Introduction 

Pregnancy is a beautiful journey marked by profound emotional and physical changes. However, it can also encompass unexpected changes. Pruritus, commonly known as itching, emerges as a prevalent yet overlooked condition during pregnancy.

Pruritus can present differently in intensity and location for pregnant women. It can cause discomfort therefore we must have a comprehensive understanding of its causes, symptoms, and treatment to empower expecting or future mothers that navigating each aspect of pregnancy can be done with comfort and confidence. 

What is pruritus? 

• Pruritus comes from the Latin “pririre” meaning “to itch”. It encompasses sensations that trigger the desire to scratch or rub the affected skin² 
• Between 23% to 38% of pregnant women experience pruritus, while severe itching is present in around 2% of cases.³ It is a distressing symptom that could indicate the onset of a pregnancy-related condition
• When pregnant, pruritus is caused due to various factors such as hormonal changes, physical changes, and underlying medical conditions

Hormone changes 

• During pregnancy, women undergo significant hormonal changes, particularly an increase in estrogen levels, which plays a crucial role in supporting the development of the foetus 
• Changes in hormones can affect the skin and make it more susceptible to dryness and itching² 

Skin stretching 

• During pregnancy, the uterus expands to accommodate the growing foetus, which exerts pressure on the surrounding skin
• This stretching leads to dryness, irritation, and itching, especially in areas where the skin is under tension, such as the abdomen, breasts, thighs, and buttocks² 

Causes of pruritus 

The presence of an itch during pregnancy is due to: 

• Pregnant women who have pre-existing skin conditions, like eczema or psoriasis, may experience exacerbations during pregnancy.⁴ These conditions can intensify the itching and contribute to discomfort 
• The most common conditions that occur during pregnancy are:
  • Obstetric cholestasis that does not involve a rash⁴ 
  • Polymorphic eruption and atopic eruption during pregnancy are characterised by a rash⁴

Cholestasis of pregnancy 

• Cholestasis is impaired bile flow from the liver that typically manifests in the third trimester⁵ 
• While this is less common, cholestasis of pregnancy is a more cause of pruritus
• Cholestasis of pregnancy is associated with intense itching, predominantly on the palms of the hands and soles of the feet⁵ 
• It requires immediate medical attention to mitigate the potential maternal and foetal health risks

Pruritic urticarial papules and plaques of pregnancy (PUPPP) 

• They are polymorphic eruptions of pregnancy. It is most frequently seen in the third trimester, although cases have been documented in early pregnancy and after childbirth⁶ 
• Skin changes that occur are eruptions of plaques and papules. The rash comes with an itch
• Polymorphic eruption of pregnancy can be linked to having more than one baby and having a male baby

Pruritus symptoms during pregnancy

Pruritus during pregnancy can present with a variety of symptoms, from slight itching to significant discomfort and skin alterations. Identifying these signs is crucial for prompt intervention and successful handling. 

• Itching is the main symptom of pruritus during pregnancy, and it can differ in how severe it is and where it is felt
• Pregnant women may feel itching on the belly, chest, legs, buttocks, and hands and feet. If, they have cholestasis during pregnancy⁷ 
• Long-lasting itching can result in noticeable alterations- redness, dryness, or rash-like eruptions on the skin
• These modifications emphasise the inflammation beneath the surface and the necessity of specific treatments to relieve symptoms and improve skin condition
• Persistent itching affects their quality of life, disrupting their daily activities, sleep, and emotional health⁷ 
• Dealing with this requires a multifaceted strategy that focuses on and addresses the root causes of itching and the related symptoms⁷

Complications

The effects of pruritus during pregnancy can differ for both the mother and the foetus based on the cause. 

• Cholestasis of pregnancy may lead to issues for the mother, like difficulty absorbing nutrients and excessive bleeding after giving birth due to low levels of vitamin K caused by liver issues⁸ 
• A study discovered a higher occurrence of gallbladder problems, such as gallstones, in affected patients
• Intrahepatic cholestasis of pregnancy (ICP) can lead to issues for the baby such as being born prematurely, having trouble breathing, and being underweight at birth

Managing pruritus 

• Prompt medical evaluation is crucial in cases of severe or persistent pruritus, especially if other worrying symptoms are present, to rule out underlying medical conditions like cholestasis of pregnancy⁹ 
• Healthcare professionals conduct diagnostic examinations such as liver function tests and bile acid measurements. They help to evaluate liver function and make treatment plans

Treating pruritus during pregnancy

Treatment should prioritise easing symptoms and avoiding adverse effects on the foetus. 

• Efficient management of itching during pregnancy involves a mix of preventative steps, lifestyle changes, and specific treatments to relieve symptoms and enhance the mother’s health
• Reassurance, education, psychological techniques, antipruritic creams, and mild steroid ointments help to manage minor symptoms

Lifestyle changes

Keeping skin well-hydrated

• It is crucial for preventing dryness and itching
• Pregnant women should ensure drinking enough water and include moisturizing products like scent-free lotions or oils in their skincare regimen¹⁰ 
• Emollients with glycerin, hyaluronic acid, or ceramides restore the natural barrier and improve moisture retention¹⁰ 

Mild cleansing methods 

• Abrasive soaps and cleansers remove the natural oils and worsen dryness and irritation of the skin
• Cleansing techniques like washing with warm water and gently patting the skin with a soft towel can reduce irritation and enhance comfort¹⁰ 

Choosing the right clothes 

• Wearing loose-fitting, breathable clothing made of natural fibres like cotton or bamboo minimizes friction and irritation and can help reduce itching¹⁰ 

 Regulating body temperature 

• Extreme temperatures, either very hot or cold, can cause or intensify itching¹⁰ 
• Keeping the indoor environment comfortable and avoiding extreme temperatures can help regulate the skin's temperature and reduce itch-causing stimuli

Preventing irritants 

• Identify and steer clear of potential irritants such as strong detergents, scented products, and environmental allergens to manage itch and prevent the worsening of current skin ailments¹⁰ 
• Choosing fragrance-free household and personal care items can reduce the chance of skin sensitisation and allergic reactions¹⁰ 

Medication

Topical treatments

• Non-prescription topical treatments like hydrocortisone creams or calamine lotion can offer relief for mild to moderate itching¹¹ 
• They are typically safe during pregnancy; however, potent steroids could lead to foetal growth restriction, skin thinning, and more stretch marks
• It is advisable to start with mild to moderate-potency steroids for topical treatment
• Nevertheless, pregnant women should be careful and seek advice from a healthcare provider before taking any medication or using any topical products while pregnant to guarantee the well-being of both the mother and the baby

Ursodeoxycholic acid (UDCA)

• Ursodeoxycholic acid (UDCA) is a possible treatment for pregnancy-related cholestasis to enhance bile flow and relieve symptoms, along with careful observation of the health of the mother and baby to prevent any potential issues⁵ 

Summary

Dealing with itching during pregnancy is difficult. It involves understanding the various reasons, symptoms, and ways to manage it. Expectant mothers can effectively control pruritus and reduce its impact on their quality of life by taking proactive steps, such as implementing preventive measures and seeking timely medical help. Choosing comfort and putting self-care first during pregnancy supports the health of mothers and allows them to fully engage in the life-changing process of becoming a mother.

Healthcare providers, family members, and peers are crucial in offering support, advice, and comfort to pregnant women dealing with the challenges of pruritus during pregnancy as a caring community. By educating, empathising, and working together, we help women approach pregnancy with confidence, resilience, and deep gratitude for the wonderful experience of bringing new life into the world.