Intrahepatic cholestasis of pregnancy (ICP) affects 0.5–1.5% of UK pregnancies and is associated with a 1–2% risk of stillbirth when bile acids ≥100 µmol/L — this is 20–30× higher than background risk. Stillbirth risk is unpredictable and can occur at any gestational age once ICP is established. RCOG Green-top Guideline 43 (2011, updated 2022) mandates urgent investigation of any suspected ICP presentation. The diagnosis must be actively excluded in EVERY pregnant woman presenting with pruritus, regardless of gestational age — it is the most time-critical diagnosis in this clinical scenario.

The absence of primary skin rash with generalised pruritus (especially palms/soles, nocturnal) in the third trimester is the hallmark of ICP — this combination should trigger immediate investigation regardless of liver function test results at presentation. LFTs can be normal early in ICP (bile acids are the more sensitive initial marker). Varicella in pregnancy is a medical emergency — maternal pneumonia affects 5–10% of infected pregnant women and carries significant maternal mortality. Varicella exposure without immunity in pregnancy → urgent varicella zoster immunoglobulin (VZIG) within 10 days.

PEP/PUPPP (Polymorphic Eruption of Pregnancy) is the most common dermatosis of pregnancy and has an excellent prognosis — reassurance is the most important management once ICP is excluded. Its periumbilical sparing differentiates it from Pemphigoid gestationis, which starts periumbilically. Pemphigoid gestationis is associated with thyroid autoimmunity and Graves' disease — check TFTs. The key clinical priority is distinguishing the benign dermatoses from ICP, which requires laboratory investigations in all cases of pruritus without obvious localised cause in pregnancy.

Documentation of fetal movements at every GP contact with a pregnant woman presenting with pruritus is critical — RCOG GTG 43 notes that stillbirth in ICP typically occurs without warning, often within 24–48 hours of the last normal CTG. Assessment of blood pressure is mandatory because HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets) may present with upper abdominal discomfort that patients describe as itch, alongside hypertension — this is a life-threatening emergency. Full skin inspection is essential — any primary lesion excludes ICP and triggers a dermatological differential.

Serum bile acids are the most sensitive diagnostic test for ICP and must be performed urgently — same-day where possible. LFTs alone are insufficient: a prospective study showed normal LFTs in 21% of confirmed ICP cases at initial presentation. Fasting bile acids are more sensitive but should not delay testing. The severity classification (mild, moderate, severe) directly determines obstetric management — women with bile acids ≥100 µmol/L are managed as severe ICP with delivery planned at 35–36 weeks in most UK centres. CTG does not predict acute stillbirth in ICP — the mechanism (sudden cardiac arrhythmia from bile acid toxicity) occurs rapidly without warning signs.

RCOG GTG 43 mandates that all cases of suspected ICP are referred to an obstetric unit for assessment and management — this includes bile acid testing, fetal surveillance planning, and delivery timing decisions. GP management of ICP beyond initial recognition and referral is not appropriate. Pemphigoid gestationis requires skin biopsy with direct immunofluorescence for definitive diagnosis — this is a specialised investigation not available in primary care. The urgency of same-day DAU (Day Assessment Unit) referral for suspected ICP reflects the unpredictable nature of stillbirth risk.

Ursodeoxycholic acid (UDCA) is the only treatment shown to reduce bile acid levels in ICP and improve maternal symptoms — it is standard of care (RCOG GTG 43). It does not eliminate stillbirth risk — hence delivery timing decisions remain paramount. A large multicentre RCT (PITCHES, NEJM 2019) found UDCA improved maternal itch but did not significantly reduce adverse perinatal outcomes, prompting ongoing review of the evidence. Oral fluconazole in pregnancy: a Danish study suggested increased miscarriage and cardiac defect risk with doses ≥150mg — topical clotrimazole remains the recommended treatment for vulvovaginal candidiasis in all trimesters of pregnancy.

Fetal movement monitoring is one of the most important interventions for women with ICP — the RCOG advises awareness campaigns (Kicks Count charity) show that women who report immediately on reduced movements have better outcomes. ICP Support (icpsupport.org) is a patient-led charity that provides evidence-based information — referral to this resource empowers patients with self-monitoring and reduces unnecessary GP visits while ensuring appropriate contact. Sleep disruption from nocturnal itch in ICP significantly affects quality of life and maternal mental health — addressing this directly improves adherence to monitoring and reduces anxiety-related complications.

Post-delivery follow-up for ICP is essential — bile acids should normalise within 10 days postpartum. Persistent elevation suggests underlying liver disease (primary biliary cholangitis, hepatitis C, Gilbert's syndrome) requiring specialist investigation. The high recurrence rate (70–90%) means future pregnancy planning must include this history — early bile acid monitoring from 20 weeks in subsequent pregnancies is standard practice at most UK obstetric units. Documentation in patient records is a GP responsibility — a future GP seeing the patient for contraception or pre-conception advice needs to know about ICP history to counsel appropriately about COCP risk and future monitoring.