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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


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Acquired dermal melanocytosis: Appearance during pregnancy

Adam I. Rubin, MD
S. Van Laborde, MD
Matthew J. Stiller, MD

New York, New York

J Am Acad Dermatol 2001;45:609-13 Abstract quote

We report the first case of acquired dermal melanocytosis (ADM) appearing during pregnancy. A 23-year-old Hispanic woman presented to the Dermatology Clinic of Columbia-Presbyterian Medical Center during the second trimester of pregnancy with a nonpalpable blue-gray patch with interspersed discrete brown macules on the right lower extremity. It had appeared during the first trimester of pregnancy. Cutaneous biopsy specimens revealed dermal melanocytes.

A review of all reported cases of this rare dermatosis in the international literature is presented.



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.

A case-control study of polymorphic eruption of pregnancy.

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.

J Am Acad Dermatol. 2008 Jan;58(1):63-7. Abstract quote

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.


Myometrial Inflammation in Human Delivery and Its Association With Labor and Infection

Leea T. Keski-Nisula, MD, PhD, Marja-Leena Aalto, MD, PhD, Pertti P. Kirkinen, MD, PhD, Veli-Matti Kosma, MD, PhD, and Seppo T. Heinonen, MD, PhD

Am J Clin Pathol 2003;120:217-224 Abstract quote

The presence of inflammation in decidual and myometrial samples as defined by histopathologic examination and the association between the myometrial inflammation and different maternal infectious morbidity and labor-related clinical variables were evaluated in 648 consecutive women who underwent cesarean section at various gestational periods.

Altogether, 1,205 histologic (559 decidual and 646 myometrial) samples were studied.
In normal pregnancies, myometrial inflammatory lesions were detected rarely before parturition, indicating their abnormality in these cases. After ruptured fetal membranes with advanced cervical dilatation and in patients with clinical chorioamnionitis, myometrial samples commonly were infiltrated by leukocytes, up to moderate and marked densities. Moderate to marked myometrial inflammation showed no diagnostic value in high-risk term parturients for the prediction of postoperative endometritis.

Our study is the first to show the frequency of myometrial inflammation in nonselected consecutive pregnant women and, thus, is important for better understanding the myometrial inflammatory response during human parturition.



Outcomes at 3 Months After Planned Cesarean vs Planned Vaginal Delivery for Breech Presentation at Term

The International Randomized Term Breech Trial

Mary E. Hannah, MDCM; Walter J. Hannah, MD; Ellen D. Hodnett, RN, PhD; Beverley Chalmers, PhD; Rose Kung, MD; Andrew Willan, PhD; Kofi Amankwah, MD; Mary Cheng, MD; Michael Helewa, MD; Sheila Hewson, BSc; Saroj Saigal, MD; Hilary Whyte, MD; Amiram Gafni, PhD; for the Term Breech Trial 3-Month Follow-up Collaborative Group


JAMA. 2002;287:1822-1831 Abstract quote

The Term Breech Trial found a significant reduction in adverse perinatal outcomes without an increased risk of immediate maternal morbidity with planned cesarean delivery compared with planned vaginal birth. No randomized controlled trial of planned cesarean delivery has measured benefits and risks of postpartum outcomes months after the birth.

To compare maternal outcomes of planned cesarean delivery and planned vaginal birth at 3 months post partum.

Follow-up study to the Term Breech Trial, a randomized controlled trial conducted between January 9, 1997, and April 21, 2000.

Setting and Participants
A total of 1596 of 1940 women from 110 centers worldwide who had a singleton fetus in breech presentation at term responded to a follow-up questionnaire at 3 months post partum.

Main Outcome Measures
Breastfeeding; infant health; ease of caring for infant and adjusting to being a new mother; sexual relations and relationship with husband/partner; pain; urinary, flatal, and fecal incontinence; depression; and views regarding childbirth experience and study participation.

Baseline information was similar for both the cesarean and vaginal delivery groups. Women in the planned cesarean delivery group were less likely to report urinary incontinence than those in the planned vaginal birth group (36/798 [4.5%] vs 58/797 [7.3%]; relative risk, 0.62; 95% confidence interval, 0.41-0.93). Incontinence of flatus was not different between groups but was less of a problem in the planned cesarean delivery group when it occurred (P = .006). There were no differences between groups in other outcomes.

Planned cesarean delivery for pregnancies with breech presentation at term may result in a lower risk of incontinence and is not associated with an increased risk of other problems for women at 3 months post partum, although the effect on longer-term outcomes is uncertain.

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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Last Updated January 31, 2008

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