Intrahepatic cholestasis of pregnancy (ICP) is a liver condition in which bile acids build up in the blood and cause itching without a rash, often worst on the palms and soles. The Royal College of Obstetricians and Gynaecologists (RCOG) diagnoses it at a peak bile acid level of 19 µmol/L or more, and with a single baby the stillbirth risk rises above the background rate only from 100 µmol/L.
This page sets out what each bile acid band means, the timing of birth that RCOG, the US Society for Maternal-Fetal Medicine (SMFM) and the European Association for the Study of the Liver (EASL) each suggest, and a checker for your own result. It also covers the symptoms, the tests, what treatment can and cannot do, and what happens after the birth.
The short answer: under RCOG 2022, a peak below 19 µmol/L is not cholestasis; 19–39 is mild, 40–99 moderate and 100 or more severe. Below 100, the stillbirth rate in the largest analysis was close to the UK background. At 100 or more it was 3.44%, and RCOG suggests considering planned birth at 35–36 weeks.
Bile acid levels in pregnancy: what each band means
RCOG names the bands after the peak result, the highest bile acid level recorded in your pregnancy. A single later result that comes down does not move you back a band. The stillbirth figures come from Ovadia and colleagues, who pooled individual records of 5,269 women with ICP from 27 studies, and RCOG built its advice on them.
| Peak bile acids, µmol/L | RCOG 2022 | Stillbirth | What RCOG tells women |
|---|---|---|---|
| < 19 | Gestational pruritus, not ICP | — | Repeat the tests if the itch carries on |
| 19–39 | Mild ICP | 0.13% (3 of 2,310) | Risk similar to the background risk |
| 40–99 | Moderate ICP | 0.28% (4 of 1,412) | Similar to the background risk until 38–39 weeks |
| ≥ 100 | Severe ICP | 3.44% (18 of 524) | Higher than the background risk |
For comparison, the UK stillbirth rate from 28 weeks in 2015 was 0.29%. Ovadia's lowest group held every ICP case below 40 µmol/L, which RCOG's table labels 19–39. The 95% confidence intervals were 0.02–0.38%, 0.08–0.72% and 2.05–5.37%.
The upper limit of normal for bile acids in pregnancy, measured without fasting, is 18 µmol/L in the study of 560 women RCOG relies on. Many laboratories still flag results against a lower, non-pregnant limit. RCOG estimates that moving the line to 19 removed the diagnosis from almost one woman in five previously told she had ICP, and women below that line showed no rise in stillbirth.
When guidelines suggest planned birth
The three bodies agree that the peak level sets the timing. They draw their lines in different places, and the table keeps each in its own words rather than averaging them into a rule nobody wrote.
| Guideline | Mild, 19–39 | Moderate, 40–99 | Severe, ≥ 100 |
|---|---|---|---|
| RCOG 2022 (UK) | Consider planned birth by 40, or ongoing care | Consider planned birth at 38–39 | Consider planned birth at 35–36 |
| SMFM 2021 (US) | Delivery between 36+0 and 39+0 | Offer delivery at 36+0 | |
| EASL 2023 (Europe) | Consider induction by 39 completed weeks | Consider induction by 39 | Delivery from 35 |
SMFM draws a single line, at 100 µmol/L. EASL's bands are below 40, 40 to 100, and above 100. All three are suggestions to discuss, and RCOG frames them as shared decisions.
Other conditions move the plan. RCOG notes that gestational diabetes, pre-eclampsia or twins appear to raise the stillbirth risk in ICP and may bring birth earlier. In one Chinese cohort, twins with ICP had a stillbirth rate of 3.9%, against 0.8% in twins without it.
Bile acid checker
Enter your highest bile acid result in this pregnancy and, if you like, the week you are in now. The checker places the number in its RCOG band and shows what each guideline links to that band. It does not diagnose, it cannot see your liver tests or your history, and the plan is always one you make with your obstetric team.
—
The highest result sets the band, and one reading can mislead: RCOG repeats bile acids about 1 week after the first raised result, because high values often come down. Twins, gestational diabetes or pre-eclampsia change the plan. If your baby moves less, call your maternity unit now; see when to get help.
Symptoms of cholestasis in pregnancy
The main symptom is itching on skin that looks normal. RCOG describes it as often generalised, able to affect the palms of the hands and the soles of the feet, varying in intensity and often worse at night, when it can ruin sleep. The amount of itch does not track the bile acid level, so a mild itch can come with a high result.
Itching is common: about 25% of pregnant women have it, and most do not have and do not develop ICP. Dark urine and pale stools occur less often. Jaundice affects fewer than 1% of women with ICP. In the UK, ICP affects about 0.7% of pregnancies, and 1.2–1.5% of women of Indian-Asian or Pakistani-Asian origin. Our guide to itching in pregnancy shows how to tell the ordinary kind from this pattern at home.
How cholestasis is diagnosed
Two blood tests: total bile acids and liver function tests (such as ALT and AST). RCOG makes the diagnosis on itching of normal-looking skin plus a peak bile acid level of 19 µmol/L or more. Raised liver enzymes with normal bile acids do not count as ICP, because only bile acids predict stillbirth.
- Other causes come first. A doctor or midwife takes a history and examines you to rule out pre-eclampsia, drug reactions, allergic reactions and skin conditions. Itching with a rash is unlikely to be ICP, although eczema and ICP can exist together.
- Extra tests are not routine. RCOG no longer advises routine viral, autoimmune or liver ultrasound tests, and keeps them for an unusual picture, very early onset or results that do not settle after birth.
- A normal result is not the end. With ongoing itch and normal results, RCOG advises repeating the tests, because ICP can follow up to 15 weeks later. EASL suggests every 2 to 3 weeks before week 32 and at least weekly after it.
Our guide to blood tests in pregnancy covers the rest of the routine panel and the tests and scans hub shows when each one falls.
Why it matters for the baby
Stillbirth is the main concern, and the table above shows how tightly it tracks the peak level. Preterm birth rises with it too: in the singleton pregnancies RCOG quotes, 16.5% of babies were born before 37 weeks below 40 µmol/L, 19.1% at 40 to 99 and 30.5% at 100 or more, part of it from planned early births. Meconium in the waters and admission to the neonatal unit are more common in moderate and severe ICP.
ICP also travels with two other conditions. In the same meta-analysis, 12.2% of women with ICP had pre-eclampsia against 3.4% without it, and 13.2% had gestational diabetes against 5.9%. RCOG asks for your blood pressure and urine checks to continue alongside the bile acid tests.
RCOG states that ultrasound scans and CTG do not predict or prevent stillbirth in ICP, because the babies grow normally and deaths have followed normal traces. Watching your baby's movements still matters: RCOG advises every woman with ICP to go to her maternity unit straight away with any concern. Our guide to baby movements and kick counts explains what a change looks like.
Monitoring after the diagnosis
RCOG advises care in a consultant-led maternity unit and a second bile acid test about 1 week after the first raised one, before any decision, since levels of 40 or even 100 often come down. After that, the frequency depends on your band:
- Mild: weekly tests can be useful as you approach 38 weeks, to inform the timing of birth.
- Moderate: weekly tests are considered, especially from about 35 weeks, in case the level reaches 100.
- Severe: further routine tests may not change the plan, so RCOG does not require them.
Treatment: what helps and what to avoid
RCOG 2022 is blunt: no treatment improves the pregnancy outcome or lowers bile acids, and treatments for the itch help only a little. That changed after the PITCHES trial, which gave ursodeoxycholic acid or a placebo to 605 women in 33 UK units. Death, preterm birth or neonatal admission happened in 23% of babies with the drug and 27% with placebo, a difference the trial could not separate from chance. The itch fell by about 5 mm on a 100 mm scale, where women had said 30 mm would be worthwhile.
The guidelines now split. RCOG says not to offer ursodeoxycholic acid routinely to reduce harm to the baby, while noting that it may reduce spontaneous late preterm birth at 40 µmol/L or more. SMFM 2021 recommends it as the first-line treatment for the itch, and EASL 2023 suggests considering it. If your doctor offers it, the trade-off is yours to discuss.
What is standard
- Emollients such as aqueous cream, with or without menthol, to ease the skin. RCOG lists no known harm.
- Chlorphenamine at night, an antihistamine RCOG suggests may help, mostly through drowsiness; its effect on ICP itch is uncertain.
- Ursodeoxycholic acid if your doctor offers it, knowing it eases the itch a little and does not prevent stillbirth.
- Vitamin K only when there is a reason: fatty stools that suggest poor fat absorption, or an abnormal clotting test.
- Cool baths and loose cotton clothing, which the RCOG leaflet also suggests.
What to avoid
- Starting a medicine on your own for the itch, including remedies sold for the liver. Ask your doctor or pharmacist first and say you are pregnant.
- Rifampicin or other agents outside specialist care. RCOG keeps them for research or a specialist's decision in early, severe disease.
- Treating a calmer itch as a lower risk. Itch does not follow the bile acid level, and only the blood test tells you where you stand.
- Skipping the repeat test because a cream or tablet helps.
Labour and birth with cholestasis
ICP on its own does not change how you give birth. RCOG advises induction when a planned birth is chosen, unless there is another reason for a caesarean, and offers standard pain relief, epidural included. At a peak of 100 µmol/L or more, RCOG offers continuous monitoring of the baby's heart in labour; below that, you decide with your team. There is no added risk of heavy bleeding after the birth.
After the birth, the next pregnancy and contraception
The itching usually stops within hours or days. RCOG advises liver function tests and bile acids at least 4 weeks after birth, and its leaflet places them at the 6-week check. If itching or abnormal results last beyond 6 weeks, your doctor looks for another cause, which may mean a liver specialist. EASL expects results to be normal within 3 months.
ICP is more likely to come back in a future pregnancy, and RCOG declines to put a number on it because the studies are small. It advises liver tests and bile acids at booking next time, as a baseline. A Swedish study found later gallstone disease more often after ICP, and RCOG does not recommend routine screening for it.
ICP does not limit your contraception. Under the UK eligibility criteria RCOG quotes, the copper coil, hormonal coil, implant, injection and progestogen-only pill can all be used without restriction. The combined pill can be used once your tests are back to normal, unless a combined pill gave you cholestasis before; then RCOG advises progestogen-only or non-hormonal methods. If itching returns on the combined pill, see your doctor.
When to get help the same day
Call your maternity unit now, day or night, if: your baby is moving less than usual, or the pattern of movements has changed. Do not wait until the morning or your next bile acid test.
Call your maternity unit or doctor the same day if: your skin or the whites of your eyes turn yellow; your urine goes dark or your stools pale; you have pain in the upper abdomen; you have a bad headache, problems with your vision or sudden swelling of your face or hands, which can signal pre-eclampsia; or the itching gets much worse.
Call 999 in the UK or 911 in the US, or your local emergency number, if: you have heavy bleeding, severe abdominal pain or a fit, or you cannot reach your maternity unit and your baby has stopped moving.
Frequently Asked Questions
What are normal bile acid levels in pregnancy?
RCOG 2022 puts the upper limit of normal for non-fasting bile acids in pregnancy at 18 µmol/L, based on 560 women. It diagnoses cholestasis when itching comes with a peak of 19 µmol/L or more. Some laboratories print a lower limit for non-pregnant adults, so a result flagged as high can still sit below the RCOG line.
When does cholestasis of pregnancy start?
Most often in the third trimester, from around week 28, although it can begin earlier. RCOG notes that itching can come first and the blood results later: women with itching and normal results can develop cholestasis up to 15 weeks afterwards, so the test is repeated if the itch carries on.
Is cholestasis of pregnancy dangerous for the baby?
The risk depends on the peak bile acid level. In the largest analysis, of 5,269 women, stillbirth occurred in 0.13% below 40 µmol/L and 0.28% at 40 to 99, close to the UK background of 0.29%, and in 3.44% at 100 or more. Preterm birth and meconium in the waters are also more common.
Do I need to fast before a bile acid test?
No. RCOG 2022 says bile acids can be taken at a convenient time and do not need to be fasting. Readings after a meal run higher, and that is the point: the aim is to catch the peak value, which is the number that predicts risk. Its 19 µmol/L line is a non-fasting cut-off.
Does ursodeoxycholic acid help cholestasis of pregnancy?
It does not lower the risk to the baby. In the PITCHES trial of 605 women, adverse outcomes were 23% with it and 27% with placebo, no clear difference. RCOG no longer offers it routinely for that purpose. SMFM still recommends it first-line for itching and EASL suggests considering it, so whether you take it is a decision with your doctor.
When will I be induced with cholestasis?
It depends on your peak bile acids and on any other conditions. RCOG suggests considering planned birth at 35–36 weeks at 100 µmol/L or more, at 38–39 weeks at 40 to 99, and by 40 weeks below 40. SMFM uses 36 weeks above its line of 100. RCOG suggests induction as the method; cholestasis on its own is no reason for a caesarean.
Does cholestasis of pregnancy go away after birth?
The itching usually stops within the first few days after birth. RCOG advises checking liver function tests and bile acids at least 4 weeks after birth to confirm they are back to normal. If results are still abnormal beyond 6 weeks, your doctor looks for another liver condition.
Will I get cholestasis again in my next pregnancy?
Your chance is higher than average, but RCOG says the size of that risk is unclear because the studies behind the quoted rates are small. It advises liver function tests and bile acids at booking in the next pregnancy, to have a normal baseline. Repeat tests only follow if symptoms return.
Cholestasis of pregnancy: at a glance
Cholestasis of pregnancy is itching of normal skin with a peak bile acid level of 19 µmol/L or more under RCOG 2022. Bands run mild (19–39), moderate (40–99) and severe (≥ 100). Stillbirth risk stayed near the background rate below 100 and reached 3.44% above it, which is why RCOG suggests considering birth at 35–36 weeks there, 38–39 in the moderate band and by 40 in the mild one. Ursodeoxycholic acid does not protect the baby. Reduced movements mean a call to the maternity unit straight away.
Inside Baby Novum: the lab results journal takes a custom test name, so each bile acid result sits with its date, value, unit and notes, and the kick counter keeps a log of each movement session. History charts and unlimited lab records come with Premium.
Read next
Sources
- Girling, Knight and Chappell for the RCOG: Intrahepatic cholestasis of pregnancy, Green-top Guideline No. 43 (BJOG 2022)
- RCOG: Intrahepatic cholestasis of pregnancy, patient information
- Ovadia et al., Lancet 2019: Adverse perinatal outcomes of intrahepatic cholestasis of pregnancy and biochemical markers, aggregate and individual patient data meta-analyses
- Chappell et al., Lancet 2019: Ursodeoxycholic acid versus placebo in intrahepatic cholestasis of pregnancy (PITCHES)
- Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy (American Journal of Obstetrics & Gynecology 2021)
- European Association for the Study of the Liver: Clinical Practice Guidelines on the management of liver diseases in pregnancy (Journal of Hepatology 2023)
- EASL: Intrahepatic cholestasis of pregnancy management algorithm (2023, PDF)
- NHS: Itching and intrahepatic cholestasis of pregnancy
Baby Novum is an informational and tracking tool, not a medical device, and does not provide medical diagnosis or treatment. Always consult your doctor or midwife about your pregnancy.