Itching in Pregnancy: What Is Normal and When It Could Be Cholestasis

Is itching during pregnancy normal?

Itching in pregnancy is common and usually not caused by anything serious, the NHS says, but it can sometimes be a sign of a liver condition called intrahepatic cholestasis of pregnancy (ICP) that needs treatment. The Royal College of Obstetricians and Gynaecologists (RCOG) says itching affects 25 in 100 pregnant women and that most of them will not have ICP.

The NHS puts everyday itching down to changing hormone levels and your skin stretching as your baby grows, and says it usually stops after the birth. Itching can also be the first sign of ICP, so the RCOG says to tell your midwife or doctor about it.

Why do your hands and feet itch during pregnancy?

Itchy palms and soles can be a sign of intrahepatic cholestasis of pregnancy (ICP), and the NHS says to get urgent medical help if the palms of your hands or the soles of your feet itch. ACOG describes the main symptom of ICP as severe itching without a rash, commonly on the palms and soles and typically worse at night.

The RCOG says the itching can start at any time in pregnancy but usually begins after 28 weeks and can disturb your sleep. ACOG says ICP symptoms usually start in the third trimester. Some women itch for days or weeks before their blood tests become abnormal, the RCOG adds, so the tests should be repeated if the itching continues and no other cause is found.

What is cholestasis of pregnancy?

ICP is the most common liver condition in pregnancy, according to ACOG: the flow of bile from the liver is blocked and parts of the bile are deposited in the skin.

The RCOG says ICP affects about 7 in 1,000 women in the UK, and up to 15 in 1,000 women of Indian-Asian or Pakistani-Asian origin. Cleveland Clinic gives about 1 to 2 in 1,000 pregnancies, and MedlinePlus says up to 2%, varying by country and population.

Cleveland Clinic lists a higher risk if a family member has had ICP, you had it in a past pregnancy, you are carrying twins or more, or you have a history of liver disease or hepatitis C. ICP may also make preeclampsia or gestational diabetes more likely, the RCOG says.

According to the RCOG, ICP raises the chance of your baby being born early (before 37 weeks) and of passing meconium before birth, and there are no known long-term health risks to the baby.

Only severe ICP raises the risk of stillbirth, the RCOG says. With mild ICP (bile acids of 19 to 39 micromol/L) and no other risk factors, the chance of stillbirth is no different from someone without ICP; with severe ICP (100 micromol/L or more), around 3 in 100 women have a stillbirth after 36 weeks. The NHS says most people with ICP make a full recovery and have a healthy birth.

How is cholestasis of pregnancy diagnosed and treated?

ICP is diagnosed with blood tests: the Society for Maternal-Fetal Medicine (SMFM) recommends measuring bile acids and liver enzymes, and the RCOG says your skin will also be checked for other causes such as eczema.

US and UK guidance differ on medicine. SMFM recommends ursodeoxycholic acid as the first-line medicine for the mother's symptoms of ICP. The RCOG says ursodeoxycholic acid may slightly reduce itching in a small number of women and may lower the chance of an early birth, but does not prevent stillbirth, and that no treatment helps the baby or lowers bile acids.

Treatments for the itch are of limited benefit, the RCOG says, but include creams such as aqueous cream, with or without menthol, and antihistamines to help you sleep. Check with your doctor, midwife or pharmacist before using any medicine.

Once you have ICP, the RCOG says you should be under an obstetrician's care, with blood tests usually repeated after a week. It also says to keep a close eye on your baby's movements and go to your maternity unit straight away if you are worried.

Will you need to give birth early with cholestasis?

Whether you are advised to give birth early with ICP depends on your bile acid level and on other risk factors such as twins, gestational diabetes or preeclampsia, the RCOG says. SMFM recommends offering delivery at 36 weeks 0 days when total bile acids are 100 micromol/L or more, and delivery between 36 weeks 0 days and 39 weeks 0 days when they are below 100.

For a single baby with no other complications, the RCOG suggests a planned birth at 35 to 36 weeks for bile acids of 100 or more, at 38 to 39 weeks for 40 to 99, and a planned birth by 40 weeks, or waiting for labor, for 19 to 39.

The RCOG says the choice is between an induction, a planned C-section or waiting for labor, and that ICP alone is no reason for a C-section. ACOG says symptoms often go away a few days after the birth, and the RCOG says blood tests should be checked at your 6-week postnatal visit. ACOG and the RCOG both say ICP can come back in a later pregnancy.

How can you ease itchy skin in pregnancy?

For ordinary itching, the NHS and ACOG suggest gentle skin care:

• pat or tap your skin instead of scratching, and keep your nails short (NHS)
• have cool or warm baths or showers, not hot, for no longer than 20 minutes (NHS)
• use unperfumed moisturizer regularly (NHS); ACOG suggests a heavy moisturizer twice a day
• wash with mild, fragrance-free soap; ACOG suggests adding uncooked oatmeal or baking soda to your bath
• wear loose clothing made from natural fibers such as cotton (NHS)
• cut back on spicy food and caffeine, which the NHS says can make skin feel itchier

ACOG says an over-the-counter anti-itch cream may help. The NHS says a pharmacist can suggest creams and antihistamines that are safe in pregnancy if you tell them you are pregnant, and that a GP or midwife may prescribe antihistamine tablets, emollients or steroid cream.

When should you call your doctor or midwife?

Call your OB-GYN or midwife right away if you have any of the itching below, which the NHS says could be ICP needing urgent treatment. In the UK, the NHS says to call your maternity unit, or 111 if you cannot reach it.

• Very itchy skin, for example itching that keeps you awake at night.
• Itchy palms of your hands or soles of your feet.
• Itching that is worse at night.

If you have ICP and are worried about your baby's movements, the RCOG says to go to your maternity unit straight away.

Cleveland Clinic says to call your healthcare provider if you have intense itching, light-colored poop and extreme tiredness, and it lists dark pee and yellowing of your skin or eyes (jaundice) among the less common signs of ICP.

The NHS says to see a doctor (a GP in the UK), though not urgently, if itching is affecting daily life, does not get better with a pharmacist's treatment, keeps coming back, or comes with a new rash, lump or swelling.