Intrahepatic cholestasis of pregnancy (ICP) affects 0.5–1.5% of UK pregnancies and is associated with a stillbirth risk of about 3% when peak bile acids are ≥100 µmol/L — roughly ten times the background risk (Ovadia et al., Lancet 2019). Stillbirth risk is unpredictable and can occur at any gestational age once ICP is established. RCOG Green-top Guideline 43 (Intrahepatic cholestasis of pregnancy, 2022; replaced the 2011 obstetric cholestasis guideline) 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 → post-exposure prophylaxis with oral aciclovir or valaciclovir from day 7 to day 14 after exposure (UKHSA PEP guidance, 2025); VZIG only if antivirals cannot be taken.

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 — check TFTs if thyroid disease is clinically suspected. 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 — stillbirth in ICP can occur without warning, and a normal CTG does not eliminate that risk. Assessment of blood pressure is mandatory because pre-eclampsia and HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets) may present with upper abdominal pain alongside hypertension — itching is not a typical HELLP feature. 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 — in singleton pregnancies without other risk factors, bile acids ≥100 µmol/L are managed as severe ICP and planned birth at 35–36 weeks may be considered, individualised by the obstetric team. A normal CTG does not eliminate stillbirth risk in ICP; fetal surveillance follows the local obstetric plan.

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 widely used in ICP, but RCOG GTG 43 (2022) advises against routinely offering it to reduce adverse perinatal outcomes. It does not eliminate stillbirth risk — hence delivery timing decisions remain paramount. A large multicentre RCT (PITCHES, Lancet 2019) found UDCA did not reduce adverse perinatal outcomes and gave only a small reduction in maternal itch, 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.

Awareness of the baby's usual movement pattern, with immediate contact with maternity triage if movements are reduced or changed, is one of the most important safety messages for women with ICP; formal twice-daily counting is not a universal UK recommendation and may increase anxiety. 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 — RCOG GTG 43 recommends confirming resolution of itch and normalisation of bile acids/LFTs at least 4 weeks after birth; symptoms often improve within days, but biochemical normalisation may take longer. Persistent elevation suggests underlying liver disease (primary biliary cholangitis, hepatitis C, Gilbert's syndrome) requiring specialist investigation. The high recurrence risk means future pregnancy planning must include this history — RCOG GTG 43 recommends baseline LFTs and bile acids at booking in a subsequent pregnancy, with repeat testing guided by symptoms. 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 contraception (UKMEC — previous ICP alone does not contraindicate combined hormonal contraception) and future monitoring.