Intrahepatic cholestasis of pregnancy can start with something that feels “small” but becomes impossible to ignore: itching. Not the mild, dry-skin itching 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 associated with higher risks for the baby. So the plan is not guesswork. It is blood tests, trend-following, symptom control, and careful birth planning.

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

What intrahepatic cholestasis of pregnancy (ICP) means

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 does not flow out properly, its components—especially bile acids—build up in the bloodstream.

That explains the classic symptom. Circulating bile acids can irritate nerve endings in the skin, so the body “shows” a liver imbalance through intense itching.

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The important point: diagnosis and risk assessment depend on blood levels of bile acids, not only on how itchy you feel.

When it usually starts and why it improves after birth

Intrahepatic cholestasis of pregnancy usually begins in late second trimester or third trimester—often after 28 weeks, though earlier onset is possible.

Why late pregnancy? Oestrogen and progesterone metabolites peak and can interfere with bile transport out of liver cells in women who are genetically susceptible.

After delivery, hormone levels drop quickly. Bile flow recovers, itching often eases within days, and bile acids/liver enzymes usually return towards normal over the next days to weeks.

How it differs from “normal pregnancy itch”

Many pregnant women itch due to stretched skin, heat, sweating, or dryness. In Intrahepatic cholestasis of pregnancy, features that raise suspicion include:

Intense, persistent itching, often worse at night
Palms and soles commonly affected
No primary rash at the beginning (scratch marks appear later)
Blood tests showing elevated bile acids (sometimes with raised liver enzymes)

How common is intrahepatic cholestasis of pregnancy?

Intrahepatic cholestasis of pregnancy is uncommon overall, but rates vary by region and population.

In India, exact prevalence varies by study and setting, and may be under-reported because itching is sometimes dismissed as “normal”. Globally, figures often cited range from about 0.1–1% in many European settings to higher rates in specific populations.

Symptoms parents may notice

The typical itching pattern

The classic itch in Intrahepatic cholestasis of pregnancy is often described as:

Starting on the palms and soles, then spreading to arms, legs, trunk
Becoming worse in the evening or at night (nocturnal itching)
Occurring without a rash at first (skin looks normal until you scratch)

If you are awake at 2 a.m. rubbing your hands and feet against bedsheets, you are describing a common ICP story.

Why “itching without a rash” matters

In Intrahepatic cholestasis of pregnancy, skin can look normal initially. Visible signs are usually excoriations (scratch marks) later.

This detail helps clinicians separate ICP from other pregnancy skin conditions that typically do show a primary rash, such as:

Atopic eruption/eczema (dry inflamed patches)
Urticaria (raised welts)
PUPPP (itchy bumps starting on the abdomen, often on stretch marks)
Pemphigoid gestationis (can blister, often near the belly button)

If you develop a clear rash, the diagnosis may need re-checking.

Other possible signs

Not everyone has these, but Intrahepatic cholestasis of pregnancy can also come with:

Jaundice (yellowing of eyes/skin, uncommon)
Dark urine
Pale stools
Marked fatigue and irritability from sleep loss

If stools become pale or you bruise easily, clinicians may consider fat-soluble vitamin absorption issues (especially vitamin K) and check clotting tests.

When to seek care

During the second or third trimester, night-time itching—especially on hands and feet—should be reported promptly.

Also contact your maternity unit urgently if you notice:

Reduced fetal movements
Yellow eyes/skin
Rapidly worsening itching
Dark urine, pale stools
Fever, severe abdominal pain, severe headache, visual changes

How to explain symptoms to your clinician

Good symptom description speeds up the right testing. Share:

Which week itching started and whether it is worsening
Where it is strongest (palms/soles or generalised)
Night-time severity and sleep impact
Whether there is a rash or only scratch marks
Any jaundice, dark urine, pale stools
New medicines/supplements or recent illness

Why bile acids rise in intrahepatic cholestasis of pregnancy

What bile acids do

Bile acids are made in the liver from cholesterol. They help break down fats in the gut. Most are reabsorbed and recycled—this is called enterohepatic circulation.

Why they rise in ICP

In Intrahepatic cholestasis of pregnancy, the liver’s export of bile acids into bile is reduced. Late-pregnancy hormones can disrupt transporter proteins. Genetics increases susceptibility.

What may drive ICP

Intrahepatic cholestasis of pregnancy is multifactorial:

Hormones: high oestrogen/progesterone metabolites can impair bile transport
Genetic susceptibility: variants in transporter genes have been linked (ABCB11, ABCB4, ATP8B1, NR1H4, ABCC2)
Higher hormone exposure: multiple pregnancy and IVF/assisted reproduction are reported more often
Season/nutrition hypotheses: winter peaks and micronutrients (vitamin D, selenium) have been discussed, but prevention is not proven

If you have gallstones, hepatitis, or other liver issues, your clinician will check carefully rather than assuming it is ICP.

Diagnosis and tests

Core criteria: itching plus raised bile acids

Diagnosis usually relies on:

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

Because ICP is a diagnosis of exclusion, other liver and pregnancy conditions may be ruled out.

Serum bile acids: the key test

Bile acids help confirm Intrahepatic cholestasis of pregnancy, assess severity, and guide monitoring and delivery timing.

Common thresholds used in many protocols:

>10 µmol/L: compatible with ICP (with typical symptoms)
≥40 µmol/L: higher fetal risk than mild disease
≥100 µmol/L: clearly increased risk, planning often becomes more intervention-focused

Liver tests (ALT/AST, bilirubin, GGT)

ALT/AST are often raised
Bilirubin is usually normal, if elevated, jaundice can occur
GGT may be normal

Normal liver enzymes do not exclude Intrahepatic cholestasis of pregnancy.

Fasting vs non-fasting and repeat testing

Bile acids can fluctuate. Some labs prefer fasting, some accept non-fasting. The practical aim is consistency when tracking trends.

If itching is typical but bile acids are initially normal, repeat testing is common—often within 1–2 weeks, sooner if symptoms are severe.

Additional evaluation

Your clinician may add:

Hepatitis screening
PT/INR (clotting) if severe disease or bleeding concerns
Abdominal ultrasound to exclude obstruction/gallstones
Blood pressure, urine protein, platelets if preeclampsia/HELLP is a concern

Earlier onset (second trimester)

Earlier onset does not automatically mean severe disease, but it may mean longer exposure time, so teams often monitor more closely.

Risk factors

Risk is higher with:

Previous Intrahepatic cholestasis of pregnancy (recurrence common)
Family history
Multiple pregnancy
IVF/assisted reproduction
Pre-existing liver/biliary disease
Hepatitis C

Risks for baby and parent

For the mother

For mothers, Intrahepatic cholestasis of pregnancy is mainly a quality-of-life issue: itching, broken sleep, mood strain.

Rarely, severe cholestasis may affect fat-soluble vitamin absorption (vitamin K), which can influence clotting.

For the baby

Most babies do well with monitoring and timely birth planning. Still, Intrahepatic cholestasis of pregnancy is associated with:

Preterm birth (spontaneous or planned)
Fetal distress in labour
Meconium-stained liquor (which can affect breathing after birth)

Stillbirth risk

Stillbirth is rare overall, but risk is more clearly increased at very high bile acid levels, particularly ≥100 µmol/L. This is why these results change monitoring and delivery discussions.

Treatment options and symptom relief

Ursodeoxycholic acid (UDCA)

Ursodeoxycholic acid (UDCA) (ursodiol) is the most commonly used medicine for Intrahepatic cholestasis of pregnancy. It can:

Improve bile flow and reduce bile acids
Reduce itching in many women

Even with UDCA, monitoring and delivery planning remain important.

Dosing principles

Doses are individualised. Many protocols use around 10–15 mg/kg/day, adjusted based on symptoms and bile acid trends. Do not change the dose yourself.

Antihistamines

Some antihistamines may be used mainly at night for sedation and sleep support. They do not treat the underlying condition.

Non-medicine itch relief

Small measures can reduce suffering:

Lukewarm showers (hot water worsens itching)
Fragrance-free emollients
Loose cotton clothing, avoid overheating
Cool bedroom, breathable bedding
Cold compresses on hands/feet at bedtime

If you are scratching until you break the skin, inform your care team.

If UDCA is not enough

In specialist care, rifampicin may be discussed in selected cases with careful monitoring.

Monitoring during pregnancy

Maternal monitoring

Typically includes:

Serial bile acids and liver tests every 1–2 weeks (more often if severe)
Symptom review (especially sleep impact)
PT/INR if severe disease or bleeding concerns

Fetal surveillance

Depending on levels and gestational age, your team may recommend:

NST/CTG (fetal heart rate monitoring)
Ultrasound for growth and amniotic fluid
Close attention to fetal movements at home

Reduced fetal movements should be assessed promptly.

What may change the plan quickly

Sudden worsening itch
Rapidly rising bile acids
Jaundice, dark urine, pale stools
Reduced fetal movements

Delivery timing and birth planning

Balancing ICP risk with prematurity

The goal is to reduce fetal risk without avoidable prematurity. Planning depends on:

Current bile acid level and trend
Gestational age
Fetal monitoring and movements
Overall maternal health

Timing by bile acid level (typical windows)

Protocols vary, but many teams discuss:

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

Mode of delivery

Intrahepatic cholestasis of pregnancy alone is not an automatic indication for caesarean. Many women can have induction and vaginal birth, caesarean is for standard obstetric reasons.

After birth: recovery and follow-up

Symptom and lab resolution

Itching often improves within days and commonly resolves within 2–3 weeks. Blood tests usually normalise over days to weeks.

Postpartum follow-up

Follow-up blood tests confirm resolution. If abnormalities persist, further liver evaluation is needed.

Breastfeeding

Breastfeeding is usually possible. UDCA is generally considered compatible with breastfeeding. If other medicines were used, decisions should be individualised with your clinician, watching the baby for unusual sleepiness or feeding difficulty.

Future pregnancies

Recurrence risk

Recurrence is common, often discussed around 40–60%. In future pregnancies, tell your doctor early so testing can be arranged quickly if itching returns.

Prevention

There is no proven universal prevention. The most effective strategy is early recognition of symptoms and early bile acid testing, followed by tailored monitoring and delivery planning.

Key takeaways

Intrahepatic cholestasis of pregnancy is a pregnancy-related liver condition where bile acids rise in the blood.
Typical symptoms are intense night-time itching, often on palms/soles, usually without a primary rash.
Diagnosis and severity depend on serum bile acids, rising levels guide monitoring and delivery timing.
UDCA is commonly used to reduce itching and improve labs, but close obstetric follow-up is still needed.
Reduced fetal movements, jaundice, or rapidly worsening symptoms need prompt medical attention.
Support exists through your maternity team, and you can download the Heloa app for personalised advice and free child health questionnaires.

Questions Parents Ask

Can ICP affect my baby’s long-term health?

It’s completely understandable to worry about what happens beyond birth. The reassuring news is that most babies do well, especially when bile acids are monitored and birth timing is planned. In the newborn period, your baby may simply need routine checks (and sometimes closer observation if they were born early). If you’re concerned, you can ask the maternity and pediatric teams what follow-up they recommend after delivery and what signs (like feeding difficulties or unusual sleepiness) would justify an extra check.

Is there an “ICP diet” that lowers bile acids or itching?

Many parents look for something they can do today to feel better. At the moment, there isn’t one proven diet that reliably lowers bile acids in ICP. That said, some families find symptom relief by keeping meals lighter in fat (since bile helps digest fat) and avoiding personal triggers. If itching is affecting sleep, it may also help to focus on hydration and gentle, regular meals. You can also ask whether vitamin levels (especially fat-soluble vitamins like A, D, E, K) ever need monitoring in your situation.

Should I consider genetic counseling or testing?

ICP can run in families, and researchers have linked it to certain bile-transport genes. However, genetic testing is not routinely used to “predict” ICP or its severity in a specific pregnancy. If you have a strong family history, very early onset, or repeated episodes, it may be worth discussing genetic counseling for clearer context and future planning.

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