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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- ICP = pruritus without rash + raised serum bile acids (≥19 µmol/L) in pregnancy
- Pruritus characteristically worse on palms and soles, worse at night, no primary rash (excoriations only)
- Severity grading: mild (19–39 µmol/L), moderate (40–99 µmol/L), severe (≥100 µmol/L)
- Stillbirth risk only significantly increased when bile acids ≥100 µmol/L
- Ursodeoxycholic acid (UDCA) may relieve pruritus but evidence does not support improvement in perinatal outcomes
- Delivery timing: individualised — typically 37–38 weeks for moderate, 35–36 weeks for severe ICP
Overview
Intrahepatic cholestasis of pregnancy (ICP), also known as obstetric cholestasis, is a liver disorder specific to pregnancy characterised by pruritus with raised serum bile acid concentrations. The pathophysiology involves impaired hepatic bile acid excretion, likely mediated by the effects of oestrogen and progesterone metabolites on bile acid transporters in genetically susceptible women. It typically presents in the third trimester and resolves completely after delivery. The clinical significance lies in the association between very high bile acid levels and adverse fetal outcomes, particularly stillbirth.
Epidemiology
ICP affects approximately 0.7% of pregnancies in the UK, with higher rates in South Asian populations (1.2–1.5%). It is more common in multiple pregnancies, with a history of previous ICP (recurrence rate ~45–90%), and in women who have had cholestasis with the combined oral contraceptive pill. There is seasonal variation, with higher incidence in winter months. Genetic factors (mutations in bile acid transporter genes) and environmental factors both contribute.
Clinical Features
Symptoms
Pruritus — worse on palms and soles, typically worse at night, may be generalised. No primary rash
Pruritus usually begins in the third trimester (occasionally earlier)
Dark urine and pale stools (in severe cases — obstructive picture)
Fatigue and sleep disturbance from intense itching
Reduced fetal movements
Signs
Excoriations from scratching (no primary rash)
Mild jaundice (uncommon — present in <25%)
Hepatomegaly (rare)
Steatorrhoea (rare — from fat malabsorption)
Investigations
First-line
Serum bile acidsKey diagnostic test. ≥19 µmol/L supports ICP diagnosis. Classify: mild 19–39, moderate 40–99, severe ≥100. Repeat after 1 week and then weekly approaching 38 weeks
LFTsALT/AST raised in ~60%. Transaminases may rise before bile acids
Second-line
Coagulation screenProthrombin time may be prolonged — vitamin K malabsorption from cholestasis
Hepatitis B and C serologyRoutine exclusion of viral hepatitis is no longer recommended unless clinically indicated
Liver USSOnly if other liver pathology suspected — typically normal in ICP
Specialist
Autoimmune liver screenANA, SMA, anti-mitochondrial antibodies — only if clinical suspicion of autoimmune liver disease
1
Symptomatic relief
- Topical emollients (aqueous cream ± menthol)
- Antihistamines (chlorphenamine) may help with sleep but limited evidence for itch itself
- Ursodeoxycholic acid (UDCA) 250 mg BD, increasing to 500 mg BD — may relieve pruritus. Note: PITCHES trial (2019) showed no improvement in perinatal outcomes
2
Monitoring
- Serial bile acid measurements: weekly as approaching 38 weeks
- LFTs: monitor alongside bile acids
- Vitamin K 10 mg PO daily if prothrombin time prolonged
- Advise monitoring fetal movements — attend immediately if reduced
3
Delivery timing
- Individualised based on peak bile acid levels:
- Mild (19–39 µmol/L): planned birth by 40 weeks (no evidence of increased stillbirth risk)
- Moderate (40–99 µmol/L): consider birth at 37–38 weeks
- Severe (≥100 µmol/L): consider birth at 35–36 weeks — highest stillbirth risk
- Balance prematurity risks against stillbirth risk — shared decision-making
4
Postnatal
- Symptoms and biochemistry resolve within days to weeks of delivery
- Check LFTs and bile acids at 6–12 weeks postpartum to confirm resolution
- Avoid oestrogen-containing contraception (may trigger recurrence)
- Counsel about recurrence risk in future pregnancies (45–90%)
Complications
- Stillbirth: Significantly increased only when bile acids ≥100 µmol/L. Mechanism unclear — possibly fetal cardiac arrhythmia from bile acid toxicity
- Preterm birth: Both spontaneous and iatrogenic (from early delivery)
- Meconium-stained liquor: Increased incidence
- Postpartum haemorrhage: Slightly increased risk — vitamin K malabsorption and coagulopathy
- Vitamin K deficiency: From cholestasis-related fat malabsorption
UKMLA Exam Tips
- 1ICP = pruritus (palms/soles, worse at night, NO rash) + raised bile acids. Classic exam presentation
- 2Bile acids ≥19 µmol/L = diagnostic. Severity: mild 19–39, moderate 40–99, severe ≥100
- 3Stillbirth risk only significantly increased at bile acids ≥100 µmol/L
- 4UDCA may improve itching but DOES NOT improve perinatal outcomes (PITCHES trial)
- 5Resolves completely after delivery — if LFTs/bile acids do not normalise, investigate other causes
- 6Avoid COC postnatally — use progesterone-only methods or non-hormonal contraception
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