Itching is common in pregnancy — most of it benign, from stretching skin and hormonal changes. But one specific pattern of itching is not benign: intense, generalised itching, particularly on the palms and soles, worse at night, in the second or third trimester. This pattern is the hallmark of intrahepatic cholestasis of pregnancy (ICP) — a liver condition that significantly elevates the risk of stillbirth and preterm birth.

Dr. Shachi Singh, consultant obstetrician at Prakash Hospital, Sector 33, Noida, explains ICP in detail.

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What ICP Is

ICP is a liver disorder specific to pregnancy, caused by impaired bile flow from the liver into the bile ducts. Bile acids — which normally flow from the liver through the bile ducts to the intestines — accumulate in the liver and spill into the bloodstream, depositing in the skin (causing itching) and crossing the placenta to reach the baby.

The mechanism by which accumulated bile acids harm the baby is not fully understood, but they cause cardiac arrhythmias in fetal heart muscle and are associated with acute events leading to stillbirth.

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Symptoms

Itching — the cardinal symptom:

• Intense, often described as unbearable
• Typically starts on the palms of the hands and soles of the feet — before spreading to the rest of the body
• Worse at night — severely disrupting sleep
• No rash in the areas of itching (distinguishes ICP from skin conditions that itch)
• Does not respond to antihistamines or moisturisers

Jaundice: Occurs in a minority (10 to 15%) of ICP cases — yellowing of the skin and whites of the eyes. When jaundice is present, the bile acid levels are typically severely elevated.

Dark urine and pale stools: From bilirubin accumulation.

Right upper abdominal discomfort: From liver involvement.

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Investigation

Serum bile acids: The most important diagnostic test. Total bile acids above 10 to 14 μmol/L in pregnancy confirms ICP. The severity of fetal risk correlates with bile acid levels:

• Bile acids 10 to 39 μmol/L: mild ICP — stillbirth risk modest but elevated
• Bile acids 40 to 99 μmol/L: moderate ICP
• Bile acids 100 μmol/L and above: severe ICP — significantly elevated stillbirth risk

Liver function tests (ALTs, ASTs): Often elevated in ICP — up to 10 times the upper limit of normal in severe cases.

Bilirubin: May be elevated, particularly if jaundice is present.

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The Stillbirth Risk: Why ICP Is Taken So Seriously

ICP is one of the few pregnancy conditions associated with a risk of acute, unpredictable stillbirth — occurring in late pregnancy, often without warning, in women with otherwise well-appearing fetuses. The stillbirth risk is related to bile acid level:

• Bile acids below 40 μmol/L: stillbirth risk modest, close to background
• Bile acids 40 to 100 μmol/L: stillbirth risk approximately 1 to 2%
• Bile acids above 100 μmol/L: stillbirth risk approximately 3 to 4%

For context: baseline stillbirth risk in normal pregnancy is approximately 0.4%. Even "moderate" ICP carries a meaningful elevation. This is why proactive management and delivery planning are essential.

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Management

Ursodeoxycholic acid (UDCA / Urso): The primary treatment. UDCA improves bile flow from the liver, reduces serum bile acid levels, reduces itching, and importantly reduces the concentrations of bile acids crossing the placenta. It is the safest and most effective available treatment for ICP. Given orally in divided doses, adjusted to the severity of the condition.

Weekly bile acid monitoring: Serial bile acid tests track the severity and guide the urgency of delivery planning.

Fetal monitoring: CTG monitoring (fetal heart rate tracing) from 34 to 36 weeks — though it is important to understand that CTG monitoring in ICP provides some reassurance but does not reliably predict the acute events that cause stillbirth. Delivery timing, not monitoring, is the primary protective intervention.

Delivery timing:

• Mild ICP (bile acids below 40 μmol/L): induction of labour at 37 to 38 weeks
• Moderate ICP (40 to 100 μmol/L): induction at 36 to 37 weeks
• Severe ICP (above 100 μmol/L): discussion of delivery from 35 to 36 weeks, balancing prematurity risks against stillbirth risk

After delivery: Bile acids and liver function tests normalise rapidly after delivery — within days to weeks. ICP resolves completely after delivery. Itching improves within 24 to 48 hours of delivery. ICP is likely to recur in subsequent pregnancies (recurrence rate approximately 60 to 70%).

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What to Do if You Have Intense Itching in Pregnancy

Contact your obstetrician promptly. Do not wait to see if it settles. Any intense, generalised itching — particularly on palms and soles, worse at night — in the second or third trimester requires blood tests (bile acids and liver function) to be done urgently. If bile acids are elevated, management should begin without delay.

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Obstetric Care in Noida and Greater Noida

Dr. Shachi Singh at Prakash Hospital, Sector 33, Noida, diagnoses and manages intrahepatic cholestasis of pregnancy for women across Noida and Greater Noida.

To book a consultation with Dr. Shachi Singh, call: +91 97023 46853

Clinic Hours: Monday to Saturday, 9 AM – 6 PM | Sunday, 10 AM – 2 PM

Clinic Address: D-12A, 12B, Sector-33, G.B. Nagar, Noida, Uttar Pradesh 201301

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This blog is for educational purposes only. Intense itching in pregnancy must be assessed urgently — do not wait.