017 (...) Pruritus is a common symptom in patients with various hepa- tobiliary disorders, including cholestasis of pregnancy. 138–140 The skin in hepatic pruritus is often generally hyperpigmented and excoriated. 141 The hands and feet are often the worst- affected areas. 139 Pruritus in association with fatigue at presen- tation may be a marker for more aggressive disease, for exam- ple primary biliary cholangitis. 142 There is a poor correlation between pruritus and bile acid levels, suggesting that other

2018 British Association of Dermatologists

10. Itch in pregnancy: What is the differential diagnosis of itch in pregnancy?

Itch in pregnancy: What is the differential diagnosis of itch in pregnancy? Itch unrelated to pregnancy | Diagnosis | Itch in pregnancy | CKS | NICE Search CKS… Menu Itch unrelated to pregnancy Itch in pregnancy: What is the differential diagnosis of itch in pregnancy? Last revised in April 2020 What is the differential diagnosis of itch in pregnancy? Alternative causes that do not typically cause rash include: Drugs — for example opioids. Endocrine disorders — for example thyroid disorders (...) , leukaemia, and multiple myeloma. For further information, see the CKS topics on and . Neurological disorders — for example multiple sclerosis. For further information, see the CKS topic on . Psychological causes — for example psychogenic pruritus. Renal disease — around half of people with chronic kidney disease experience itch. For more information, see the CKS topic on . For more information on managing generalized itch, see the CKS topic on . Other skin conditions that can cause widespread itch

2018 NICE Clinical Knowledge Summaries

11. Pruritus in Pregnancy

Pruritus in Pregnancy Pruritus in Pregnancy Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Pruritus in Pregnancy Pruritus (...) in Pregnancy Aka: Pruritus in Pregnancy , Pregnancy Related Pruritus , Pruritus gravidarum , Prurigo gravidarum II. Causes See Common, intense involving May spread to thighs, buttocks, s and arms Prurigo of Pregnancy (Common) Onset in second-half of pregnancy s and s over arms and Associated with or (uncommon) Autoimmune disorder with association Occurs in second-half of pregnancy s and bullae form on , extremities (Common) No in mild form (Prurigo gravidarum) Trunk and extremity itching without rash

2018 FP Notebook

12. Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy. Full Text available with Trip Pro

bile acid profile, composed of primary or secondary, conjugated or non-conjugated bile acids, may provide more specific disease information.To assess and compare, independently or in combination, the diagnostic accuracy of total serum bile acids or serum bile acids profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women, presenting with pruritus. To define the optimal cut-off values for components of serum bile acid profile; to investigate possible sources (...) ), ProQuest Dissertations & Thesis Database, and Index to Theses in Great Britain and Ireland.Prospective or retrospective diagnostic case-control or cross-sectional studies, irrespective of publication date, format, and language, which evaluated the diagnostic accuracy of total serum bile acids (TSBA) or components of serum bile acid profile for the diagnosis of intrahepatic cholestasis of pregnancy in pregnant women of any age or ethnicity, in any clinical setting, symptomatic for pruritus.We selected

2019 Cochrane

13. Overview of pregnancy complications

Overview of pregnancy complications Overview of pregnancy complications - Summary of relevant conditions | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Overview of pregnancy complications Last reviewed: February 2019 Last updated: September 2018 Introduction Complications in pregnancy can result from conditions that are specifically linked to the pregnant state as well as conditions that commonly arise or occur incidentally in women who are pregnant (...) need for folate. Complications include neural tube defects, spontaneous abortion, and placental abruption. Goh YI, Koren G. Folic acid in pregnancy and fetal outcomes. J Obstet Gynaecol. 2008;28:3-13. http://www.ncbi.nlm.nih.gov/pubmed/18259891?tool=bestpractice.com In pregnant women, iron deficiency anaemia is defined as haemoglobin below 110 g/L (<11 g/dL). Goddard AF, James MW, McIntyre AS, et al; British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut

2018 BMJ Best Practice

14. Overview of pregnancy complications

Overview of pregnancy complications Overview of pregnancy complications - Summary of relevant conditions | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Overview of pregnancy complications Last reviewed: February 2019 Last updated: September 2018 Introduction Complications in pregnancy can result from conditions that are specifically linked to the pregnant state as well as conditions that commonly arise or occur incidentally in women who are pregnant (...) need for folate. Complications include neural tube defects, spontaneous abortion, and placental abruption. Goh YI, Koren G. Folic acid in pregnancy and fetal outcomes. J Obstet Gynaecol. 2008;28:3-13. http://www.ncbi.nlm.nih.gov/pubmed/18259891?tool=bestpractice.com In pregnant women, iron deficiency anaemia is defined as haemoglobin below 110 g/L (<11 g/dL). Goddard AF, James MW, McIntyre AS, et al; British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut

2018 BMJ Best Practice

15. The Management of High or Low Body Mass Index During Pregnancy

in urine. Folic acid supplementation may rarely cause allergic reactions including erythema, pruritus and/or urticaria. Doses of folic acid up to 5.0 mg have not been known to have adverse effects on pregnant women or their fetus. Recommendation For clients with a BMI = 30 kg/ m 2 , midwives should discuss the benefits of a diet high in nutrient-dense, folate- containing foods before and during pregnancy to reduce the risk of NTDs. For clients who cannot maintain a high- folate diet, midwives may also (...) ://www.ncbi.nlm.nih.gov/pubmed/8173001 123. Furber CM, McGowan L. A qualitative study of the experiences of women who are obese and pregnant in the UK. Midwifery [Internet]. 2011;27(4):437–44. Available from: http://dx.doi.org/10.1016/j.midw.2010.04.001 124. Kakarla N, Dailey C, Marino T, Shikora SA, Chelmow D. Pregnancy after gastric bypass surgery and internal hernia formation. Obstet Gynecol [Internet]. 2005 May;105(5 Pt 2):1195–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1586357928 AOM Clinical Practice

2019 Ontario Midwives

16. Cholestasis of pregnancy

disease with bile acid levels >40 micromol/L or severe pruritus remote from term can be treated effectively with ursodeoxycholic acid. Close fetal surveillance with delivery near term can be expected with premature delivery reserved for those with severe, worsening disease despite treatment. Definition Intrahepatic cholestasis of pregnancy (ICP) is a pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and the placenta. The cause (...) -quality evidence found higher incidence of respiratory distress syndrome in neonates delivered of mothers who suffered from intrahepatic cholestasis of pregnancy. Poor quality observational (cohort) studies or methodologically flawed randomized controlled trials (RCTs) of <200 participants. History and exam presence of risk factors pruritus, sparing the face excoriations without rash mild jaundice previous hx of intrahepatic cholestasis of pregnancy (ICP) hx hepatitis C FHx of intrahepatic cholestasis

2017 BMJ Best Practice

17. Nausea/vomiting in pregnancy: Promethazine

Nausea/vomiting in pregnancy: Promethazine Promethazine | Prescribing information | Nausea/vomiting in pregnancy | CKS | NICE Search CKS… Menu Promethazine Nausea/vomiting in pregnancy: Promethazine Last revised in February 2020 Promethazine What dosage of promethazine should I prescribe? Promethazine is available as promethazine hydrochloride or promethazine teoclate. Either preparation may be used: Promethazine hydrochloride is available in two strengths — 10 mg or 25 mg tablets. Prescribe (...) of the head and face, extrapyramidal effects. Antimuscarinic effects — blurred vision, dry mouth, and urinary retention. Skin — urticaria, rash, pruritus, photosensitivity. Gastrointestinal — anorexia, gastric irritation, jaundice (rare). Cardiovascular — palpitations, hypotension, arrhythmias. Irritability and excitement in the neonate — avoid the use of promethazine in the two weeks prior to delivery. [ ; ] What are the contraindications and cautions when prescribing promethazine? Promethazine should

2018 NICE Clinical Knowledge Summaries

18. Itch in pregnancy: Promethazine

Itch in pregnancy: Promethazine Promethazine | Prescribing information | Itch in pregnancy | CKS | NICE Search CKS… Menu Promethazine Itch in pregnancy: Promethazine Last revised in April 2020 Promethazine Contraindications and cautions Promethazine is not contraindicated in pregnancy (but is not specifically licensed for use in pregnancy). Use around the time of delivery may cause irritability, paradoxical excitability, and tremor in the neonate. Promethazine should not be used in people (...) — promethazine may thicken or dry lung secretions and impair expectoration. [ ; ] Adverse effects Adverse effects of promethazine include: Neurological — dizziness, restlessness, headaches, nightmares, sedation that can persist for up to 12 hours (affected people should not drive or operate heavy machinery), muscle spasms and tic-like movements of the head and face, extrapyramidal effects. Anticholinergic effects — blurred vision, dry mouth, urinary retention. Skin — urticaria, rash, pruritus

2018 NICE Clinical Knowledge Summaries

19. CRACKCast E177 – Acute Complications of Pregnancy

encephalopathy may also result. Intrahepatic cholestasis of pregnancy typically presents with generalized pruritus and mild jaundice. Nausea and Vomiting in Pregnancy Hyperemesis gravidarum is defined as nausea and vomiting that cause starvation metabolism, weight loss, dehydration, and prolonged ketonemia and ketonuria. Initial management involves rehydration with IV fluids, antiemetics, and demonstration of ability to take oral hydration. Thromboembolism in Pregnancy Thromboembolic disease accounts (...) of sexually transmitted diseases, in general, the tetracyclines and quinolones are contraindicated in pregnant patients. Treatment of genital tract infections may be important for preventing preterm labor and decreasing transmission to the infant. PID is very rare in pregnancy and does not occur after the first trimester. Given the risk of endometrial infection in pregnancy and the need to consider other diagnoses, pregnant patients who have suspected PID require hospitalization and IV antibiotics

2018 CandiEM

20. Prognostic and mechanistic potential of progesterone sulfates in intrahepatic cholestasis of pregnancy and pruritus gravidarum. Full Text available with Trip Pro

pregnancy = 29/100), demonstrating that all three progesterone sulfates are prognostic for ICP. Concentrations of progesterone sulfates were associated with itch severity and, in combination with autotaxin, distinguished pregnant women with itch that would subsequently develop ICP from pruritus gravidarum (group 2: ICP n = 41, pruritus gravidarum n = 14). In a third group of first-trimester samples all progesterone sulfates were significantly elevated in serum from low-risk asymptomatic women who (...) Prognostic and mechanistic potential of progesterone sulfates in intrahepatic cholestasis of pregnancy and pruritus gravidarum. A challenge in obstetrics is to distinguish pathological symptoms from those associated with normal changes of pregnancy, typified by the need to differentiate whether gestational pruritus of the skin is an early symptom of intrahepatic cholestasis of pregnancy (ICP) or due to benign pruritus gravidarum. ICP is characterized by raised serum bile acids and complicated

2015 Hepatology

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