Itching in Pregnancy — and When to Worry About Cholestasis

When to call

This section is first because the whole point of this page is the phone call.

Contact your maternity service about any itching in pregnancy, within 24 hours. That is Tommy's explicit instruction: "If you have any itching, contact your maternity service within 24 hours. Try to be specific about where you are itchy and how severe it is." It adds the honest context in the same breath: "Itching is very common in pregnancy and only a small number of people who itch will have ICP."

Tommy's is clear about why the threshold is so low: "ICP can be very serious, so it is vital that you tell your midwife or doctor if you are feeling itchy, even if you think it's mild."

The NHS treats specific features as needing urgent help now. Get urgent medical help if you are pregnant and:

• "you have very itchy skin – for example, it keeps you awake at night"
• "the palms of your hands or soles of your feet are itchy"
• "the itching is worse at night"

The NHS says these "could be signs of intrahepatic cholestasis of pregnancy (ICP) that needs urgent treatment", and to call your maternity unit — or 111 if you cannot reach them.

Go to your maternity unit straight away if you notice any change in your baby's movements. The RCOG's advice for anyone with ICP is direct: "You should keep a close eye on your baby's movements and if you are worried, you should go to your local maternity unit for a checkup straight away." Tommy's lists movements that feel weaker, or that have stopped, as reasons to be seen. Call your local emergency number (999 in the UK and Ireland, 911 in the US and Canada, 000 in Australia, or 111 in New Zealand) if you collapse or become severely unwell.

What to ask for: a blood test measuring bile acids and liver function. If your first test is normal but the itching continues, ask for it to be repeated — Tommy's notes that "some people may have itching for days or weeks before their blood tests become abnormal."

Why this page leads with the call

Because the difference between the harmless version and the serious version is not something you can feel. It is a number in a blood test. The RCOG sets out the risk by severity, and the contrast is stark:

• Mild ICP (peak bile acids 19–39 micromol/L): "the chance of you having a stillbirth is no different to someone who doesn't have ICP."
• Moderate ICP (40–99 micromol/L): the risk remains similar until around 38 to 39 weeks.
• Severe ICP (100 micromol/L or more): "Around 3 in 100 women with severe ICP have a stillbirth after 36 weeks of pregnancy."

Tommy's gives the same 3% figure, and adds that "most people with ICP will have bile acid levels lower than this."

Those bands come from the RCOG's Green-top Guideline No. 43, which sets the thresholds at 19–39, 40–99, and 100 micromol/L or more.

Notice what that means. A mild result is genuinely reassuring; a severe result triggers closer monitoring and a planned earlier birth. Either way, the blood test is what unlocks the right answer. Itching that goes unreported gets neither.

What ICP is

The RCOG: "ICP is a condition that affects your liver during pregnancy. ICP causes a build-up of bile acids in your body." Bile acids are normally made in the liver and flow to your gut to help you digest food; in ICP they build up instead. You may also see it called obstetric cholestasis — the older name for the same condition.

How common: the RCOG says that in the UK "it affects about 7 in 1000 women (less than 1%)" — roughly 1 in 140 pregnancies — and that "it is more common among women of Indian-Asian or Pakistani-Asian origin, with up to 15 in 1000 women (1.5%) affected." Most itching in pregnancy is not ICP, which is why a test is the sensible way to settle it.

What the itching is like

The features that matter, from the RCOG and Tommy's:

• No rash. The RCOG is emphatic: the main symptom is "itching of your skin without any rash", and "there is no rash with ICP."
• Often palms and soles. Tommy's: "The itch is often more noticeable on the palm of the hands and soles of the feet, but you may feel it all over your body."
• Worse at night — and the NHS treats night-time itching that keeps you awake as an urgent feature.
• Usually after 28 weeks, though the RCOG notes it "can start at any time during pregnancy".

Less common additional symptoms Tommy's lists: dark urine, pale stools, and jaundice.

One important calibration: how badly you itch does not track how severe the ICP is. That is precisely why Tommy's says to report it even if you think it is mild.

What ordinary pregnancy itching is

Most of it is benign. Tommy's: "As your baby grows, the skin on your stomach stretches, which may feel mildly itchy. Itching can also be caused by hormone changes."

Itching with a rash is a different category, and usually less worrying. Tommy's advises contacting your GP or midwife if you are itchy and have a rash — the commonest causes are eczema and atopic eruption of pregnancy, which "are unlikely to harm you or your baby."

Note the trap, though: the absence of a rash points towards ICP, not away from it. "It's just dry skin, there's nothing to see" is not reassurance.

What happens if you are diagnosed

Monitoring. The RCOG: "Once you have been diagnosed with ICP, you should be under the care of an obstetrician. Your blood tests will usually be repeated after one week and an individualised plan of care will be made for you." In some women bile acids return to normal without treatment and the diagnosis is revisited. Tommy's says tests may be repeated weekly at first.

Timing of birth, per the RCOG:

• Mild ICP: "Planned birth by the time of your due date (40 weeks) may be considered."
• Moderate (40–99 micromol/L): "Planned birth at 38-39 weeks' gestation may be recommended."
• Severe (100 micromol/L or more): "Planned birth at 35-36 weeks' gestation may be recommended."

What treatment does and does not do

Be clear-eyed about this, because it is widely overstated.

The RCOG says: "Treatments to improve your itching are of limited benefit but might include: skin creams such as aqueous cream, with or without the addition of menthol" and "antihistamines, which may help you sleep at night." On the drug people ask about most: "Ursodeoxycholic acid may reduce your chance of giving birth prematurely but it does not prevent stillbirth."

The Cochrane review of drug treatments for ICP covered 26 trials and 2,007 women. Compared with placebo, ursodeoxycholic acid "probably results in a small improvement in pruritus score" — a mean difference of 7.64 points on a 100 mm scale (moderate-certainty evidence, two trials, 715 women). The reviewers' verdict: "the size of the effect is small and for most pregnant women and clinicians, the reduction may fall below the minimum clinically worthwhile effect." Evidence on stillbirth was very low certainty, and there was insufficient evidence for every other drug tested.

So creams and antihistamines are for comfort and sleep. What manages the actual risk is monitoring and the timing of birth. The NHS notes that "most people with ICP will make a full recovery and have a healthy birth."

What actually helps

• Report it and ask for the specific test — bile acids and liver function. Ask for a repeat if itching continues and the first result was normal.
• Monitor movements and report any change immediately.
• For comfort: the NHS suggests patting your skin instead of scratching, cool or warm (not hot) baths of no more than 20 minutes, unperfumed emollients, short nails and loose cotton clothing.
• Ask a pharmacist — the NHS says they can suggest creams and antihistamines that are safe in pregnancy.

Afterwards

Tommy's: "ICP itching will stop soon after you've given birth, usually in hours or days." The RCOG adds that "it can take several weeks for your blood tests to return to normal", and that "there is an increased chance that you will have ICP again in future pregnancies" — worth flagging early next time so monitoring can start sooner.