Cutaneous manifestation in pregnancy

Back ground: During pregnancy there is immunologic, metabolic, endocrine and vascular changes responsible for physiological and pathological skin changes. Aims and Objectives: The objectives of the study to determine the pattern of the skin changes associated withpregnancy and to examine in detail both physiological and specific dermatosis. To identify the various clinical types of pregnancyspecific physiological changes and to know the proportion of these cutaneous manifestation in pregnant women. Materials and Method: The study was a cross sectional study carried out at the out patient department of gynaecological and obstetrics at Adhichunchanagiri Institute of Medical Sciences, Bellur, Karnataka. Study was a period of 6 months. A total of 200 pregnant females, irrespective of their parity and gestational age were examined for any dermatological complaint. Result: The age of the study population ranged from 17 to 39 years (mean=24years), the study population included 200, (60%) primigravida, 40% multigravida. Skin changes were grouped in to: physiological changes (all cases), other dermatoses affected by pregnancy (80 cases), specific dermatoses (20 cases). Most common physiological changes were pigmentary alteration 184 cases (92%), followed by straie seen in 172 cases (86%). Of the various specific dermatoses of pregnancy, Pruritic utricarial papules and plaques of pregnancy was the most common disorder (13 cases), followed by Pruritus gravidarum (6 cases). The most common dermatoses affected by pregnancy Vulvovaginal candidiasis (30 cases), acne vulgaris (20 cases), eczemas (10 cases). Conclusion: Pregnant women are prone to suffer from a wide range of dermatological problems apart from specific dermatoses of pregnancy. The study emphasizes the need for a detailed and meticulous examination of these patients to detect various disorders.


Introduction
In pregnancy cutaneous changes results from altered metabolic, immunological and endocrine factors. These changes are the positive adaptation of mother to accommodate and support the fetus as it develops through gestation [1]. Physiological skin changes in pregnancy include changes in pigmentation, alteration in connective tissue, vascular system as well as changes in hairs and nails [2]. Some skin eruptions are specific to pregnancy and are called pregnancy specific dermatosis.
Along with this, the pre-existing skin conditions may either improve or exacerbate in pregnancy due to immunological changes in pregnancy. As cell mediated immunity is depressed during normal pregnancy, this accounts for increased severity and frequency of skin infections as candidiasis. However, detailed reports encompassing the physiological changes and specific dermatoses of pregnancy and its effects of various dermatoses on these women are scanty in literature. Many studies have focused on a particular dermatosis or other diseases and condition related to pregnancy [1,2]. Existing studies show a wide range of variations in the incidence of Specific dermatoses of pregnancy. For these reasons, a clinical study was conducted to study both physiological changes and specific dermatoses of pregnancy.
The detailed reports encompassing the physiological changes and pregnancy specific dermatosis and effects of various dermatosis on pregnant women are scanty in literature. Correct diagnosis is important for management and also for prognosis because some of the skin disorders like Pemphigiod gestation are associated with fetal risk. For this reasons a clinical study was conducted to study both physiological changes and pregnancy specific dermatosis. Detailed dermatological examination was performed for patients to look for physiological changes and specific dermatoses. In case of specific dermatosesthe morphology of skin lesions, distribution, and site involved were studied.

Original Research Article
The diagnosis was based mainly on clinical grounds, history of a pre-existing skin disease also noted a routine examination of blood and urine and serology were done in all cases.

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 64 | P a g e

Discussion
Pregnancy is a unique physiological state characterized by metabolic, immunologic, and hormonal readjustments. These make a pregnant woman vulnerable to all dermatoses occurring in the nonpregnant state and also to certain eruptions related to the physiologic burden of gestation. Many of the symptoms and signs are so common that they are not usually considered as being abnormal, but regarded as physiological and can sometimes provide contributory evidence of pregnancy [4]. The most common physiological changes are pigmentalterations, stretch marks, vascular changes and Telogen effluvium [3].
In this study, most women 184 (92%) experienced physiological changes. In a study by Kumari et al[4], physiological changes were observed in all patients studied (100%). In the study by Raj et al [5], which included 1175 pregnant women, only 114 (9.7%) experienced some skin changes.Among the physiological changes, the most common was hyperpigmentation seen in 526 (87.67%) cases.
The mostcommon pattern was lineanigra ( fig.1) .4) in 2% of the cases. No cases of palmar erythema were seen in our study. Raj. et al. [5] reported the prevalence of palmar erythema to be 33.3%. Pregnancy gingivitis is due to hormonal changes as well as local Irritation, nutritional deficiencies may also be responsible [3]. It was seen in 5/200 patients in our study. In a study by Muzzaffar et al. [7], 23/140 (16.4%) had gingival edema and redness.
Increased appearance of Montgomery's tubercles is wellknown during pregnancy in 30-50% of pregnant women [3]. In our study, Montgomery's tubercles were seen in 6% of the patients.
An increased frequency of infection was seen in our study, which is common during pregnancy and is probably related to low cellular immunity. During pregnancy, the cells of the hyperplastic vaginal epithelium get filled with glycogen, desquamate, and contribute to low vaginal acidity, thereby creating an environment suitable for growth of Candida. We found vulvovaginal candidiasis in 15% of patients, Other infections seen were tinea versicolor (2.5%), scabies (2.5%), pityriasis rosea (2.5%), and acne vulgaris (10%).
Nail changes such as brittleness, subungual hyper keratosis, oncholysis and leuconychia have been reported during pregnancy. However, no significant nail changes in pregnant females were observed in our study.
Specific dermatoses of pregnancy represent a heterogeneous group of ill-defined pruritic skin diseases unique to pregnancy. Holmes and Black [11] proposed a

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 65 | P a g e simplified clinical classification of the specific dermatoses of pregnancy. This classification basically subdivided the specific dermatoses of pregnancy into the following four groups: Pemphigoid (herpes) gestation, Polymorphic eruption of pregnancy, Prurigo of pregnancy,Pruritic folliculitis of pregnancy [11].
Based on the study conducted by Ambros-Rudolph et. Al [12] on 505 pregnant patients, a new classification has been proposed and introduced a new term called ''atopic eruption of pregnancy," which covers all patients formerly diagnosed as having prurigo of pregnancy, pruritic folliculitis, and eczema of pregnancy. The incidence of these specific disorders of pregnancy is 0.5-3.0% [8]. In our study of 200 women, 20 (10%) cases of specific dermatoses were seen. Of these, the most common was polymorphic eruption of pregnancy is 13cases (6.5%)( fig.5) Two recent studies from India (9,13) reported a higher prevalence, with PEP being the most common PSDs in their respective studies. PEP ocuurs in 1 of 160-240 pregnancies and is more common in white women [14]. It occurs classically in primigravida duringthe third trimester of pregnancy or occasionally postpartum and does not reoccur in subsequent pregnancies. Incidence of PEP is higher in multiple gestation. All the affected patients in our study were primigravida and all carried single gestationpregancies.

Conclusion
Physiological dermatoses are common in primigravida compared to multigravida. Infective dermatosis during pregnancy should be diagnosed at the earliest to prevent morbidity during antenatal period. Specific dermatoses of pregnancy are also not uncommon, can be a source of significant distress to the patients which warrants specific care in turn influences the maternal and fetal outcome. The awareness, recognition of these skin conditions, familiarity with their treatment, antepartum surveillance, early diagnosis and prompt treatment is essential for improving maternal and fetal prognosis thus minimizes their morbidity.
Fetal risks have only been associated with PG and ICP, but with the overlappingsymptoms between the diseases pruritis in pregnancy should never be neglected.
Interdisciplinary management involving dermatologists, pediatricians, obstetricians, and gastroenterologists is mandatory to acquire a better outcome for the mother and the fetus.