Cholestasis in Pregnancy

f you've suddenly developed intense itching during pregnancy, particularly at night and without a rash, you've probably got a very good reason to want to scratch your skin off. Most itching in pregnancy isn't anything to worry about. But sometimes it can be a sign of a liver condition called intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis. ICP is usually manageable, but it does need to be diagnosed and monitored because it can increase certain risks for your baby. Here's what you need to know.

What is Intrahepatic Cholestasis of pregnancy?

Intrahepatic cholestasis of pregnancy is a condition that affects how your liver works during pregnancy. Your liver normally produces bile acids, which help your body digest fats. With ICP, bile acids build up in your bloodstream instead of flowing normally from your liver into your digestive system. ICP usually develops towards the end of pregnancy, although it can happen earlier. The condition normally gets better after your baby is born.

What does Cholestasis Feel Like?

The main symptom of ICP is itching without a rash. The itching can:

Be mild or extremely intense
Be anywhere on your body
Be particularly noticeable on your palms and the soles of your feet
Be worse at night
Keep you awake or make it difficult to sleep
Develop gradually or become very noticeable quite quickly

You may also experience dark urine, pale or greasy stools or, rarely, jaundice (yellowing of the skin or whites of the eyes). It's worth knowing that itching is very common in pregnancy. Around 1 in 4 pregnant women experience it, and most of them will not have ICP.

But itching can be the first, and sometimes only, symptom of ICP. If you're pregnant and have intense itching, particularly if it's worse at night or affecting your palms or soles, tell your midwife, GP or maternity team.

Is Cholestasis Dangerous?

ICP usually doesn't cause serious health problems for you, although the itching can be incredibly uncomfortable and can have a big impact on your sleep and emotional wellbeing. The main concern is your baby's wellbeing. The risk to your baby depends largely on the level of bile acids in your blood. This is why you'll be offered blood tests and why your care may change depending on your results.

ICP can also increase the chance of your baby being born prematurely, either because labour starts naturally or because your maternity team recommends birth earlier. There is also an increased chance of your baby passing meconium before birth. The risk of stillbirth is particularly associated with severe ICP, where bile acid levels are 100 micromol/L or higher.

How is Cholestasis Diagnosed?

If you have symptoms that suggest ICP, you'll usually have blood tests to check:

Bile acids

This is the particularly important test for ICP. Your bile acid level helps your maternity team understand the severity of the condition and the potential risk to your baby.

Liver function tests

You may also have liver function tests (LFTs), which look at how well your liver is working. Your liver function tests can be abnormal with ICP, but they can also be normal even when your bile acids are raised. This is why a normal liver function test doesn't necessarily rule out ICP.

What if my blood tests are normal?

Sometimes the itching starts before the blood tests become abnormal. If you're still experiencing unexplained itching and your first blood tests are normal, your maternity team may repeat your bile acids and liver function tests. So if the itching continues, don't assume that one normal blood test means the issue has definitely been ruled out.

How are Bile Acid Levels Classified?

RCOG uses the following categories:

Bile acid level Classification

19-39 micromol/L Mild ICP

40-99 micromol/L Moderate ICP

100 micromol/L or more Severe ICP

Your highest recorded bile acid level is important when your maternity team is considering your care and the timing of your baby's birth.

It's also worth remembering that how intensely you itch doesn't necessarily tell you how high your bile acids are. You can have incredibly itchy skin with relatively low bile acid levels, or less dramatic itching with higher levels.

What happens if I'm diagnosed with ICP?

Once you've been diagnosed, you'll usually have ongoing care with your maternity team and an obstetrician. Your blood tests will generally be repeated, with the frequency depending on your individual situation. Your care plan may include:

Monitoring your bile acid levels
Monitoring your liver function
Checking your general wellbeing
Keeping an eye on your baby's movements
Discussing medication to help with symptoms
Talking about when and how your baby should be born

You don't automatically need lots of extra scans just because you've been diagnosed with ICP. RCOG guidance says that additional ultrasound scans aren't routinely needed solely because of ICP. Your care will depend on your individual circumstances, including your bile acid levels and whether you have any other pregnancy complications.

Can Cholestasis be Treated?

There isn't currently a treatment that completely removes the risk associated with ICP. There are treatments that may help with the itching.

Ursodeoxycholic acid (UDCA) is sometimes prescribed. It may slightly reduce itching for some people and may have other benefits, but importantly, it does not prevent stillbirth. Other things that may help with itching include:

Cool baths or showers
Loose-fitting cotton clothing
Unperfumed moisturisers or emollients
Antihistamines, which may sometimes help with sleep
Keeping your bedroom cool at night

These measures can make you more comfortable, but they don't replace medical assessment and monitoring.

What does it mean for my baby's birth?

This is one of the areas where your bile acid level really matters. If you're having one baby and don't have other pregnancy complications, current RCOG guidance says:

Bile acids 19-39 micromol/L

Planned birth by your due date may be considered. If you have no other risk factors, you may also choose to wait for labour to start naturally because your stillbirth risk is no different from someone without ICP.

Bile acids 40-99 micromol/L

Planned birth around 38-39 weeks may be recommended if there are no other risk factors.

Bile acids 100 micromol/L or more

Planned birth around 35-36 weeks may be recommended because the risk of stillbirth is higher with severe ICP.

These are not simply automatic rules. Your maternity team should take into account your bile acid levels, how they have changed over time, your gestation, your symptoms, other pregnancy complications and your individual circumstances. If you're being advised to have your baby early, ask your team to explain why that timing has been recommended for you.

Does cholestasis mean I need an induction?

Not necessarily. If planned birth is recommended, your options may include:

Induction of labour
Planned caesarean birth
In some circumstances, waiting for labour to start naturally

ICP itself does not mean that you have to have a caesarean birth. If there are no other reasons why a vaginal birth would be unsuitable, you can still plan for a vaginal birth, including an induction if that is what you choose. Your pain relief options are not automatically restricted because you have ICP either. This is a good example of why a diagnosis and a birth recommendation aren't quite the same thing. You can have a medical reason for recommending birth by a certain point while still having choices about how that birth happens.

Explore next: Induction of Labour

What about Monitoring my Baby?

You'll be asked to keep paying attention to your baby's usual movements. If your baby's movements change, become less frequent or you are worried about them, contact your maternity unit straight away. Don't wait until your next appointment.

Depending on your individual circumstances, your maternity team may also recommend monitoring your baby's heart rate during labour.

If your bile acids are 100 micromol/L or higher, or you have other risk factors, RCOG recommends continuous monitoring of your baby's heart rate during labour. Explore next: When to Seek Help

Will I need to have my baby in hospital?

Your recommended place of birth may depend on your bile acid levels and your individual circumstances. Your maternity team can explain whether you need to give birth in a consultant-led maternity unit and whether access to a neonatal unit is recommended.

If you're planning to give birth somewhere such as a midwife-led unit or at home, ask specifically how your ICP diagnosis affects those options. You can also ask what would happen if your bile acid levels changed later in pregnancy.

What happens after my baby is born?

The good news is that ICP usually gets better after birth. Your itching should settle, although it can take a little while for your blood tests to return to normal. At your postnatal follow-up, your healthcare professional should check that your symptoms have gone and arrange blood tests to make sure your bile acids and liver function have returned to normal. If they haven't, you may need further investigation.

ICP can also happen again in a future pregnancy. If you've had ICP before, tell your midwife or doctor early in your next pregnancy. Your bile acids and liver function can be checked at the beginning of pregnancy and monitored if you develop symptoms again.

Questions to ask your maternity team

If you've been diagnosed with, or are being investigated for, ICP, you might want to ask:

What are my current bile acid levels?
What were my previous results?
How often will my blood tests be repeated?
Do I need any other tests or investigations?
What does my current bile acid level mean for my baby's risk?
Do I need any additional monitoring?
What should I do if my baby's movements change?
When are you recommending that my baby is born, and why?
What are my options for how my baby is born?
Would induction be appropriate for me?
Does ICP affect where I can give birth?
Will I need continuous monitoring during labour?
What can I use to help with the itching?
Will I need a postnatal blood test?
What should I do differently in a future pregnancy?

You don't need to ask all of these. Pick the questions that are relevant to you and take them to your next appointment.

Explore Next

When to Seek Help
A practical guide to symptoms in pregnancy that need checking, including changes in your baby's movements.

Gestational Diabetes
What gestational diabetes is, how it is diagnosed and what it can mean for pregnancy and birth.

High Blood Pressure in Pregnancy
Understanding gestational hypertension, pre-eclampsia and what your blood pressure readings mean.

Induction of Labour
Understanding why induction may be recommended and what your options are.

Understanding Your Options
More resources to help you understand recommendations and make informed decisions about your care.