FFinalistSouthampton · 2027
Obstetrics & gynaecology
AKT · Obstetrics & gynaecology/Antenatal & medicallow yield

Jaundice in pregnancy

Obstetric cholestasis / pregnancy-specific liver disease

Overview

Jaundice or deranged liver function in pregnancy — most commonly intrahepatic cholestasis of pregnancy (obstetric cholestasis): pruritus (esp. palms/soles) WITHOUT a rash and raised bile acids, carrying a risk of stillbirth.

Recognise

  • Intense PRURITUS, classically palms and soles, WITHOUT a primary rash, often worse at night
  • Raised serum bile acids ± raised transaminases
  • May have mild jaundice; resolves after delivery

Red flags

  • Very high bile acids (stillbirth risk); features of pre-eclampsia/HELLP or acute fatty liver of pregnancy (a different emergency)

Differentials & how to tell them apart

Acute fatty liver of pregnancythird trimester, nausea/vomiting, hypoglycaemia, coagulopathy — an emergency
HELLP / pre-eclampsiahypertension, low platelets, haemolysis
Viral hepatitis / gallstonesserology, USS
Pruritic eruptions of pregnancya primary RASH is present

Investigations

Serum BILE ACIDS + LFTs; exclude other causes (viral hepatitis serology, USS liver/biliary). Monitor fetal wellbeing.

Management

Ursodeoxycholic acid + bile-acid monitoring + planned delivery timing

  1. 1Obstetric cholestasis: check bile acids/LFTs, exclude other causes, ursodeoxycholic acid for itch, monitor bile acids and fetal wellbeing.Gate: Very high bile acids → consider earlier planned delivery (stillbirth risk rises with bile-acid level)
  2. 2Resolves after delivery — recheck LFTs postnatally; high recurrence in future pregnancies; avoid oestrogen contraception if it triggered itch.
Ursodeoxycholic acid — symptom relief (evidence on outcomes debated)
Emollients/antihistamine — itch
Vitamin K — if prolonged/clotting affected

Key points

Itching of palms and soles WITHOUT a rash = obstetric cholestasis until proven otherwise. Distinguish from acute fatty liver of pregnancy (an emergency with hypoglycaemia/coagulopathy).

Monitor & prognosis

Bile acids, LFTs, fetal surveillance; postnatal LFT resolution.

Maternal resolution after delivery; fetal risk drives timing.

Source: RCOG Green-top 43