Intrahepatic cholestasis of pregnancy can begin with something that seems almost small, but becomes impossible to ignore: itching. Not the mild, dry-skin itch many women get in late pregnancy. This one often feels deep, relentless, and worse at night, especially on the palms and soles. You may look at your skin and think, “Why is it itching so much when there’s no rash?”

Because Intrahepatic cholestasis of pregnancy is a liver condition, not a skin condition. And it matters because the key marker, raised bile acids in the blood, can be linked with higher risks for the baby. So the plan is not guesswork. It is blood tests, trend-following, symptom relief, and thoughtful birth planning, adapted to your results and your week of pregnancy.

Intrahepatic cholestasis of pregnancy: what it is and why it matters

What intrahepatic cholestasis of pregnancy (ICP) means (also called obstetric cholestasis)

Intrahepatic cholestasis of pregnancy (ICP), also called obstetric cholestasis, is a pregnancy-related liver disorder where bile flow slows down. Bile is made by the liver and helps digest fats. When bile flow is impaired, bile components, especially bile acids, build up in the bloodstream.

Many families find it surprising that a liver issue can cause such severe itching. A simple explanation: circulating bile acids can irritate nerve endings in the skin, so the skin becomes the place where an internal imbalance shows up.

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Intrahepatic cholestasis of pregnancy matters because higher bile acid levels are associated with higher fetal risk. That is why diagnosis and risk assessment depend on blood tests, not on itch severity alone.

When it usually starts (late second to third trimester) and why it often resolves after birth

Intrahepatic cholestasis of pregnancy most often begins in late second trimester or third trimester, frequently after around 28 weeks (though it can start earlier). Hormones peak in late pregnancy, especially oestrogen and progesterone metabolites, and these can interfere with bile acid transport out of liver cells in susceptible women.

Symptoms typically improve quickly after delivery as hormone levels fall and bile flow recovers. Many women notice itching easing within days. Blood tests (bile acids and liver enzymes) usually move back towards normal over days to weeks. In many cases, itching is gone within 2 to 3 weeks after birth.

How it differs from common pregnancy itch (often no primary rash)

Many pregnant women itch sometimes because skin is stretched, dry, or more sensitive. Intrahepatic cholestasis of pregnancy has features that raise suspicion beyond “normal pregnancy itch”:

Intense, persistent itching, often worse at night
Palms and soles commonly involved
Usually no primary rash at first (marks are often from scratching)
Blood tests show elevated bile acids, sometimes with abnormal liver enzymes

How common is intrahepatic cholestasis of pregnancy?

Intrahepatic cholestasis of pregnancy is considered uncommon overall, but rates vary by region and population. Globally cited figures include around 0.1 to 1% in many European settings and higher rates in some populations.

In India, exact prevalence differs across studies and care settings, and the condition can be under-recognised because itching is sometimes dismissed as heat or dry skin. If the pattern fits (night itch + palms/soles + no rash), it deserves testing.

Symptoms parents may notice

Typical itching pattern (palms/soles, worse at night) and “itching without a rash”

The itch in Intrahepatic cholestasis of pregnancy can feel deep and relentless. Many women describe:

Itching that starts on the palms of the hands and soles of the feet, then spreads
Symptoms that peak in the evening or overnight (nocturnal itching)
Little to no rash at first, you may only see scratch lines or scabs later

Pruritus without visible plaques: why that detail matters

In Intrahepatic cholestasis of pregnancy, the skin can look normal initially. Over time, the main visible signs are often excoriations (scratch marks).

This detail helps clinicians consider other diagnoses that typically do have a primary rash pattern, such as:

Eczema/atopic eruption (dry, inflamed patches)
Urticaria (raised, short-lived welts)
PUPPP (often starts on the abdomen, commonly around stretch marks)
Pemphigoid gestationis (may blister, often around the belly button)

If a rash appears or changes, your doctor may reassess because the treatments and urgency can be different.

Other possible signs (jaundice, dark urine, pale stools, fatigue, sleep disruption)

Not everyone has additional signs, but Intrahepatic cholestasis of pregnancy can also include:

Yellowing of eyes/skin (jaundice, uncommon)
Dark urine
Pale or clay-coloured stools
Marked fatigue (often due to broken sleep)
Major sleep disruption

If stools become pale or bruising seems easy, your clinician may think about fat-soluble vitamin absorption (including vitamin K) and check clotting tests if needed.

When to seek care (especially if sleep is affected)

In the second or third trimester, night-time itching, especially on hands and feet, deserves prompt medical advice, particularly if it is keeping you awake and your skin otherwise looks fairly normal.

Also contact your maternity team promptly if you notice:

Reduced fetal movements or a clear change in your baby’s usual pattern
Yellow eyes/skin
Rapidly worsening itching
Dark urine, pale stools, fever, severe abdominal pain, severe headache, or visual changes

How to describe symptoms to a clinician (timing, severity, sleep impact)

Clear details help your clinician decide which tests to order and how urgently to repeat them. Useful points:

When the itching started (which week) and whether it is worsening
Where it is strongest (palms/soles? whole body?)
Night-time pattern and sleep impact
Whether there is a rash (or only scratch marks)
Any jaundice, dark urine, or pale stools
Any new medicines, supplements, or recent illnesses

Why bile acids rise in intrahepatic cholestasis of pregnancy

What bile acids do and why they rise

Bile acids are made in the liver from cholesterol. They help digest fats and are normally secreted into bile, stored in the gallbladder, and released into the gut. Most bile acids are then reabsorbed and recycled (the enterohepatic circulation).

In Intrahepatic cholestasis of pregnancy, bile acids rise because the liver’s ability to export them into bile is reduced. Late pregnancy hormones can disrupt transporters that move bile acids out of liver cells, and genetic susceptibility increases the risk.

What may drive ICP (hormones, genetic susceptibility, and associated factors)

Intrahepatic cholestasis of pregnancy is multifactorial:

Hormones: late pregnancy oestrogen and progesterone metabolites can impair bile transport
Genetics: variants in bile transporter genes have been linked (ABCB11, ABCB4, ATP8B1, NR1H4, ABCC2)
Associated pregnancy factors: multiple pregnancy and IVF/assisted reproduction are reported more often, likely due to higher hormone exposure

If there is a prior liver or biliary history (gallstones, hepatitis), clinicians will be careful not to attribute everything to ICP without checking for other treatable causes.

Diagnosis and tests

Core criteria: itching plus elevated serum bile acids

Diagnosis is usually based on:

Pruritus (often without a primary rash)
Elevated serum bile acids (commonly >10 µmol/L in practice)

Because other conditions can look similar, your doctor will also look for other liver diseases and pregnancy complications.

Serum bile acids: the key test for confirmation and severity

Bile acids help to:

Confirm Intrahepatic cholestasis of pregnancy in the right clinical context
Assess severity
Guide monitoring and delivery timing discussions

Commonly used thresholds (protocols vary):

>10 µmol/L: compatible with ICP when symptoms fit
≥40 µmol/L: higher fetal risk compared with lower levels
≥100 µmol/L: clearly increased risk and often more intervention-focused planning

Liver tests: ALT/AST, bilirubin, and GGT

Liver tests may show:

Elevated ALT and AST
Bilirubin usually normal, if it rises, jaundice may occur
GGT sometimes normal

Normal liver tests do not exclude Intrahepatic cholestasis of pregnancy.

How bile acid testing works (fasting vs non-fasting, repeats if symptoms persist)

Bile acids can fluctuate. Some teams prefer fasting samples, others use non-fasting tests. The practical point is comparability: repeat tests under similar conditions when following trends.

If itching is typical but bile acids are normal initially, repeat testing is common within 1 to 2 weeks (sooner if symptoms are severe).

When additional evaluation helps

Because Intrahepatic cholestasis of pregnancy is a diagnosis of exclusion, additional checks may include:

Hepatitis testing
Coagulation tests (PT/INR) if severe disease or bleeding concerns
Abdominal ultrasound to rule out obstruction like gallstones
Blood pressure, urine protein, and blood counts to screen for preeclampsia/HELLP when needed

Risks for baby and parent

For the mother

For mothers, Intrahepatic cholestasis of pregnancy is mainly about symptom burden: itching can be exhausting, affect mood, and disrupt sleep. Symptoms usually improve after birth.

Rarely, marked cholestasis may affect absorption of fat-soluble vitamins (including vitamin K), which can influence clotting.

For the baby

Most babies do well, especially when ICP is identified and monitored. Still, Intrahepatic cholestasis of pregnancy is associated with:

Preterm birth (sometimes spontaneous, often planned)
Fetal distress during labour
Meconium in the amniotic fluid

Stillbirth risk

Stillbirth is rare overall. The association is clearer when bile acids reach very high levels, particularly ≥100 µmol/L.

Treatment options and symptom relief

Ursodeoxycholic acid (UDCA)

Ursodeoxycholic acid (UDCA) (ursodiol) is the most commonly used treatment for Intrahepatic cholestasis of pregnancy. It aims to improve bile flow, reduce bile acids, and reduce itching.

Dosing principles

Dosing depends on local protocols and individual response. A common approach is around 10 to 15 mg/kg/day, adjusted based on symptoms and blood tests. Do not change doses on your own.

Antihistamines and non-medicine steps

Some antihistamines may be offered at night mainly for sedation. Preventing overheating often helps in Indian weather, especially in summer months. Comfort measures can also help:

Lukewarm showers
Fragrance-free emollients
Loose cotton clothing, avoid overheating
Cool bedroom
Cold compresses on hands and feet at bedtime

Monitoring during pregnancy

Monitoring commonly includes serial bile acids and liver tests, symptom review, and sometimes fetal surveillance such as NST/CTG and ultrasound, depending on bile acid levels and gestational age. Reduced fetal movements should be assessed promptly.

Delivery timing and birth planning

Timing aims to reduce fetal risk while avoiding avoidable prematurity. Many teams discuss:

Bile acids ≥100 µmol/L: delivery often considered from around 36 weeks
Moderate disease: delivery often discussed between 37 and 39 weeks

Intrahepatic cholestasis of pregnancy alone is not an automatic reason for caesarean.

After birth: recovery and follow-up

Itching often improves within days and typically resolves within 2 to 3 weeks. Postpartum follow-up blood tests confirm bile acids and liver enzymes return to normal.

Breastfeeding is usually possible after Intrahepatic cholestasis of pregnancy. UDCA is generally considered compatible with breastfeeding.

Future pregnancies and longer-term outlook

Recurrence is common (often discussed around 40 to 60%). There is no proven universal prevention strategy, but early recognition and early bile acid testing can change monitoring and delivery planning.

Key takeaways

Intrahepatic cholestasis of pregnancy is a pregnancy-related liver condition where bile acids rise in the blood.
Classic symptoms are intense night-time itching, often on palms/soles, usually without a primary rash.
Diagnosis and severity depend on serum bile acids and their trend over time.
UDCA is commonly used, alongside regular monitoring and a birth plan.
Seek urgent care for reduced fetal movements, jaundice, rapidly worsening symptoms, heavy bleeding, severe headache with visual changes, or severe abdominal pain.
Support exists through your maternity team, and you can download the Heloa app for personalised advice and free child health questionnaires.

Intrahepatic cholestasis of pregnancy (icp): symptoms, risks, and care