Synopsis
Assess pregnancy-related itch using bile acids and competing diagnoses, then individualise symptom relief, surveillance and birth timing according to fetal risk.
- Suspect intrahepatic cholestasis when pregnancy itch occurs without a primary skin eruption, often affecting palms and soles.
- Measure total bile acids and liver enzymes; persistent symptoms warrant repeat testing even when initial results are normal.
- RCOG defines mild disease by peak bile acids 19–39 micromol/L, moderate by 40–99 and severe by 100 or more.
- Use the highest relevant bile acid concentration and the complete pregnancy history when discussing risk and timing of birth.
- Ursodeoxycholic acid can offer limited itch relief; it is not proven to prevent stillbirth and cannot replace a birth plan.
- Confirm symptom and biochemical resolution after birth, and investigate persistent abnormalities rather than assuming they remain pregnancy-related.
Key red flags
Reduced or altered fetal movements require prompt maternity assessment even when recent bile acids or fetal checks were reassuring.
Jaundice with vomiting, right upper quadrant pain, bleeding, hypoglycaemia or altered consciousness is atypical for straightforward cholestasis and requires urgent hospital investigation.
Bile acids reaching 100 micromol/L or above require specialist review of the planned birth date and coexisting risk factors.