What Is Cholestasis in Pregnancy?
Cholestasis in pregnancy, also known as intrahepatic cholestasis of pregnancy (ICP), is a liver condition that only happens during pregnancy. It doesn’t mean your liver is broken-it means bile, a fluid your liver makes to help digest food, isn’t flowing the way it should. Instead of moving out of the liver and into the intestines, bile builds up in your bloodstream. This causes one main symptom: intense itching, usually on the palms of your hands and soles of your feet, with no rash. The itching often gets worse at night and can be so bad it keeps you from sleeping.
ICP usually shows up in the second half of pregnancy, most often after 30 weeks. That’s when hormone levels, especially estrogen, peak. These hormones interfere with how liver cells move bile out of the body. Women who have a family history of ICP, are carrying multiples, or got pregnant through IVF are at higher risk. If your mom or sister had it, your chance goes up 12 to 15 times. Latina women, especially those from Chile or Bolivia, have much higher rates-up to 5.6%-compared to about 1 in 1,000 in the U.S. overall.
Why It Matters More Than Just Itching
While the itching is awful, the real concern isn’t what it does to you-it’s what it can do to your baby. High levels of bile acids in your blood are linked to serious risks, including stillbirth. When bile acids go above 100 micromoles per liter (µmol/L), the risk jumps from about 0.28% to 3.4%. That’s why doctors don’t just treat the itch-they monitor bile acid levels closely.
Other complications include early labor (30-60% of cases), fetal distress, and meconium staining (when the baby passes its first poop in the womb). These risks are why ICP is treated differently than other pregnancy conditions. Unlike preeclampsia or HELLP syndrome, ICP doesn’t cause high blood pressure or low platelets. It’s not about your blood pressure-it’s about your bile.
How Is It Diagnosed?
There’s no single test for ICP, but doctors rely on two key things: symptoms and blood work. If you’re itching without a rash, especially in the third trimester, your doctor should check your bile acid levels. The gold standard is a serum total bile acid test. A level above 10 µmol/L confirms ICP. Levels above 40 µmol/L are considered severe, and above 100 µmol/L are very high risk.
Liver enzymes like ALT and AST are often elevated too-about 60-70% of the time-but those can be high for other reasons during pregnancy, so they’re not enough on their own. A newer marker called autotaxin is showing promise. One 2020 study found it was 98.6% accurate at spotting ICP, even before bile acids climb. But it’s not widely available yet.
Most U.S. doctors only test if you have symptoms. But in places like Sweden, all pregnant women get screened for bile acids in the third trimester. That’s led to a 35% drop in stillbirths linked to ICP. In the U.S., only 42% of OB-GYN offices routinely screen unless you complain. That means many cases are diagnosed late-on average, 7 to 10 days after symptoms start.
What Are the Safe Treatments?
The first-line treatment for ICP is ursodeoxycholic acid (UDCA). It’s a bile acid your body naturally makes, but in pill form, it helps your liver move bile out faster. The standard dose is 10 to 15 mg per kilogram of body weight per day. For a 70 kg woman, that’s about 700-1,050 mg daily. Studies show it cuts itching by 70% and may lower the chance of early delivery by 25%.
But here’s the catch: a 2022 Cochrane Review of 19 studies found that while UDCA helps with itching, there’s still no strong proof it lowers stillbirth risk. That’s why doctors don’t just rely on the pill-they combine it with close monitoring.
Another option is S-adenosyl methionine (SAMe), taken at 800-1,600 mg daily. It’s used if UDCA doesn’t work or causes side effects like nausea. Small studies show it reduces itching by 40-50%, but there’s not enough data to say it’s as safe or effective as UDCA.
Cholestyramine is sometimes used, but it’s not ideal. It’s a powder you mix with water, and it can block vitamin K absorption. That’s risky because vitamin K helps your blood clot. After delivery, low vitamin K could lead to heavy bleeding. It also causes constipation and bloating, which are already common in pregnancy.
How Is the Baby Monitored?
If you have ICP, your baby will be watched closely. Starting at 32 to 34 weeks, you’ll usually have non-stress tests twice a week. These check your baby’s heart rate in response to movement. Some centers also do biophysical profiles or ultrasounds to check amniotic fluid levels.
Delivery timing depends on your bile acid levels. The Royal College of Obstetricians and Gynaecologists recommends delivery at 37-38 weeks if your bile acids are under 40 µmol/L. If they’re above 100 µmol/L, delivery may be planned as early as 34-36 weeks. The goal isn’t to deliver too early-it’s to deliver before the risk of stillbirth rises too high.
But new data from 2023 suggests that with strict monitoring and UDCA treatment, stillbirth risk stays below 0.5% even at 38 weeks, as long as bile acids stay under 40 µmol/L. That means some women may avoid early delivery if their numbers stay stable.
What Happens After Delivery?
Good news: ICP goes away fast. In 95% of cases, itching disappears within 1-3 days after your baby is born. Liver enzymes and bile acid levels return to normal within a few weeks.
But your risk isn’t over. Women who’ve had ICP are 3.2 times more likely to develop liver problems later in life-like gallstones, chronic hepatitis, or even hepatitis C. That’s why it’s important to tell your future doctors you had ICP. You should also avoid birth control pills with estrogen, as they can trigger a return of symptoms.
There’s also a strong chance ICP will happen again. If you had it in one pregnancy, you have a 60-70% chance of getting it in the next. That’s why early screening is key in future pregnancies.
What’s New in ICP Care?
Technology is helping. In 2023, the FDA approved a new point-of-care test called CholCheck®. It gives bile acid results in 15 minutes instead of waiting 1-3 days. It’s already in use in 65% of high-risk maternity hospitals. That means faster diagnosis, faster treatment, and better outcomes.
Researchers are also testing a new class of drugs called autotaxin inhibitors. Early trials show they reduce itching by 68% in just four weeks. They’re not available yet, but they could be a game-changer.
The 2024 International Cholestasis of Pregnancy Consensus Statement, coming this spring, is expected to shift focus from single bile acid readings to tracking how levels change over time. Instead of just reacting to one high number, doctors may start watching the trend-slower increases might mean safer delivery at 38 weeks, while rapid spikes could mean earlier delivery.
What Should You Do If You’re Itching?
If you’re in your third trimester and have unexplained, intense itching-especially on your hands and feet-don’t wait. Tell your provider right away. Ask for a bile acid test. Don’t assume it’s just dry skin or a normal pregnancy itch.
Get educated. Women who understand ICP have 22% less anxiety and stick to treatment 18% better. Know your numbers. Know your risks. Know your options.
And if your doctor doesn’t test for it, ask why. You have the right to ask for the test. ICP is rare, but it’s serious. And with the right care, most women go on to have healthy babies.
When to Call Your Doctor
- Itching starts in the second half of pregnancy, especially at night
- Itching is worse on your palms or soles
- You have no rash but the itching is severe
- You’ve had ICP before
- You’re carrying twins or got pregnant with IVF
- Your mom or sister had ICP
What to Expect at Your Appointment
- Blood test for total bile acids (most important)
- Liver enzyme tests (ALT, AST)
- Discussion of family history
- Referral to a maternal-fetal medicine specialist
- Plan for fetal monitoring and delivery timing
Myths About ICP
- Myth: ICP is just bad skin. Truth: It’s a liver problem with real risks to your baby.
- Myth: UDCA is dangerous. Truth: It’s been used safely for decades and is the standard of care.
- Myth: If I feel fine, I don’t need testing. Truth: You can have high bile acids without feeling sick-itching is the only symptom.
- Myth: ICP means I’ll have a C-section. Truth: Most women deliver vaginally. Delivery timing matters more than method.