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Cholestasis of pregnancy

Also known as Intrahepatic cholestasis of pregnancy, ICP, Obstetric cholestasis. Usually the third trimester (after about 28 weeks).

It often starts as an itch on the palms and soles, worse at night, with nothing on the skin to explain it. That itch is the signature of cholestasis of pregnancy, a late-pregnancy liver condition in which bile flow slows and bile acids build up in your blood. The itching is miserable but not the real danger. Higher bile acid levels raise the risk of stillbirth, which is why it is monitored closely and usually managed with a planned early delivery. The itching clears once your baby is born.

Know the warning signs When to call a provider
How common
About 1 to 2 in 1,000
Higher in some populations, up to about 5% of US Latina women.
When
Third trimester
Usually after 28 weeks, sometimes earlier.
Urgency
Call your provider
Intense itching in late pregnancy should be checked, not ignored.
Outlook
Good with monitoring
Itching resolves after birth; timed delivery lowers fetal risk.

Understanding it

What is cholestasis of pregnancy?

Cholestasis of pregnancy, also called intrahepatic cholestasis of pregnancy or ICP, is a liver disorder of the second half of pregnancy, usually the third trimester. Normally the liver makes bile that flows out to digest fats; in cholestasis that flow slows and bile acids build up in the blood. It affects roughly 1 to 2 in 1,000 US pregnancies, up to about 5% among US Latina women.

The symptom people notice is itching, and not ordinary itching: intense, classically on the palms and soles, worse at night, and, tellingly, without a rash, sometimes severe enough to keep you awake and scratching. If that itching sets in late in pregnancy, call your provider and ask for a bile-acid blood test.

What makes cholestasis matter is its effect on the baby. Higher bile acid levels are linked to a higher risk of stillbirth, along with preterm birth and meconium, and the risk climbs most steeply when levels are very high. That is why it is monitored with repeat blood tests and fetal surveillance, and why delivery is usually planned a bit early.

For you there is reassurance: the liver almost always recovers completely, and the itching disappears within days of birth. With monitoring and a well-timed delivery, most babies do well. Two things to carry forward: cholestasis is likely to recur, and estrogen-containing birth control can bring the itching back.

Symptoms

What are the symptoms?

The defining symptom is intense itching without a rash, on the palms and soles and worse at night. Because the danger is to the baby, not something you feel, the key is to report the itching and stay alert to your baby's movements.

Early signs

  • Intense itching, often starting on the palms of the hands and soles of the feet
  • Itching that is worse at night and can disrupt sleep
  • Itching without a rash (aside from scratch marks)
  • Sometimes dark urine or pale stools
  • Sometimes fatigue or, less often, yellowing of the skin or eyes

Emergency signs — call 911

  • A noticeable decrease in your baby's movements, which should be reported right away
  • Yellowing of the skin or the whites of the eyes (jaundice)
  • Dark urine or pale stools along with the itching
  • New or rapidly worsening severe itching in late pregnancy

Why it matters

Risks to you and baby

Stillbirth

This is the serious concern. The risk rises with the level of bile acids in your blood, climbing most sharply when levels are very high (at or above 100). Monitoring bile acids and delivering at the right time aim directly at reducing it.

Preterm birth

Cholestasis often leads to an early delivery, sometimes planned to lower the fetal risk and sometimes because labor begins on its own.

Meconium and fetal distress

Affected babies are more likely to pass meconium before birth and to show distress, which fetal monitoring watches for.

For you, mostly discomfort

The itching can be exhausting, but your liver almost always recovers fully after delivery. Rarely, poor bile flow impairs the absorption of fats and vitamin K, which your provider can address.

How it's found

How is it diagnosed?

Cholestasis is confirmed with a blood test for bile acids, supported by liver function tests, after ruling out other causes of itching or liver trouble.

Serum bile acid test

The key test. A total bile acid level above 10 confirms the diagnosis. Higher levels (at or above 40, and especially 100) mean higher fetal risk and guide the timing of delivery.

Liver function tests

Liver enzymes (transaminases) are often elevated, helping confirm the picture and track it over time.

Ruling out other causes

Your provider checks that the itching and liver changes are not due to another liver or skin condition.

When you have significant itching in the second half of pregnancy. Because itching can precede the rise in bile acids, testing may be repeated if the first result is normal but symptoms persist.

Treatment

How is it managed?

Care has three parts: easing the itch, watching your baby closely, and timing delivery to your bile acid level. The timed delivery most directly protects your baby.

Treatment paths

A medication called ursodeoxycholic acid (ursodiol, or UDCA) relieves the itching and lowers bile acid levels. But while it helps the itch, it has not been shown to prevent the fetal risks, so it does not replace monitoring and a timed delivery. Your baby is watched with antenatal testing.

Medication

Ursodeoxycholic acid is the usual medication. It eases itching and lowers bile acids, though the evidence it prevents adverse outcomes for the baby is limited, which is why timed delivery and monitoring stay central.

Monitoring

Bile acid levels are rechecked, your baby's wellbeing is followed with non-stress tests or biophysical profiles, and you watch fetal movement closely.

Can it recur?

Very often, in roughly 45% to 90% of future pregnancies. Afterward, estrogen-containing birth control can bring the itching back, so tell your provider your history when choosing contraception.

What you can do

Can it be prevented?

  • It cannot be prevented

    Because cholestasis is driven by pregnancy hormones and a genetic predisposition, there is no way to keep it from developing.

  • The protective steps are during pregnancy

    Once diagnosed, monitoring your bile acids, watching your baby, and delivering at the right time reduce the risk. Reporting itching early lets this start sooner.

  • Be cautious with estrogen afterward

    If you have had cholestasis, estrogen-containing contraceptives can trigger itching. Ask your provider about alternatives.

Who is more at risk

Risk factors

A prior pregnancy with cholestasis
The strongest predictor, given the high rate of recurrence.
Recurs in about 45% to 90% of later pregnancies
Family history
A close relative who had cholestasis raises your risk, reflecting the genetic component.
Carrying multiples
A twin or higher-order pregnancy increases the risk.
Existing liver conditions
A history of liver disease, such as hepatitis C or gallstones, raises the risk.
Background and ancestry
It is more common in some populations, including US Latina women and people of South American or Northern European descent.

Do not wait

When to call your provider or 911

  • Call right away if your baby is moving less than usual.
  • Call promptly for intense itching in late pregnancy, especially on the palms and soles or worse at night, so your bile acids can be checked.
  • Seek evaluation for yellowing of the skin or eyes, dark urine, or pale stools.
  • If diagnosed, keep all monitoring appointments and report worsening itching or any change in your baby's movements.
  • Discuss birth control before leaving the hospital, since estrogen-containing methods can bring the itching back.

Talking to your team

Questions to ask your provider

  • What is my bile acid level, and what does it mean for my baby's risk?
  • How often will my bile acids and my baby's wellbeing be checked?
  • When are you planning for me to deliver, and why?
  • Will ursodeoxycholic acid help my itching, and what should I expect?
  • What should I do if I notice my baby moving less?
  • What birth control is safe for me afterward?

Keep reading

More on cholestasis of pregnancy

All pregnancy guides articles

Good to Know

Cholestasis of pregnancy FAQs

Common questions about cholestasis of pregnancy, answered.

Is this just normal pregnancy itching?

Not if it is intense, on the palms and soles, worse at night, and rash-free. Ordinary pregnancy itching is mild, from stretching skin; this kind deserves a bile-acid blood test.

Is it dangerous for my baby?

It can be. Higher bile acid levels are linked to a higher risk of stillbirth, along with preterm birth and meconium, which is why it is monitored closely and delivery planned a bit early.

Will the itching ever stop?

Yes. It almost always disappears within days of birth, once the hormones driving it fall. Your liver typically recovers completely.

Does the medication cure it or protect my baby?

Ursodeoxycholic acid eases the itching and lowers bile acid levels, which helps how you feel. But it has not been shown to prevent the risks to the baby, so it does not replace monitoring and a timed delivery.

Why do I have to deliver early?

Because the risk of stillbirth rises later in pregnancy and with higher bile acid levels. A planned early delivery, tailored to your level, cuts that risk while giving your baby as much time as is safe.

Will I get it again next time?

Most likely. Cholestasis recurs in a large share of future pregnancies, often quoted as 45% to 90%. Tell your provider your history early so monitoring can begin promptly.

Can I take the birth control pill afterward?

Be cautious. Estrogen-containing contraceptives can trigger the same itching in someone who has had cholestasis. Ask about non-estrogen options.

What can I do for the itch at home?

Cool baths, loose clothing, and keeping cool can take the edge off. But they are no substitute for the bile-acid test, the medication, and the monitoring that protect your baby.

Medically Reviewed · Updated

Reviewed by Dr. Grace Lin, MD, FACOG · OB-GYN

Obstetrician-gynecologist focused on reproductive and sexual health for women: pregnancy, BV, yeast, trichomoniasis and HPV/cervical screening. Our editorial guidelines →

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