Part 29 (1/2)

Use of 5-fluorouracil is not recommended because it is an antineoplastic agent and there are no human studies of the topical administration of this agent during pregnancy.

For small, isolated lesions, surgical excision, electrocoagulation, and cryotherapy generally produce satisfactory results. A CO laser is a very effective tool in the treatment 2 of large or ma.s.sive v.u.l.v.ar condyloma ac.u.minata (Ferenczy, 1984; Hankins et al et al., 1989; Malfetano et al et al., 1981).

Atopic/allergic dermat.i.tis This condition is characterized by a pruritic rash and is secondary to a variety of inciting factors, such as stress, soap (especially with aroma additives), and irritants.

252.

Use of dermatologics during pregnancy Atopic/allergic dermat.i.tis is usually treated by (1) removal of the inciting factors and (2) topical or systemic steroids. Topical steroids are recommended during pregnancy and generally prove satisfactory.

Erythema multiforme The etiology of erythema multiforme, another dermat.i.tis, is virtually unknown. It is characterized by erythematous 'target lesions.' An increased frequency of outbreaks occurs during pregnancy among women with this condition. The condition can be treated with antihistamines during pregnancy. If antihistamines are not sufficient, steroids may be effective in some cases. Triamcinolone should not be used.

Papular dermat.i.tis of pregnancy Papular dermat.i.tis is very rare (< 1=”” percent)=”” and=”” is=”” limited=”” to=”” pregnancy=”” (spangler=”” et=”” al=”” et=”” al.,=”” 1962).=”” recurrence=”” in=”” subsequent=”” pregnancies=”” is=”” known=”” and=”” it=”” is=”” a.s.sociated=”” with=”” an=”” increased=”” frequency=”” of=”” pregnancy=”” loss.=”” papular=”” dermat.i.tis=”” is=”” characterized=”” by=”” small,=”” erythematous=”” papules=”” that=”” usually=”” involve=”” all=”” of=”” the=”” skin.=”” high-dose=”” systemic=”” steroids,=”” such=”” as=”” prednisone,=”” are=”” used=”” to=”” treat=”” this=”” dermat.i.tis.=”” triamcinolone=”” should=”” not=”” be=””>

Pruritic urticarial papules and plaques of pregnancy Pruritic urticarial papules and plaques of pregnancy, also known as PUPPP, are common during pregnancy. Papular dermat.i.tis of pregnancy can occur any time during gestation, but PUPPP tends to occur in late pregnancy. Recurrence of PUPPP in subsequent pregnancies is rare. Pruritis and erythematous papules and plaques characterize PUPPP.

Unlike papular dermat.i.tis, PUPP is not a.s.sociated with an increase in pregnancy loss.

The rash usually starts on the abdomen and spreads to the extremities, with facial sparing (Alcalay et al et al., 1988; Yancy et al et al., 1984). Treatment consists primarily of topical steroids, although oral prednisone may be required for severe cases. Triamcinolone should not be used.

Herpes gestationis Another rare dermatologic disease of unknown etiology is herpes gestationis. Contrary to what might be implied from the name, herpes gestationis is not a viral infection but an autoimmune disease. It is peculiar to pregnancy and may recur in subsequent gestations. Erythematous papules and large, tense bullae, usually on the abdomen and extremities characterize this disease. Some investigators have reported that an increased frequency of pregnancy loss is a.s.sociated with this condition in some studies (Lawley et et al al., 1978), but not in others (Katz et al et al., 1976). Treatment consists primarily of oral prednisone (3050 mg daily). Triamcinolone should not be used.

Key references 253.

Key references Almond-Roesler B, Orfanos CE. Tran-acitretin is metabolized back into etretinate. Importance for oral retinoid therapy. Hautarzt 1996; 47 47: 173.

Barbero P, Lotersztein V, Bronberg R, Perez M, Alba L. Acitretin embryopathy. A case report.

Birth Defects Res A Clin Mol Teratol 2004; 70 70: 831.

Carmichael SL, Shaw GM. Maternal corticosteroid use and risk of selected congenital anomalies. Am J Med Genet 1999; 86 86: 242.

Coberly S, Lammer E, Alashari M. Retinoic acid embryopathy. Case report and review of literature. Pediatr Pathol Lab Med 1996; 16 16: 823.

Johnson, PD, Dawson BV, Goldberg, SJ. Cardiac teratogenicity of trichloroethylene metabolites. J Am Coll Cardiol 1998; 32 32: 540.

Loureiro KD, Kao KK, Jones KL et al. Minor malformations characteristic of the retinoic acid embryopathy and other birth outcomes in children of women exposed to topical tretinoin during early pregnancy. Am J Med Genet 2005; 136A 136A: 117.

Rodriguez-Pinilla E, Martinez-Frias ML. Corticosteroids during pregnancy and oral clefts. A casecontrol study. Teratology 1998; 58 58: 2.

Shepard TH, Brent RL, Friedman JM et al. Update on new developments in the study of human teratogens. Teratology 2002; 65 65: 153.

Further references are available on the book's website at14.Drug overdoses during pregnancy Clinical management 256.

Anorectic overdoses 270.

Nonnarcotic a.n.a.lgesic overdoses 257.

Hormonal agent overdoses 270.

Nutritional supplement overdoses 264.

Antidepressant overdoses 271.

Antianxiolytic overdoses 267.

Anticonvulsant overdoses 271.

Hypnotic and sedative overdoses 267.

Overdoses of other drugs 272.

Narcotic a.n.a.lgesic overdoses 268.

Overdoses of nondrug chemicals 272.

Antibiotic overdoses 269.

Summary 273.

Antihistamine and decongestant Key references 274.

overdoses 269.

Appendix 274.

Antipsychotic overdoses 270.

Usually, drug overdoses during pregnancy are a suicide gesture or, less often, an attempt to induce abortion. Accidental overdoses are rare. Quinine overdoses are a.s.sociated with an attempt to induce abortion over 90 percent of the time, but most other overdoses of the drug are also attempted suicide. Successful suicide during pregnancy occurs among one in every 88 000400 000 live births (Table 14.1) (Rayburn et al et al., 1984).

Among 162 pregnant women who presented with an indication of poisoning, 86 percent were overdoses (78 percent suicide attempts and 8 percent induced abortion attempts (Czeizel et al et al., 1984)). Maternal death a.s.sociated with suicide gestures occurs in approximately 1 percent of gravid women and more than 95 percent of suicide gestures involve ingestion of a combination of drugs (Rayburn et al et al., 1984). In New York city, suicide was identified as the cause of 13 percent of maternal deaths (Dannenberg et al et al., 1995).

Use of drug megadoses that are potentially lethal in pregnant women involves two patients: mother and fetus. a.s.sessment of the pregnant woman who has potentially toxic (megadoses) amounts of drugs must begin with laboratory evaluation of the substance(s) ingested (i.e., serum levels). The top three substances used in suicide gestures in the USA in the late 1970searly 1980s were nonnarcotic a.n.a.lgesics, nutritional supplements, and antiaxiolytics (Table 14.1). In Finland in the late 1990s, the pattern was similar with the top three substances used in suicide attempts being benzodiazepines, a.n.a.lgesics, and psychotropics (antipsychotics/antidepressants) (Table 14.2).

The data in Tables 14.1 and 14.2 only provide a best guess, given that there is no history for a.s.sessing a pregnant woman who has made a suicide gesture. If the patient is Drug overdoses during pregnancy Drug overdoses during pregnancy 255.

Table 14.1 Drugs used in suicide gestures among 111 pregnant women in the USA Drug cla.s.s Drugs used in suicide gestures among 111 pregnant women in the USA Drug cla.s.s Percent Nonnarcotic a.n.a.lgesics (acetaminophen, aspirin, ibuprofen) 26 Nutritional supplements (prenatal vitamins, iron) 12.Antianxiolytics (diazepam, hydroxyzine, other benzodiazepines) 11 Hypnotics and sedatives (phen.o.barbital, flurazepam, and others) 10 Narcotic a.n.a.lgesics (codeine, propoxyphene, and others) 8.Antibiotics (cephalexin, amoxicillin, trimethoprim sulfamethoxazole) 7 Antihistamines (diphenhydramine, others) 6.Antipsychotics (thioridazine, trifluoperazine) 3.Anorectics (sympathomimetics, phenylpropanolamine) 2.Hormonal agents (corticosteroids, oral contraceptives) 2.Antidepressants (doxepin, amitriptyline) 2.Anticonvulsants (phenytoin, carbamazepine) 2.Other drugs (miscellaneous drugs from other cla.s.ses) 6.Nondrug chemicals (turpentine, camphorated oil, ammonia) 2 Compiled from Rayburn et al., 1984.

Table 14.2 Suicide attempts by pregnant women in Finland: 1977 to 1999a n Suicide attempts by pregnant women in Finland: 1977 to 1999a n Percentage a.n.a.lgesics 21/43.

49.Acetaminophen (paracetamol) 6.Acetylsalicylic acid (aspirin) 5.Carsioprodol 1.Codeine 1.Ibuprofen 2.Indomethacin 1.Phen.o.barbital 2.Salicylamide 3.Benzodiazepines 15/43.

35.Diazepam 8.Estrazolam 1.Flinitrazepam 2.Nitrazepam 2.Oxazepam 1.Triazolam 1.Antipsychotic 2/43.

5.Flupentixol 1.Fluphen.a.z.ine 1.Antidepressants 2/43.

5.Doxepin 1.Nomifensine 1.Iron supplement 1/43.

2.3.

Appet.i.te suppressant 1/43.