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Health condition · Clinically reviewed

Cholestasis of pregnancy, the itch, the bile acids, and the timing.

The most common liver disorder in pregnancy - reversible, treatable, and safest when it is picked up early and monitored well.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against the RCOG Green-top Guideline No. 43 and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK obstetric practice including bile-acid-based risk stratification and timing of delivery.

Key facts

ICP at a glance.

The essentials, in plain English - what it is, who it affects, and how it is managed in UK maternity care today.

  • What it is

    Intrahepatic cholestasis of pregnancy (ICP), previously called obstetric cholestasis - the most common liver disorder in pregnancy and reversible after birth.

  • How common

    Around 0.7 to 1.5 per cent of UK pregnancies, higher in women of South Asian or Latin American background, previous ICP, IVF pregnancies and multiple pregnancy.

  • When it starts

    Usually in the third trimester (around 28 to 30 weeks), though it can appear earlier.

  • Hallmark

    Severe itching, often on the palms and soles and worse at night, with no rash.

  • Key test

    Fasting total bile acids - a value above 19 micromol per litre is diagnostic; severity is graded mild, moderate or severe.

  • First-line drug

    Ursodeoxycholic acid (UDCA) is commonly used for symptom relief; timing of delivery is guided by bile-acid severity.

Why this guide matters

Itch is a symptom, bile acids are a number.

ICP is one of the few pregnancy conditions where a single blood result changes the plan. The three points below shape everything else on this page.

  • Never dismiss unexplained itch

    Widespread itch in pregnancy, particularly on the palms and soles or at night, deserves a bile-acid test - even without a rash or jaundice.

  • Severity guides delivery timing

    Peak bile acids of 100 micromol per litre or more raise the stillbirth risk and shift delivery earlier, per RCOG guidance.

  • It resolves after birth

    Symptoms usually settle within days of delivery and liver blood tests normalise within weeks - postnatal follow-up confirms it.

How the diagnosis is made

From unexplained itch to a clear plan.

The steps a UK maternity team will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Focused history

    Onset, severity and timing of itch, sleep disturbance, previous ICP, family history and current pregnancy risk factors.

  2. 02

    Assessing

    Examination

    Look for scratch marks and excoriations; the absence of a primary rash helps separate ICP from other pregnancy skin conditions.

  3. 03

    Assessing

    Rule out other rashes

    Differentiate from polymorphic eruption of pregnancy, pemphigoid gestationis, AGEP and drug reactions.

  4. 04

    Confirming

    Bile acids and LFTs

    Fasting total bile acids plus ALT, AST, GGT and bilirubin - the diagnostic core. Values may be normal very early.

  5. 05

    Confirming

    Exclude other liver disease

    Viral hepatitis A, B, C and E, autoimmune screen (ANA, AMA, ASMA) and a liver ultrasound to exclude gallstones and biliary obstruction.

  6. 06

    Planning

    Assess pregnancy risks

    Fasting glucose or OGTT and a preeclampsia workup, given the associated risks of gestational diabetes and preeclampsia.

  7. 07

    Planning

    Multidisciplinary planning

    Obstetrics, maternal medicine, hepatology and fetal medicine agree monitoring, timing of delivery and follow-up.

Typical timeline: from first itch to a settled monitoring plan within a week.

Symptoms

What ICP actually feels like.

A hallmark itch without a rash, often with fatigue and disrupted sleep - and a short list of features that mean it is time to escalate.

  • Severe itch, no rash

    Widespread pruritus, often worst on the palms and soles and at night, with only scratch marks on the skin.

  • Fatigue and malaise

    Poor sleep from the itch, low energy and reduced concentration are common and often under-recognised.

  • Dark urine and pale stools

    Reflects impaired bile flow; may appear alongside mild jaundice in a minority of women.

  • Jaundice (uncommon)

    Yellowing of the skin or eyes occurs in fewer than one in ten women with ICP and warrants urgent review.

  • Steatorrhoea

    Pale, greasy stools from fat malabsorption when cholestasis is more marked.

  • Upper GI discomfort

    Nausea, poor appetite or a heavy right upper quadrant sensation without true pain.

  • Insomnia and low mood

    Relentless night-time itch can drive sleep deprivation, anxiety and low mood, all needing active support.

  • Red flag - abdominal pain

    True abdominal pain is not a feature of ICP and points to another cause such as HELLP, preeclampsia or gallstones.

Treatment

How ICP is managed in the UK.

Structured monitoring, ursodeoxycholic acid for symptom relief and delivery timing guided by peak bile acids - per the RCOG Green-top Guideline.

  • Ursodeoxycholic acid (UDCA)

    Commonly prescribed at around 15 mg per kg per day for symptom relief and improvement in liver blood tests; the PITCHES trial showed no reduction in adverse perinatal outcomes but safety is well established.

  • Weekly monitoring

    Weekly bile acids and LFTs, alongside growth scans and CTG - noting CTG is not a reliable predictor of stillbirth in ICP.

  • Symptomatic itch relief

    Chlorphenamine or hydroxyzine at night, emollients, oatmeal baths, cool loose clothing and calamine can all help.

  • Vitamin K

    Oral vitamin K 10 mg per day is reserved for the rare case of prolonged prothrombin time, particularly before delivery.

  • Timed delivery - severe

    Total bile acids of 100 micromol per litre or more: delivery at 35 to 36 weeks to reduce stillbirth risk, per RCOG guidance.

  • Timed delivery - moderate

    Bile acids 40 to 99 micromol per litre: delivery around 38 to 39 weeks, individualised in the MDT.

  • Timed delivery - mild

    Bile acids under 40 micromol per litre: expectant management to term unless the picture deteriorates.

  • Postnatal review

    Repeat LFTs at 6 to 12 weeks postnatally to confirm normalisation, plus counselling on recurrence, contraception and future pregnancies.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist evidence, current at the time of last review.

Key references

Guidelines and evidence we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your maternity team knows your pregnancy and can tell you which parts apply to you. If in doubt - and always for reduced fetal movements - get seen the same day.

  • RCOG. Green-top Guideline No. 43: Intrahepatic Cholestasis of Pregnancy (2022 update).

  • Ovadia C et al. Association of adverse perinatal outcomes with total bile acid concentrations. Lancet 2019.

  • PITCHES Trial Collaborative Group. Ursodeoxycholic acid versus placebo in ICP. Lancet 2019.

  • ICP Support UK. Patient information on obstetric cholestasis.

Red flags

When ICP needs urgent attention.

Most cases can be safely monitored in a shared-care model. These features change the plan and should prompt same-day maternity contact.

  • Bile acids of 100 or more

    Severe ICP significantly increases the risk of stillbirth - triggers early delivery planning and specialist input.

  • Rapidly rising bile acids or LFTs

    A steep rise between weekly bloods, even from a lower base, warrants earlier review of the delivery plan.

  • True abdominal pain

    ICP does not cause abdominal pain - consider HELLP, preeclampsia, acute fatty liver of pregnancy or gallstone disease.

  • Reduced fetal movements

    Any reduction in movements is an obstetric emergency and needs same-day maternity assessment.

  • Jaundice

    Yellowing of the skin or eyes is uncommon in ICP and warrants urgent hepatology and obstetric review.

  • Meconium-stained liquor in labour

    More common with ICP and mandates continuous fetal monitoring and neonatal input at delivery.

  • Severe mental-health impact

    Sleep deprivation from itch can drive anxiety and low mood - active support and perinatal mental-health referral matter.

  • Symptoms starting very early

    Onset well before the third trimester is unusual and needs a broader hepatology workup for other liver disease.

  • Persistent LFT abnormality postnatally

    If liver blood tests have not normalised by 6 to 12 weeks, refer to hepatology for further investigation.

Living with it

A short chapter, with a clear finish line.

Four things that make the biggest difference through the last trimester - weekly bloods, protected sleep, community support and a plan for next time.

A quiet reminder

The itch ends when the baby is born.

Symptoms usually settle within days of delivery. A postnatal LFT check at 6 to 12 weeks confirms recovery and closes the loop.

  1. 01 Monitoring

    Weekly bloods matter

    Bile acids and LFTs are the compass - they guide timing of delivery and pick up worsening disease early.

  2. 02 Sleep

    Protect the night

    Cool rooms, loose cotton clothing, evening emollients and a night-time antihistamine can meaningfully reduce sleep loss.

  3. 03 Support

    You are not alone

    ICP is common enough that peer-support communities and specialist midwives can make the last trimester feel less isolating.

  4. 04 Aftercare

    Plan for next time

    Recurrence is common (around 60 to 80 per cent). A pre-pregnancy plan and early antenatal monitoring change the experience.

Frequently asked

Everything we get asked about ICP.

Quick answers on itch, bile acids, ursodeoxycholic acid, delivery timing and recurrence.

  • What is intrahepatic cholestasis of pregnancy?

    ICP, previously known as obstetric cholestasis, is a reversible liver disorder unique to pregnancy. Bile acids build up in the bloodstream, causing severe itching. It usually starts in the third trimester and resolves within days to weeks of delivery.

  • How common is ICP in the UK?

    Around 0.7 to 1.5 per cent of UK pregnancies. It is more common in women of South Asian or Latin American background, in those with a previous ICP pregnancy, in IVF pregnancies and in multiple pregnancies. Genetic changes in bile transport (ABCB4, ABCB11, ATP8B1) also increase risk.

  • How is ICP diagnosed?

    On a background of unexplained itch in pregnancy, a fasting total bile acid level above 19 micromol per litre is diagnostic. Other liver blood tests and a liver ultrasound help exclude viral hepatitis, autoimmune liver disease and gallstones. There should be no true abdominal pain.

  • Why does bile-acid level matter so much?

    A large UK-led meta-analysis (Ovadia et al., Lancet 2019) showed the risk of stillbirth rises sharply when peak total bile acids reach 100 micromol per litre or more. Severity guides how closely you are monitored and when delivery is planned.

  • Is ursodeoxycholic acid worth taking?

    UDCA is still commonly prescribed because it can ease itching and improve liver blood tests, and its safety profile in pregnancy is well established. The PITCHES trial did not show a reduction in adverse perinatal outcomes, so it is used mainly for symptom relief rather than as a fetal protection strategy.

  • Will ICP happen again in a future pregnancy?

    Recurrence is common, in the region of 60 to 80 per cent. It is worth counselling in advance and arranging early antenatal monitoring. You should also avoid combined oestrogen contraception where possible, favouring the progestogen-only pill, the Mirena or a copper coil, and discuss HRT case-by-case in later life.

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