PREGNANCY ASSOCIATED SKIN CHANGES AMONG PRIMIGRAVIDAE ATTENDING ANTENATAL CLINIC AT OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS COMPLEX, ILE- IFE, OSUN STATE, NIGERIA. A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP OF THE COLLEGE IN INTERNAL MEDICINE: SUBSPECIALITY: DERMATOLOGY. 1. Name of Candidate: Dr. Olanrewaju Fatai Olatunde, MBBS (Maiduguri), 2001. (08035765004, [email protected]) 2. Number of Candidate: AF/009/10/005/719 3. Faculty of Candidate: Internal Medicine 1 DECLARATION I hereby humbly declare that the writing and execution of the study contained in this dissertation was carried out by me and it is original and has never been presented to any other College for Fellowship, nor has it been submitted elsewhere for publication. Signature:……………………. Date:……………………….. Dr Olanrewaju Fatai Olatunde 2 SUPERVISION This study was carried out under our supervision at OAUTHC, Ile-Ife, Osun State, Nigeria. NAME OF SUPERVISORS 1. PROF. O. ONAYEMI CONSULTANT, DERMATOLOGY/VENEREOLOGY OAUTHC, ILE-IFE, OSUN STATE. Signature:…………………………………... Date: ……………………………………….. 2. PROF. (MRS).O.A. OLASODE CONSULTANT, DERMATOLOGY/VENEREOLOGY OAUTHC, ILE-IFE, OSUN STATE. Signature…………………………………… Date: ……………………………………….. 3. DR. A.B. ADEYEMI CONSULTANT, OBSTETRIC/GYNAECOLOGY, OAUTHC, ILE-IFE, OSUN STATE. Signature:…………………………………… Date: ………………………………………… 3 HEAD OF DEPARTMENT’S CERTIFICATION I hereby certify that the writing and execution of the study contained in this dissertation was carried out by Dr. Olanrewaju Fatai Olatunde under the supervision of Prof. O. Onayemi, Prof. (Mrs) O.A. Olasode, and Dr A.B. Adeyemi. Signature:………………………………. Professor A.B. Kolawole, Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun state. 4 TABLE OF CONTENTS TITLE PAGE i DECLARATION ii SUPERVISION iii HOD’S CERTIFICATION iv TABLE OF CONTENTS v DEDICATION vi ACKNOWLEDGEMENTS vii LIST OF TABLES viii LIST OF FIGURES ix KEY OF ABBREVIATIONS x SUMMARY xi CHAPTER ONE: INTRODUCTION 1 CHAPTER TWO: LITERATURE REVIEW 3 CHAPTER THREE: AIMS AND OBJECTIVES OF THE STUDY 23 CHAPTER FOUR: JUSTIFICATION OF THE STUDY 24 CHAPTER FIVE: SUBJECT, MATERIALS AND METHODS 25 CHAPTER SIX: RESULTS 31 CHAPTER SEVEN: DISCUSSION 54 CHAPTER EIGHT: CONCLUSION AND RECOMMENDATIONS 65 REFERENCES 66 APPENDICES I. PROFORMA 77 II. INFORMED CONSENT FORM 84 III. ETHICAL APPROVAL 85 5 ACKNOWLEDGEMENTS Glory is to God Almighty, my Strength in ages past, my present day help and our hope for the future. I am indeed very grateful for the mentorship and experience gathered from my great teachers of Dermatology- Prof. O. Onayemi and Prof. (Mrs.) O.A. Olasode. I want to also appreciate them for their immense support and contribution towards the success of this study. My special thanks for the support and encouragement I received from Dr A.B. Adeyemi, Consultant Obstetrician/Gynaecologist who allowed me to carry out this study on his patients and accepted to be a co-supervisor. My gratitude also goes to my Head of Department, Prof. B.A. Kolawole for his words of encouragement, great support, simple and exemplary lifestyle he impacted into my life during the period of my residency training. My sincere gratitude goes to Dr. (Mrs.) O.A. Oninla, Consultant Dermatologist, her advice and teachings were of immeasurable value. I must also thank all consultants and residents in the Departments of Medicine and Obstetrics/Gynaecology of Obafemi Awolowo University Teaching Hospital, Ile-Ife. I wish to express my sincerest gratitude to Dr O.I. Ezejiofor and Dr (Mrs) O. Oke, both Consultant Dermatologists, for their support and the time they spared reading through and correcting this work. To all the resident doctors in the Department of Dermatology especially Dr M.M. Oripelaye and Dr (Mrs.) H. Bello, I am greatly indebted to you for your support and contribution towards this study. My special appreciation and praise to the Lord Jesus, my Redeemer, Who led me through this tough path particularly during my several trips from Owo, Ondo State to Ile-Ife, Osun State. 6 LIST OF TABLES TABLE 1: Socio-demographic characteristic of the Subjects and Controls TABLE 2: General prevalence of pregnancy associated skin changes among subjects. TABLE 3: Prevalence of the three classes of pregnancy associated skin changes in subjects and controls. TABLE 4: Prevalence of the subclasses of pregnancy associated skin changes in subjects and controls TABLE 5a: Prevalence and pattern of pigmentary physiological) skin changes in pregnant subjects and controls. TABLE 5b: Prevalence and pattern of other physiological skin changes in pregnancy and controls. TABLE 6: Prevalence and pattern of some other dermatoses in pregnancy and controls. TABLE 7: Prevalence and pattern of clinical presentation of acne vulgaris in pregnancy. TABLE 8a: Association between some skin changes in pregnancy and gestational age. TABLE 8b: Association between some other skin changes in pregnancy and gestational age. 7 LIST OF FIGURES Figure 1: General prevalence of pregnancy associated skin changes among subjects and controls. Figure 2: Shows the trimester distribution of subjects recruited into the study. Figure 3: Pattern of distribution of striae gravidarum in pregnant subjects. Figure 4: Clinical pattern of melasma in pregnancy and control. Figure 5: Prevalence and pattern of anatomical sites of pruritus in pregnancy. Figure 6: Hirsutism on the abdomen. Figure 7: Hirsutism on the chin. Figure 8: Linea nigra. Figure 9: Scar hyperpigmentation on the abdomen. Figure 10a: Voigt’s lines on the posteriomedial thigh. Figure 10b: Voigt’s lines on the posteriomedial thigh. Figure 11: Nipple, areola and breast hyperpigmentation. Figure 12: Increased naevus pigmentation on the right arm. Figure 13: Skin tags on the neck area. Figure 14: Striae gravidarum on the abdomen. Figure 15: Palmar erythema at the tip of the fingers. Figure 16: Melanonychia of the 2nd, 3rd and 4th finger nails. Figure 17: Bilateral pedal oedema. Figure 18: Leg varicosity on the leg. Figure 19: Pityriasis versicolor on the abdomen. Figure 20: Acne vulgaris on the face. 8 KEYS TO ABBREVIATIONS AD - Atopic Dermatitis ACTH- Adrenocorticotrophic hormone AEP - Atopic Eruption of Pregnancy AN - Acanthosis Nigricans BMI - Body Mass Index BMZ - Basement Membrane Zone BSA - Body Surface Area EGA- Estimated Gestational Age HIV - Human Immunodeficiency Virus HSV - Herpes Simplex Virus ICP - Intrahepatic Cholestasis of Pregnancy LMP - Last Menstrual Period MSH - Melanocyte Stimulating Hormone PDL - Pigmentary Demarcation Line PEP - Polymorphic Eruption of Pregnancy PG - Pemphigoid Gestationis PSP - Pregnancy Specific Dermatosis PT - Pregnancy Test PV - Pityriasis Versicolor USS - Ultrasound Scanning VZV - Varicella Zoster Virus 9 SUMMARY BACKGROUND. The skin is the largest organ in the human body and it undergoes significant changes during pregnancy just like other systems such as endocrine, immune, metabolic and vascular systems. These pregnancy associated skin changes are neglected aspect of obstetric care despite the skin being of great cosmetic concern to the pregnant woman. These skin changes could be physiological or pathological. Pregnancy associated skin changes has been broadly classify into three which are; Physiological, Some dermatoses affected by pregnancy and Pregnancy specific dermatoses. While physiological skin changes cause cosmetic anxiety to the pregnant women, some of the pregnancy specific dermatoses can pose risk to the unborn baby and the mother. The pathogenesis of these skin changes has been attributed to physical factors, genetic factors and rise in levels of ovarian, placental and pituitary hormones during pregnancy. Documenting the prevalence and pattern of pregnancy associated skin changes in this environment was the subject of this research. AIMS AND OBJECTIVES The specific objectives are to determine the prevalence of skin changes among primigravidae, to document the clinical pattern of the skin changes and to correlate the documented skin changes with gestational age. METHODOLOGY The study was a descriptive cross-sectional observational study. Study location was the Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospitals Complex OAUTHC), Ile-Ife. Clearance was obtained from Ethics and Research Committee 10 before the patients were recruited. Patients were selected consecutively after informed consent had been obtained. Two hundred and forty subjects and 240 controls were appropriately recruited into the study. A structured questionnaire was used to collect essential information from each participant. Physical examination of the skin, hair and nail was done in a well lit room and with magnify lens where necessary. RESULTS The mean ages of the participants were 27.53±3.88 years for subjects and 27.50±4.1 years for controls. The prevalence of pregnancy associated skin changes varied between trimesters and increased as pregnancy advanced. The general prevalence in this study were 88.3 n=212) in the first trimester, 98.3 n=236) each in the second and third trimesters compared to 47.5 n=114) in controls. In some pregnant women, more than one type of skin changes were seen. Physiological skin changes ranked highest with a prevalence of 77.1 n=185) in the first trimester, 95.0 n=228) in the second trimester and 94.6 n=227) in the third trimester while only 44.6 n=107) of similar skin changes were seen in controls. Pigmentary