Name
HERPES GESTATIONIS
DESCRIPTION
DETAIL
CAUSES • Unknown but immune alterations suspected • Higher association with HLA-DR3 and HLA-DR4 • Possibly role of major histocompatibility complexes (MHC) class II antigen • Not caused by herpes virus -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS . Other pruritic conditions of pregnancy . Besnierfs prurigo gestationis with excoriated papules and no vesicles; usually limited to extensor surface of extremities . Papular urticarial papules and plaques of pregnancy (PUPPP syndrome) which has urticarial plaques and small papules with a narrow, pale halo and no vesicles; usually in primagravidas near term . Impetigo herpetiformis has sterile pustules, not vesicles, and may involve mucous membranes, groin, and inner thighs . Papular dermatitis of pregnancy . Non-pregnancy conditions to consider . Dermatitis herpetiformis (much more chronic and more often in middle-aged males) . Bullous pemphigoid . Toxic drug eruption including erythema multiforme• Tzanck smear negative • Herpes simplex virus culture negative • Peripheral eosinophilia may be present SPECIAL TESTS: Biopsy with direct immunofluorescence shows intense deposition of C3 (100%) and IgG (25-30%) along basement membrane. Serum may have circulating IgG antibasement membrane autoantibodies (10-20%) by indirect immunofluorescence; if not, half have herpes gestationis (HG) factor (a protein that fixes complement to basement membrane in-vitro human skin preparations).
TYPENOTES
RISK FACTORS: Episode in prior pregnancy, Herpes simplex does not increase riskGENERAL MEASURES • Differentiate from herpes virus infection • Relieve pruritus • Prevent secondary infection • Soothing compresses such as with aluminum acetate (Burow’s solution, Domeboro) may help relieve itching DRUG(S) OF CHOICE • Topical steroids and oral antihistamines for mild pruritus • Most will require systemic corticosteroids in doses of 20-40 mg/day (at the minimum effective dose) through first month postpartum. Often able to taper off before delivery, and then increase in the postpartum period as needed. Contraindications: Weigh risk of aggravating hyperglycemia, potential effects on maternal and fetal bone, increased susceptibility to infections versus benefit of relieving pruritus, and resolving the lesions Precautions: • Use prednisone cautiously in patients with immune impairment, diabetes, or thrombophlebitis • If prednisone has been used over several weeks, taper when discontinuing to prevent cortisol deficiency ALTERNATIVE DRUGS Pyridoxine PATIENT MONITORING Watch for secondary bacterial infection PREVENTION/AVOIDANCE • Avoid other people with infections, since there is susceptibility of open skin lesions and decreased resistance secondary to corticosteroids • Some authorities recommend cesarean section when mother is known to be infected • Avoid scalp monitors if disease involves maternal genitalia • Use of estrogens or progesterone may trigger flare-up POSSIBLE COMPLICATIONS • Secondary bacterial infection • Excess systemic medication in pregnancy • Fetal deaths • Premature births • Fetal growth retardation • Conjunctivitis • Keratitis • Cataracts • Shock • Transient herpes gestationis in the neonate EXPECTED COURSE/PROGNOSIS • Spreads during 2nd-3rd trimester • Remits after delivery within weeks • Often flares in puerperium, especially with oral contraceptives • Tends to recur in subsequent pregnancies and when recurs, it is likely to begin earlier and be more severe • Systemic steroids may suppress new lesions, relieve pruritus, and dampen course; fetal outcome may be worsened • Duration observed less in breast-feeding women
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
COMPLETE BLOOD COUNT, BIOPSY