10 Warning Signs of Obstetric Cholestasis During Pregnancy

Pregnancy brings about numerous changes to your body, and not all of them are easy to discern. One condition often missed in these early conversations is obstetric cholestasis (OC), also known as intrahepatic cholestasis of pregnancy (ICP). It is a condition of the liver that can happen in pregnancy, and the warning signs are often confused with normal pregnancy discomfort.

Here’s what you need to know before those symptoms surprise you

What Is Obstetric Cholestasis?

Obstetric cholestasis is when the bile (which usually flows from your liver to your digestive system) slows or stops. Your liver starts to hold onto more and more bile acids, and they start to leak into your blood. And that’s what causes the symptoms you feel on the outside.

The Royal College of Obstetricians and Gynaecologists (RCOG) says OC affects around 1 in 140 pregnant women in the UK. It typically develops after 20 weeks of gestation, most commonly in the late second or early third trimester. It disappears on its own after your baby is born, but there are real risks during pregnancy that need to be watched carefully.

So let’s take a closer look at the ten warning signs you should never ignore.

10 Warning Signs of Obstetric Cholestasis

1. Intense Itching Without a Rash

This is the characteristic symptom. Itching of obstetric cholestasis is not associated with any visible skin rash. This is what makes it different from conditions like eczema or heat rash. Bile acids build up in your skin and cause itch.

Women can scratch so badly that they damage their skin, according to NHS patient information from Wye Valley NHS Trust. Scratch marks may be present on the skin, but no underlying rash.

Tell your midwife straight away if you get itching for no obvious reason.

2. Itching That Is Worse at Night

“The itch, many women with OC say, worsens after dark. One of the most telling patterns is nighttime itching. It messes up your sleep, which messes up your mood, your focus, and your day-to-day functioning.

Itching in ICP is typically more noticeable on the palms of the hands and soles of the feet and often worse at night and overnight, according to the NHS. Not if you spend nights scratching your hands and feet and can’t sleep.

3. Itching on the Palms and Soles

The NHS Wales guidelines on OC management state the itch can be anywhere on the body, but the palms of the hands and the soles of the feet are the most common areas affected. It can then spread to the arms and legs and, in some cases, to the face.

This distribution is believed to be a characteristic feature of the condition. If you notice the itching is localized to these areas, be sure to tell your healthcare provider.

4. Dark Urine

In obstetric cholestasis, the urine may change color. Bile acids and bilirubin, which build up in the bloodstream, are filtered by the kidneys and passed into the urine, giving it a darker, amber, or brown color.

Other symptoms women might notice along with itching are described by Leicestershire Hospitals NHS Trust as one of the other symptoms. Whatever the reason, always talk to your midwife or doctor about dark urine during pregnancy.

5. Pale or Greasy Stools

At the other end, you might notice your stools becoming lighter in color, pale, greasy, and difficult to flush away. This is because bile isn’t reaching your digestive system like it should, which impacts how fat is broken down and how stool pigment is formed.

Stools can also change color and become smelly, the Leicestershire Hospitals NHS Trust says. A symptom that is easily overlooked, but it is a direct sign that liver function is being affected.

6. Fatigue Beyond Normal Pregnancy Tiredness

Growing a baby is exhausting. Understood well. But the exhaustion that comes with obstetric cholestasis is more than just normal pregnancy tiredness. It can be audible and persistent.

Patient.info cites clinical literature that says, in addition to the itching itself, symptoms that can accompany OC include fatigue, nausea, and reduced appetite. If you’re feeling more tired than you think you should be and you have any of the other signs on this list, don’t dismiss it as just pregnancy.

7. Nausea and Loss of Appetite

Some women with OC have nausea and a lowered interest in food. These symptoms are a reflection of the greater effect a change in liver function can have on the digestive system.

According to Patient.info, in a clinical review (updated October 2024), nausea and anorexia are some of the wider range of cholestasis symptoms that can occur in women with ICP. These alone are common during pregnancy. Here they become more important, together with itching and other signs.

8. Pain or Discomfort in the Upper Right Abdomen

Your liver is on the upper right side of your belly, just below your ribs. Some women will experience a dull ache or discomfort in this area due to increased bile acids and a stressed liver.

Patient clinical guidance notes a possible symptom of ICP as right upper quadrant pain (doctor reference, updated June 2025) along with nausea, fatigue, and changes in urine and stool. Any abdominal pain in pregnancy like this should always be checked out by a healthcare professional.

9. Jaundice (Yellowing of Skin or Eyes)

Jaundice is less common but does occur. The RCOG states that some women with ICP develop yellowing of the skin and the whites of the eyes as a result of the liver changes that occur. NHS Wales’ Healthier Together guidance puts this at about 15% of patients and typically happens between one and four weeks after the itching starts.

Jaundice goes away after delivery, but the presence of jaundice in pregnancy is a pointer to potentially very high levels of bile acids. If you develop yellow skin or eyes at any time during your pregnancy, you should get a medical review that day.

10. Sleep Disturbance and Emotional Well-being Concerns

This one is less discussed but is worth including. The itching is constant and bad, and it keeps you awake at night. As time goes on, sleep disruption can affect emotional well-being, leading to increased anxiety and low mood.

The Wye Valley NHS Trust points out that the itching, which can occur with OC, can cause problems with emotional well-being. Swansea Bay NHS guidelines also record sleep quality as part of the clinical assessment for OC, with normal sleep, disturbed sleep, and sleep loss affecting daily activities.

If you can’t sleep because you can’t stop scratching, that’s a medical problem, not just a pregnancy nuisance.

Who Is at Higher Risk?

Not all pregnant women are at the same risk. OC is more common in women of Indian Asian or Pakistani Asian origin, with an incidence of 1.5% in that population vs. less than 1% in the general pregnant population in the UK, according to Buckinghamshire Healthcare NHS Trust.

There’s a genetic component too. OC often runs in families. Women who have had OC before are more likely to get it again. Having an IVF pregnancy or carrying twins or more may also increase the chance of developing OC.

How Is Obstetric Cholestasis Diagnosed?

They don’t diagnose based on symptoms but on blood tests. Your midwife or doctor will ask you for a bile acid test and liver function tests (LFTs). Healthier Together NHS Wales says you can have abnormal bile acid levels when your LFTs are normal, so you need to have both tests.

You should not try to diagnose this yourself. Blood tests are the only sure way of confirming this.

What to do next: If you have any of the above symptoms, especially unexplained itching in the second or third trimester, tell your midwife. Don’t wait until your next visit.

What Are the Risks for Your Baby?

This is where a timely diagnosis is so important. Women with OC are more likely to have preterm delivery, meconium-stained amniotic fluid (where the baby passes its first stool before birth), and, if bile acid levels reach 100 µmol/L or more, an increased risk of stillbirth.

The RCOG guidance states that bile acids are monitored regularly throughout pregnancy in women with OC, and induction may be offered from 35 weeks, depending on bile acid levels.

Most importantly, in most women with OC with bile acids <100 µmol/L, the risk of stillbirth is comparable to that of the general pregnant population.

What Treatment Is Available?

There is no treatment for obstetric cholestasis other than delivery. Management is symptom control and close surveillance of pregnancy.

Antihistamines can help you sleep. Cool baths and loose cotton clothing may help lessen the severity of the itching. Some women are given ursodeoxycholic acid (UDCA) to help improve symptoms, though the evidence on its effect on baby outcomes is still being reviewed.

MyGynaePlus, a women’s health clinic based in West London, has specialists who provide individualised obstetric care for conditions like OC, guiding pregnant women with close surveillance and expert management through all phases of pregnancy.

When to Contact Your Midwife or Doctor

Contact your midwife or obstetric team if you have:

• Itching that doesn’t go away, especially on the hands and feet

• Itching that is worse at nighttime

• Pale stool or dark urine

• Pain in the upper right side of the abdomen

• Yellowing of the skin or eyes at all

OC is usually not a medical emergency, but it does need prompt evaluation. Swansea Bay NHS guidelines say that women with symptoms can be seen the next working day at an antenatal day assessment unit and do not need to go to A&E unless told to.

FAQs About Obstetric Cholestasis: Warning Signs

Q1: Can obstetric cholestasis occur in the first trimester?

No, OC does not develop until 20 weeks of pregnancy. It most commonly occurs in the late second or early third trimester, usually after 30 weeks. If you start itching earlier in pregnancy, other causes should be investigated.

Q2: Is itching during pregnancy always a sign of obstetric cholestasis?

No, not at all. Itching is experienced by some 23 to 25% of pregnant women, and the vast majority of them do not have OC. Common causes are more likely to be eczema, dry skin, and allergies. To confirm or rule out OC, you need a blood test.

Q3: Can obstetric cholestasis harm my baby?

It may increase some risks, such as premature birth and meconium staining of the amniotic fluid. The risk of stillbirth increases only if bile acid levels are 100 µmol/L or higher. They are well managed through regular monitoring and planned timing of delivery.

Q4: Will obstetric cholestasis go away after I give birth?

Yes.” The symptoms usually disappear within a week or so after delivery, and the mother does not have permanent liver damage. Blood tests will be needed afterwards to make sure your liver function returns to normal after the birth.

Q5: Am I more likely to get obstetric cholestasis in a future pregnancy?

Yeah. Women with a history of OC are at increased risk in subsequent pregnancies. If you’ve had OC before, let your midwife or obstetrician know at your first antenatal appointment so monitoring can begin early.