Skin disease in pregnancy
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3489 (Published 03 June 2014) Cite this as: BMJ 2014;348:g3489
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This article has presented atopic eruptions of pregnancy and polymorphic eruption of pregnancy as being the most common skin disorders of pregnancy. Tunzi & Gray (2007) have supported this, though they refer to polymorphic eruption by its former name, pruritic urticarial papules of pregnancy. Additionally, the authors of this article and the one to which I made reference have agreed that pemphigoid gestationis is rare. This article has piqued my interest as it reinforces that skin changes or conditions, that are common in pregnancy, go far beyond ‘normal’ straiae gravidarium and/or hyperpigmentation.
As I read, the article resonated with me as I visualised the conditions and thought that, indeed, for some women pregnancy must be bitter sweet. Pregnancy may be sweet because of the joy of being able to reproduce and the anticipation of adding to one’s family. On the other hand, it may be bitter because of the anticipated or actual discomforts that are associated with the morphological changes in the woman’s body and its systems, to accommodate the growing foetus. Recently, I heard two pregnant colleagues quip about their uncomfortable skin changes. They were both primigravidae. One spoke of the pruritis and eczema flare ups; the other spoke of the impact that the skin changes had on her body image and self esteem. She said ‘when people talk about pregnancy they never talk about the negative things...my skin broke out all over’. She continued to express her alteration in comfort that was secondary to her body image disturbance, which was associated with her pregnancy related skin changes.
The article focused on medical management of pregnancy-related skin conditions. But, healthcare is wholistic, which includes the psychological aspect of the individual. Therefore, it would have been interesting to have identified whether any body image alteration caused them to feel stressed. Additionally, the authors have stated that immune system changes in pregnancy influence women’s susceptibility to skin diseases. It is known that immune responses may be impacted by stress levels (Herbert & Cohen, 1993). So, it would be noteworthy to identify whether being stressed affected the severity of their skin condition and its medical management.
References
Tunzi, M. & Gray, G. R. (2007).Common skin conditions during pregnancy. American Family
Physician. 75(2), 211-218. Retrieved from http://www.aafp.org/afp/
2007/0115/p211.html
Herbert, T. B., & Cohen, S. (1993). Stress and immunity in humans: a meta-analytic review.
Psychosomatic medicine, 55(4), 364-379. Retrieved from http://journals.lww.com/
psychosomaticmedicine/Abstract/1993/07000/Stress_and_immunity_in_humans__a_met
a_analytic.4.aspx
Competing interests: No competing interests
While I welcome the review of skin conditions in pregnancy by Vaughan jones et al, there is an erroneous statement that must be challenged, namely that recurrent genital simplex at the onset of labour is 'an indication for Caesarean section'. As every MRCOG candidate will know this is not current guidance see green top guideline 30, and only in primary disease at the onset of labour is this the recommendation.
Competing interests: No competing interests
The authors have misrepresented and over-simplified the current management of genital herpes in pregnancy. The 2007 guideline of the British Association for Sexual Health and HIV (BASHH)states that vaginal delivery should be anticipated when first episode genital herpes occurs in the first and second trimesters of pregnancy. Caesarean section should be offered to all women who present in the third trimester.
BASHH will soon publish updated guidance on genital herpes. In addition, the Royal College of Obstetricians and Gynaecologists and BASHH will publish a joint guideline on management of genital herpes in pregnancy.
Competing interests: No competing interests
Re: Skin disease in pregnancy
The article on Skin disease in pregnancy describes some physiological changes. We would like to add one more from personal experience. Co-author (RAN), para 0, gravida 1, was carrying a twin pregnancy. By 27 weeks gestation the abdominal wall was tensely distended and a white circular patch had developed around the umbilicus (the photos are taken at 29 weeks gestation). She was otherwise asymptomatic.
It appeared that this was a perfusion anomaly of the peri-umbilical tissues, secondary to tense abdominal wall distension. Digital pressure applied to other areas of the abdominal wall resulted in blanching of a similar colour with remarkably delayed capillary refill, confirming our impression of a perfusion anomaly. The white patch remained unchanged throughout pregnancy.
RAN underwent Caesarean section at 37 weeks gestation, and immediately post operatively it was noted that the white patch had disappeared with normal appearance of peri-umbilcal skin.
We could find no reference to this phenomenon in the medical literature. However, we found numerous on-line comments by other mothers who had experienced similar changes. Perhaps we could call it the Newton patch?
Signed informed patient consent obtained.
Competing interests: Dr RA Newton (General Practitioner) is the daughter of Dr TA King (Consultant Anaesthetist). The pictures are of Dr RA Newton who gives consent for these to be published.