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BACKGROUND
Pregnancy is not a disease state but a profound physiologic change that occurs for the mother. In the early stages, it is not uncommon for a pregnancy to be misdiagnosed as a true disease state. During the course of the pregnancy, underlying diseases such as diabetes mellitus may be unmasked. On a similar note, pre-existing diseases may be exacerbated by the changes.
Laboratory Testing for Pregnancy
Placenta
Pre-eclampsiaOUTLINE
CLINICAL VARIANTS CHARACTERIZATION FETAL-MATERNAL HEMORRHAGE
Fetal-maternal hemorrhage detection in Ontario.Lafferty JD, Raby A, Crawford L, Linkins LA, Richardson H, Crowther M.
Hamilton Regional Laboratory Medicine Program, Hamilton.
Am J Clin Pathol 2003 Jan;119(1):72-7 Abstract quote The results from fetal-maternal hemorrhage (FMH) detection and quantitation external quality assessment surveys conducted in Ontario indicate that the rosette test had a sensitivity and specificity for an FMH of more than 10 mL of 1.0 and 0.75, respectively, compared with 0.96 and 0.92, respectively, for acid elution.
With FMH quantitation, the percentage error of the mean from the target FMH was 20% or more in 7 of 8 surveys, and coefficients of variation ranged from 39.5% to 71.8%. Inadequate Rho(D) immune globulin prophylaxis could have occurred in 19.4% of the challenges with an FMH of more than 10 mL. The rosette and acid elution techniques are both effective for the detection or exclusion of FMH, but acid elution lacks adequate accuracy and precision for reliable FMH quantitation.
Furthermore, a strategy of prescribing an extra 1,500-IU Rho(D) immune globulin dose, in addition to the dose required to treat the volume of fetal blood detected, is an effective strategy to overcome the limitations of FMH quantitation by acid elution.
SKIN PREGNANCY ASSOCIATED DERMATOSES
Department of Dermatology, Hôpital Tenon (Assistance Publique-Hôpitaux de Paris), Unité de Formation et de Recherche Pierre et Marie Curie, Paris 6, Université Pierre et Marie Curie, Paris, France.
BACKGROUND: Polymorphic eruption of pregnancy (PEP) is a pruritic disease that usually occurs in primiparous women, most commonly in the last trimester of pregnancy. The origin and pathomechanisms still remain unknown.
OBJECTIVES: We attempted to determine the parameters that may be associated with or complicate the course of PEP.
METHODS: Data of 200 pregnant women (40 PEP and 160 control) were studied retrospectively and compared statistically using univariable and multivariable analysis.
RESULTS: In multivariate analysis, pregnancy with male fetuses (P = .02) and delivery by cesarean section (P = .012) were overrepresented in the PEP group. A tendency toward more multiple gestation pregnancy in PEP was found (P = .07). The risk of PEP was not related to excessive maternal or fetal weight gain.
LIMITATIONS: This was a retrospective study.
CONCLUSION: This large case-control study confirms the already suspected association of PEP with male fetuses and cesarean deliveries in multivariate analysis. The higher rate of multiple gestation pregnancy was also established.
- The specific dermatoses of pregnancy revisited and reclassified: results of a retrospective two-center study on 505 pregnant patients.
Ambros-Rudolph CM, Mullegger RR, Vaughan-Jones SA, Kerl H, Black MM.
Department of Dermatology, Medical University Graz, Graz, Austria.
J Am Acad Dermatol. 2006 Mar;54(3):395-404. Abstract quote
OBJECTIVES: We sought to evaluate the frequency and clinical characteristics of pruritic dermatoses in pregnancy and to assess a rationalized classification.
METHODS: Data of 505 pregnant patients seen at two university-based dermatologic hospitals (1994-2004) were retrospectively studied.
RESULTS: Diagnoses included eczema in pregnancy (49.7%), polymorphic eruption of pregnancy (PEP) (21.6%), pemphigoid gestationis (PG) (4.2%), intrahepatic cholestasis of pregnancy (ICP) (3%), prurigo of pregnancy (0.8%), pruritic folliculitis of pregnancy (0.2%), and miscellaneous dermatoses (20.6%). Eczema in pregnancy, prurigo of pregnancy, and pruritic folliculitis of pregnancy showed considerable overlap and were summarized as atopic eruption of pregnancy (AEP). While PEP, PG, and ICP presented in late pregnancy, AEP started significantly earlier. Primigravidae and multiple gestations were characteristic for PEP, abdominal involvement for PEP and PG, and a history of affected pregnancies for ICP.
LIMITATIONS: This was a retrospective study.
CONCLUSION: We propose classifying the dermatoses of pregnancy as PG, PEP, AEP, and ICP. Stereotypic immunofluorescence and laboratory findings are diagnostic of PG and ICP, whereas distinct clinical characteristics facilitate discrimination between PEP and AEP.
- A prospective study of 200 women with dermatoses of pregnancy correlating clinical findings with hormonal and immunopathological profiles.
Vaughan Jones SA, Hern S, Nelson-Piercy C, Seed PT, Black MM.
St John's Institute of Dermatology, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, U.K.
Br J Dermatol. 1999 Jul;141(1):71-81. Abstract quote
In 1994 we set up a specialist clinic for pregnancy dermatoses, both to improve the management of pregnant women with skin problems and to enhance our general understanding of the pregnancy dermatoses. This clinic has provided a large database of 200 women which has formed the basis for a prospective study over a 2-year period. In each case the dermatological diagnosis was clearly defined on clinical criteria, with additional help from histopathology and direct immunofluorescence of the skin where appropriate.
We have included a number of patients who presented with relatively trivial diagnoses, as this reflects the referral patterns of our midwives, general practitioners and obstetricians within our hospital and local population.
Our results show that all patients with specific dermatoses of pregnancy conformed well to the classification established by Holmes and Black in 1983. The role of the sex hormones [oestradiol, human chorionic gonadotrophin (hCG) and cortisol] in polymorphic eruption (PEP) and prurigo of pregnancy was studied in 125 cases and compared with 138 normal healthy pregnant controls. For pruritic folliculitis (PF), serum androgens were measured to establish if these were elevated. Nearly all patients were followed up postpartum, with respect to both maternal and fetal prognosis (some were unfortunately lost to follow-up). Many patients were primiparous (47%) and presented in their third trimester (49%). This study shows a surprisingly high prevalence of eczema during pregnancy. It is possible that earlier cases in the literature termed prurigo of pregnancy may in fact have been eczema, thus explaining the low incidence of prurigo in this study. Hormonal analysis showed a significant reduction in serum cortisol levels in patients with PEP compared with normal pregnant controls (P = 0.03), although hCG and oestradiol showed no differences. Serum androgens were not significantly elevated in patients with PF compared with controls. Birthweight (analysed by the individualized birthweight ratio) was significantly reduced in both the PF and pemphigoid gestationis groups. In the PEP and PF groups there was a male/female infant ratio of 2 : 1, not noted in previous studies. In all cases studied there were no adverse effects either on maternal or fetal outcome as a result of the pregnancy dermatosis.
This study indicates that all patients fulfilled the criteria of the previous classification of the specific dermatoses of pregnancy, although we also now highlight the frequency of eczema in pregnancy and speculate as to possible causes. There were no cases of papular dermatitis of pregnancy. We feel that the specialist clinic is an important service which has improved the management of these women and identified areas for further research.
Macpherson and Pincus. Clinical Diagnosis and Management by Laboratory Methods. Twentyfirst Edition. WB Saunders. 2006.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fifth Edition. Mosby Elesevier 2008
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