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Pregnancy Skin and nail Women's health

Itch in pregnancy

Last revised in April 2025

Itch in pregnancy may be caused by a pre-existing condition, or a condition specific to pregnancy.

Itch in pregnancy: Summary

  • Itch in pregnancy may be caused by a pre-existing condition or a condition specific to pregnancy. The most common pregnancy-related causes of itch are:
    • Obstetric cholestasis (also known as 'intrahepatic cholestasis of pregnancy'), which does not present with a rash.
    • Polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis, all of which present with a rash.
  • Itch occurs in about one in five pregnant women.
  • Obstetric cholestasis is the main cause of itch without a rash in pregnancy.
    • The itch (often severe) usually starts abruptly in the third trimester; is often more noticeable on the soles and palms, but can occur anywhere on the body; and may be worse at night.
    • Obstetric cholestasis generally poses no risk to the pregnant woman. Although it is associated with an increased risk of stillbirth, for most women, this appears to be only slightly raised above background rates with specialist management. Symptoms in the woman usually resolve spontaneously after delivery.
    • Any woman with suspected obstetric cholestasis should be referred to obstetrics for same-day investigation.
  • Polymorphic eruption of pregnancy usually occurs in the third trimester. It usually only affects the first pregnancy, and is more likely in women with a multiple pregnancy.
    • The rash is intensely itchy, and consists of pruritic urticarial papules that coalesce into plaques. Typically, it starts on the abdomen, but the umbilicus is usually spared. It may later develop into widespread non-urticated erythema, with eczematous lesions and vesicles.
    • It poses no serious risk to the woman or baby; symptoms last 4–6 weeks on average, and usually resolve immediately following delivery.
    • Symptomatic treatment includes emollients, moderately potent topical corticosteroids, and sedating antihistamines.
  • Atopic eruption of pregnancy commonly presents in the first trimester. It is more likely in women with a personal or family history of atopic eczema.
    • The rash is itchy and consists of eczematous, papular lesions.
    • Although it poses no serious risk to the woman, the child may be at increased risk of developing atopic eczema.
    • Symptomatic treatment includes emollients, moderately potent topical corticosteroids, and sedating antihistamines.
  • Pemphigoid gestationis is very rare.
    • An intense itch often precedes the rash, which initially presents with erythematous urticarial papules and plaques on the abdomen (and nearly always the umbilicus), but may spread to cover the entire body and progress to form tense blisters.
    • The woman is likely to have exacerbations and remissions throughout pregnancy. It is associated with preterm birth and of the infant being small for gestational age. Pemphigoid gestationis spontaneously regresses after delivery. There is an approximately 10% chance of mild and transient skin lesions in the neonate.
    • Referral should be made to obstetrics for additional antenatal surveillance, and dermatology for treatment with topical or systemic corticosteroids.

Have I got the right topic?

From age 13 years onwards (Female).

This CKS topic covers the management of widespread itch, with or without rash, that is specific to pregnancy.

This CKS topic does not cover the management of rash without itch in pregnancy.

There are separate CKS topics on Candida - female genital,  Chickenpox, Chilblains, Dermatitis - contact, Eczema - atopic, Fungal skin infection - body and groin, Fungal skin infection - foot, Fungal skin infection - scalp, Head lice, Insect bites and stings, Itch - widespread, Measles, Pruritus ani, Pruritus vulvae, Pubic lice, Rubella, Scabies, and Scarlet fever.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

April 2025 — reviewed. A literature search was conducted in March 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

Previous changes

November 2023 — minor update. Information in the secondary care management section was revised. We have removed the timeline for elective caesarean sections in women with intrahepatic cholestasis, as recent evidence suggests a reduction in gestational age from 37 weeks downwards to 35, in some cases, to reduce foetal mortality. 

December 2022 — minor update.  Added information relating to phenothiazine derivatives potentiating QT interval prolongation based on an updated manufacturer’s SPC. 

April 2020 — reviewed. A literature search was conducted in April 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

June to July 2015 — reviewed. A literature search was conducted in June 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. No major changes to the recommendations have been made.

October 2010 — minor update. Generic chlorphenamine is no longer licensed for the treatment of pruritus. Text and prescriptions amended to reflect this. Issued in October 2010.

March to June 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2025.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 March 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2025.

New policies

No new national policies or guidelines since 1 March 2025.

New safety alerts

No new safety alerts since 1 March 2025.

Changes in product availability

No changes in product availability since 1 March 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of the cause of itch in pregnancy.
  • Manage itch in pregnancy in primary care where appropriate.
  • Appropriately refer potentially serious causes of itch and cases where itch is not adequately controlled in primary care.
  • Provide appropriate self-care advice on managing itch.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Itch (also known as pruritus) is described as an unpleasant sensation that triggers a desire to scratch [BMJ Best Practice, 2023].

What causes it?

[RCOG, 2022; PCDS, 2022; Stefaniak, 2022; PCDS, 2024] 

Obstetric cholestasis

  • Obstetric cholestasis (also known as intrahepatic cholestasis of pregnancy/ICP) is the most common cause of itch that presents without a rash in pregnancy.
  • The cause of impaired bile flow in obstetric cholestasis is currently unclear but is thought to involve a combination of hormonal, genetic, and environmental factors.
  • The cause of the itch is also not fully understood, but potential contributory factors include the deposition of bile salts in the skin, and elevated levels of lysophosphatidic acid (LPA) and a sulphated metabolite of progesterone called PM3S, all of which are pruritogens.
  • It is important to manage obstetric cholestasis effectively, as in some cases it can cause serious fetal complications.

 [RCOG, 2022; BMJ Best Practice, 2025]

Polymorphic eruption of pregnancy

  • Polymorphic eruption of pregnancy is also known as pruritic urticarial papules and plaques of pregnancy (PUPPP). It is most common in the third trimester, although it has been reported in early pregnancy and the postpartum period.
  • Skin changes associated with polymorphic eruption of pregnancy are varied, with erythematous, urticarial plaques and papules being typical. The rash is usually accompanied by an intense itch.
  • The cause of polymorphic eruption of pregnancy is not fully understood. Theories include an abnormal dermatological response to abdominal distension, an inflammatory or atopic response to an unknown antigen, a response to hormonal changes, and a graft-versus-host disease-like reaction against fetal lymphocytes in maternal tissues.
  • Polymorphic eruption of pregnancy may be associated with multiple gestation pregnancy and male infant sex. 

 [Taylor, 2016; PCDS, 2022; Chouk, 2023]

Atopic eruption of pregnancy

  • Atopic eruption of pregnancy is an umbrella term that encompasses atopic dermatitis presenting (or worsening) for the first time during pregnancy, as well as the poorly characterised entities prurigo of pregnancy and pruritic folliculitis of pregnancy.
  • It presents as an eruption of eczematous, papular lesions, and tends to affect women with a personal or family history of eczema or atopy (including childhood eczema). Atopic eruption of pregnancy spontaneously resolves after delivery, although it may recur during subsequent pregnancies.
  • Atopic eruption of pregnancy is thought to be triggered by pregnancy-specific immunologic changes.

  [Stefaniak, 2022; Adhikari, 2023; Kurien, 2024]

Pemphigoid gestationis

  • Pemphigoid gestationis is a rare autoimmune disorder that causes a bullous rash with intense itch, usually in the third trimester. It often flares up at delivery, with subsequent spontaneous regression over the following weeks to months.
  • Pemphigoid gestationis is associated with an increased risk of preterm delivery and low infant birth weight. Up to 10% of neonates born to women with pemphigoid gestationis have a mild, transient skin rash due to transplacental transfer of maternal autoantibodies.

[Parfene, 2021; Adhikari, 2023; Kurien, 2024; PCDS, 2024]

How common is it?

  • Itch is the most common dermatological symptom described in pregnancy. Its incidence (any cause) is recorded as 18–40% [Stefaniak, 2022].
  • Pregnancy-specific dermatoses vary in incidence:
    • UK studies typically report rates of obstetric cholestasis around 0.7%, with higher rates in women of Indian-Asian and Pakistani-Asian ethnicity [BMJ Best Practice, 2025]. Worldwide, the highest rates of disease are seen in China (6.1%) [Odabaş, 2024].
    • The reported incidence of polymorphic eruption of pregnancy in the literature is 0.5% in single pregnancies, 2.9–16% in twin pregnancies and 14–17 % in triplet pregnancies [Chouk, 2023].
    • Atopic eruption of pregnancy is the most frequent dermatosis seen in pregnancy and is diagnosed in 43–49% of women with a pruritic rash during pregnancy [Adhikari, 2023].
    • Pemphigoid gestationis is rare and affects about 1 in 50,000 to 1 in 60,000 pregnancies [Kurien, 2024].

What are the complications?

  • The dermatoses specific to pregnancy that are associated with a rash (polymorphic eruption, atopic eruption, and pemphigoid gestationis) are rarely associated with serious complications for the woman or the infant.
  • Obstetric cholestasis is associated with an increased risk of:
    • Stillbirth [Ovadia, 2019; RCOG, 2022].
      • Overall, this is thought to be only slightly raised above background rates with specialist management.
      • However, a large meta-analysis found that women with serum bile acid concentrations of at least 100 micromol/L exhibited a statistically significant 30-fold increased risk of stillbirth compared with those with serum bile acid concentrations of less than 40 micromol/L.
      • Women with serum bile acid concentrations of 40–99 micromol/L exhibited a statistically nonsignificant 2.4-fold increased risk of stillbirth compared with those with serum bile acid concentrations of less than 40 micromol/L.
      • The authors stated that the majority of women with obstetric cholestasis have serum bile acid concentrations of less than 100 micromol/L and can probably be reassured that the risk of stillbirth is similar to that of pregnant women in the general population, provided repeat bile acid testing is carried out until delivery.
    • Premature delivery — mainly iatrogenic.
    • Fetal distress.
    • Meconium aspiration.
    • Vitamin K deficiency, which may increase the risk of haemorrhage in both the woman and the neonate.
  • Itch (of any cause) can lead to [BMJ Best Practice, 2023]:
    • Sleep deprivation and reduced quality of life.
    • Bacterial infection of excoriations caused by scratching.
    • For women and pregnant people with gestational pruritus or ICP, there is poor correlation between severity of itch and level of bile acids [Fleminger, 2022].

What is the prognosis?

The prognosis of itch in pregnancy depends on the cause, but is generally excellent.

  • Obstetric cholestasis — itch and elevated liver enzymes usually resolve in the first few days or weeks postpartum. However, the recurrence rate in future pregnancies is 45–90% [RCOG, 2022].
  • Polymorphic eruption of pregnancy — usually regresses within a week postpartum, but may also resolve at any time before delivery or rarely, up to 6 weeks postpartum. It rarely recurs in subsequent pregnancies [Chouk, 2023].
  • Atopic eruption of pregnancy — responds well to treatment and resolves following delivery, but may recur during subsequent pregnancies [Stefaniak, 2022].
  • Pemphigoid gestationis — usually resolves within weeks to months following delivery, but it may recur in 50–70% of subsequent pregnancies, at an earlier gestational age and with increasing severity [Kurien, 2024].

Diagnosis of the cause of itch in pregnancy

When should I suspect obstetric cholestasis?

  • The main cause of itch without an associated rash in pregnancy is obstetric cholestasis. Make a working diagnosis of obstetric cholestasis if a woman reports itch that typically:
    • Starts from 28 weeks of gestation onwards (although in rare cases may start earlier).
    • Starts and/or is most noticeable on the soles and palms, but can occur anywhere. 
    • Is worse at night, when it may cause insomnia.
    • Causes severe scratching. On examination, there may be excoriation marks (which are at risk of bacterial infection).
  • Other clinical features of obstetric cholestasis may include:
    • Jaundice (present in about 10% of women).
    • Anorexia, malaise, and abdominal pain.
    • Dark urine, pale stools, and steatorrhoea (fatty stool).
  • Diagnosis of obstetric cholestasis is confirmed by elevated serum bile acids and, in some cases, abnormal liver function tests (LFTs). However, be aware that in some women, itch precedes abnormal serum bile acid and/or LFTs by several weeks.
    • Same-day referral to a local maternity unit may be required for these blood tests.
    • Pregnancy-specific reference ranges (20% lower than non-pregnant ranges) should be used when reviewing LFT results. Increases in serum transaminases, gamma-glutamyltransferase, or bile acids are consistent with obstetric cholestasis, although normal levels of bile acids do not exclude it.
    • If the clinical features do not correspond to those of obstetric cholestasis, consider a different cause of the itch.

Basis for recommendation

The clinical features of obstetric cholestasis are based on expert opinion within the Royal College of Obstetricians and Gynaecologists guideline Obstetric cholestasis [RCOG, 2022], from the charity ICP support [ICP Support, 2024], the UK Teratology Information Service [UKTIS, 2024a], the British Liver Trust [British Liver Trust, 2024] and in narrative review articles [Pillarisetty, 2023; Odabaş, 2024; BMJ Best Practice, 2025].

Blood tests

How should I determine the cause of itch with associated rash in pregnancy?

  • The underlying cause of itch can usually be diagnosed according to the timing of the onset of symptoms and the appearance of the rash.
  • Polymorphic eruption of pregnancy usually occurs in the third trimester. It usually only affects the first pregnancy, and is more likely in women with excessive maternal weight gain or with a multiple pregnancy.
    • The rash:
      • Consists of pruritic urticarial papules that coalesce into plaques. Typically, the rash starts on the abdomen, often first appearing on the striae, but the umbilicus region is usually spared.
      • May remain localized, may spread to the buttocks and proximal thighs, or may become widespread and generalized.
      • May later develop into widespread non-urticated erythema, with eczematous lesions and vesicles (but never bullae).
  • Atopic eruption of pregnancy commonly presents in the first trimester. It is more likely in women with a history of atopic eczema.
    • The rash may consist of:
      • Eczematous lesions, affecting typical atopic sites such as the face, neck, upper chest, and flexor aspects of the limbs.
      • Small erythematous papules disseminated on the trunk and limbs, and larger 'prurigo nodules' (firm itchy bumps) found mainly on the shins and extensor surfaces of the arms.
  • Pemphigoid gestationis is very rare. It typically presents during the second or third trimester.
    • An intense itch often precedes the rash that:
      • Initially presents with erythematous urticarial papules and plaques on the abdomen (and nearly always the umbilicus region), but may spread to cover the entire body.
      • Progresses to form tense blisters similar to those seen in bullous pemphigoid.
  • Obstetric cholestasis does not itself cause a rash. However, it should be considered because scratching may cause skin irritation and excoriation that may resemble a rash.
  • If the rash is not typically pregnancy-related, consider an alternative cause, not specific to pregnancy. For more information, see the CKS topic on Itch - widespread.

Basis for recommendation

The clinical features of polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis are based on expert opinion in narrative review articles [PCDS, 2022; Stefaniak, 2022; Adhikari, 2023; Chouk, 2023; Kurien, 2024; PCDS, 2024].

  • It is important to exclude secondary rash caused by obstetric cholestasis as this is a potentially serious condition [RCOG, 2022].

What is the differential diagnosis of itch in pregnancy?

  • Alternative causes that do not typically cause rash include:
    • Drugs — for example, opioids.
    • Endocrine disorders — for example, thyroid disorders (thyrotoxicosis causes itch more commonly than hypothyroidism). For more information, see the CKS topic on Hyperthyroidism.
    • Haematological causes — for example, iron deficiency (unusual cause), polycythaemia vera, or haemochromatosis (rarely causes itch). For more information, see the CKS topic on Anaemia - iron deficiency.
    • Liver disease — itch is usually secondary to cholestasis, for example, due to the formation of gallstones. For more information, see the CKS topic on Gallstones.
    • Malignancy — for example, Hodgkin's lymphoma, cutaneous T-cell lymphoma, leukaemia, and multiple myeloma. For further information, see the CKS topics on Haematological cancers - recognition and referral and Multiple myeloma.
    • Neurological disorders — for example, multiple sclerosis. For further information, see the CKS topic on Multiple sclerosis.
    • Psychological causes — for example, psychogenic pruritus.
    • Renal disease — around half of the people with chronic kidney disease experience itch. For more information, see the CKS topic on Chronic kidney disease.
  • For more information on managing generalized itch, see the CKS topic on Itch - widespread.
  • Other skin conditions that can cause widespread itch and rash include:
    • Chickenpox — for more information, see the CKS topic on Chickenpox.
    • Atopic eczema and contact dermatitis — for more information, see the CKS topics on Eczema - atopic and Dermatitis - contact.
    • Insect bites — for more information, see the CKS topic on Insect bites and stings.
    • Pityriasis rosea — for more information, see the CKS topic on Pityriasis rosea. 
    • Rubella — may occasionally present with a mildly pruritic rash. This should be excluded, particularly if the woman presents in the first trimester. For more information, see the CKS topic on Rubella.
    • Scabies — for more information, see the CKS topic on Scabies.
    • Urticaria — for more information, see the CKS topic on Urticaria.

Basis for recommendation

The information on other causes of generalized itch is derived from expert review articles [Rupert, 2022; Stefaniak, 2022; BMJ Best Practice, 2023].

Management

Scenario: Management of itch in pregnancy without rash

From age 13 years onwards (Female).

How should I manage a woman with obstetric cholestasis?

  • Arrange same-day referral to a local maternity unit for any woman with clinical features suggesting obstetric cholestasis, so that maternal serum bile acid concentrations and liver function, as well as fetal wellbeing can be assessed, and other causes of hepatic impairment can be ruled out. For further information, see the section on investigations and treatment in secondary care.
    • Women with confirmed obstetric cholestasis will be offered ongoing monitoring of serum bile acid levels/liver function tests (LFTs) and fetal wellbeing, usually via the maternity unit, until delivery.
    • If a woman has unexplained itch but bile acids and/or LFTs are normal, levels should be monitored weekly (usually by the obstetrics team) until the itch resolves. Seek specialist advice if the itch significantly worsens.
  • Prescribe symptomatic relief if required.
    • Offer an emollient to be used liberally and regularly. Menthol 0.5% or 1% in aqueous cream may also be helpful if an inert emollient does not improve itch. See the section on Emollients in the CKS topic on Eczema - atopic for further information.
    • Consider offering a sedating antihistamine such as chlorphenamine or promethazine at night (off-label indication).
  • Offer self-care advice about relieving the itch. For example:
    • Sitting directly in front of a fan, soaking in a cool bath, and applying ice packs for short periods to affected areas.
    • Applying naturally cooling substances, such as aloe to affected areas before rinsing off in a shower.
    • Wearing cool, loose, cotton clothing.
  • Offer information and advice about obstetric cholestasis. Patient information is available from the charity ICP Support, the NHS, the British Liver Trust,  and the UK Teratology Information Service.
  • Following delivery, ensure that LFTs are carried out from 2 weeks postnatally (usually by the obstetrics team). If liver function:
    • Has returned to normal, obstetric cholestasis can be confirmed as having resolved. Advise the woman that the condition has a 45–90% recurrence rate in future pregnancies.
    • Is still abnormal, repeat the tests.
      • If, after 8 weeks, the results are still abnormal, seek specialist advice from the obstetric team.

Investigations and treatment in secondary care

  • Investigations that may be carried out in secondary care include:
    • Serum bile acids and liver function tests (LFTs).
    • Viral screening for hepatitis A, B, and C; Epstein-Barr virus; and cytomegalovirus.
    • Liver autoimmune screening for chronic active hepatitis and primary biliary cirrhosis (for example anti-smooth muscle and anti-mitochondrial antibodies).
    • Urine dipstick for proteinuria.
    • Blood pressure measurement.
    • Liver ultrasound.
    • Cardiotocography to assess fetal wellbeing.
  • Drug treatments that may be initiated in secondary care include:
    • Ursodeoxycholic acid (sometimes with rifampicin as adjunct therapy).
    • Sedating antihistamines such as chlorphenamine or promethazine.
    • Vitamin K supplements.
  • Elective early delivery may be considered.

 [Ovadia, 2019; RCOG, 2022; BMJ Best Practice, 2025]

Basis for recommendation

The recommendations on how to manage women with obstetric cholestasis are based on expert opinion in the Royal College of Obstetricians and Gynaecologists guideline Obstetric cholestasis, [RCOG, 2022], in narrative review articles [Ovadia, 2019; BMJ Best Practice, 2025], and from expert guidelines produced by the British Liver Trust [British Liver Trust, 2024] and the charity ICP Support [ICP Support, 2024].

Investigations and treatment in secondary care

The information on investigations and treatment in secondary care is largely based on the Royal College of Obstetricians and Gynaecologists guideline Obstetric cholestasis [RCOG, 2022] which states that:

  • Liver function tests (LFTs) are required to formally diagnose obstetric cholestasis. Otherwise, unexplained abnormalities in transaminases, gamma-glutamyl transferase, and/or bile acids are considered sufficient to support the diagnosis.
  • Further tests may be required to exclude differential diagnoses that can cause abnormal LFT results, including pre-eclampsia and fatty liver of pregnancy, and illnesses not specific to pregnancy including hepatitis A, B, and C, Epstein-Barr and cytomegalovirus, and primary biliary cirrhosis.
  • Although cardiotocography is likely to be carried out in an initial assessment of fetal wellbeing, it does not predict future fetal wellbeing.
  • Ursodeoxycholic acid may be prescribed in secondary care as a treatment for obstetric cholestasis. The UK Teratology Information Service (UKTIS) states that there are no apparent adverse fetal or neonatal effects associated with its use in late pregnancy [UKTIS, 2024b; UKTIS, 2024a].
    • The large multicentre randomised controlled PITCHES trial found that use of ursodeoxycholic acid to treat obstetric cholestasis (n=305 exposed versus n=300 placebo) did not improve maternal bile acid concentrations, itch, or perinatal outcomes [Chappell, 2019]. Based on these data, specialist guidance from the RCOG, the British Liver Trust [British Liver Trust, 2024] and the charity ICP Support states that use of ursodeoxycholic acid should be considered carefully [RCOG, 2022; ICP Support, 2024].  Local prescribing protocols within obstetric practice may, therefore, have changed to accommodate this updated information.
  • Sedating antihistamines may offer relief from itch at night via their sedative effects. The UKTIS states that the sedating antihistamines for which there is the most pregnancy safety data are chlorphenamine and promethazine [UKTIS, 2019a; UKTIS, 2019b; UKTIS, 2024b]. 
  • Vitamin K supplementation reduces the risk of vitamin K deficiency (and associated maternal and fetal/neonatal haemorrhage) caused by reduced enterohepatic recirculation of bile acids and resultant malabsorption of fats and fat-soluble vitamins. It should only be considered when there is evidence of steatorrhoea [RCOG, 2022].
  • Elective early delivery may be considered on a case-by-case basis to reduce the risk of fetal mortality [Ovadia, 2019]. 
Follow up
  • Recommendations on follow up are largely based on the Royal College of Obstetricians and Gynaecologists guideline Obstetric cholestasis [RCOG, 2022]. It is normal for LFT results to increase for the first 10 days postnatally (a physiological response), so avoid testing during this time period.
  • Abnormal LFT results usually peak at about 8 weeks following an episode of obstetric cholestasis (although rarely they may be abnormal for longer). Therefore, an alternative or additional diagnosis to obstetric cholestasis should be considered if abnormal liver function persists at this stage [BMJ Best Practice, 2025].

Scenario: Management of itch with rash in pregnancy

From age 13 years onwards (Female).

How should I manage suspected polymorphic eruption of pregnancy?

  • Reassure the woman that although polymorphic eruption of pregnancy is unpleasant, it poses no serious risk to her or her baby.
    • Advise the woman that symptoms typically last 4–6 weeks and usually resolve immediately following delivery (if they are still present at this time).
  • Provide self-care advice to relieve itching.
  • Offer information and advice about polymorphic eruption of pregnancy. A patient information leaflet is available from the British Association of Dermatologists.
  • Prescribe symptomatic treatment where necessary.
    • Emollients can be used liberally to soothe the skin. See the section on Emollients in the CKS topic on Eczema - atopic for further information.
    • Moderately potent topical corticosteroids can be used to reduce inflammation. See the section on Topical corticosteroids in the CKS topic on Eczema - atopic for further information.
    • Offer a sedating antihistamine (such as chlorphenamine or promethazine) if itch is causing sleeping difficulties (off-label indication).
  • If the rash does not respond to treatment with topical corticosteroids, or is severe and generalized, refer to a dermatologist. A short course of oral corticosteroids may be indicated.

Basis for recommendation

The recommendations on how to manage women with polymorphic eruption of pregnancy are based on expert opinion in narrative reviews [PCDS, 2022; Stefaniak, 2022; Adhikari, 2023; Chouk, 2023; Kurien, 2024].

Natural history
  • The information about the natural history of polymorphic eruption of pregnancy is derived from expert opinion in narrative review articles [PCDS, 2022; Chouk, 2023].
Symptomatic treatment
  • The recommendations on the use of emollients, topical corticosteroids, and oral antihistamines in the management of polymorphic eruption of pregnancy are based on expert opinion in narrative reviews [PCDS, 2022; Stefaniak, 2022; Adhikari, 2023; Chouk, 2023; Kurien, 2024].
    • Sedating antihistamines may be beneficial owing to their sedative effects rather than specific antihistamine properties [Summey, 2005].
    • The UK Teratology Information Service (UKTIS) states that the sedating antihistamines for which there are most pregnancy safety data are chlorphenamine and promethazine [UKTIS, 2019a; UKTIS, 2019b; UKTIS, 2024a]. 
  • The recommendation to refer to secondary care, women with severe, generalized polymorphic eruption of pregnancy that has not responded to topical corticosteroids, is pragmatic based on what CKS considers to be good medical practice. Expert opinion in narrative reviews states that treatment with oral corticosteroids may be indicated [Chouk, 2023; Kurien, 2024].

How should I manage suspected atopic eruption of pregnancy?

  • Reassure the woman that atopic eruption of pregnancy responds well to treatment, and there is no serious risk to her or her baby.
    • However, advise that recurrence in future pregnancies is common, and that because atopy can be inherited, the infant may be at increased risk of future atopy.
  • Provide self-care advice to relieve itching.
  • Prescribe symptomatic treatment where necessary.
    • Emollients can be used liberally to soothe the skin. See the section on Emollients in the CKS topic on Eczema - atopic for further information.
    • Moderately potent topical corticosteroids can be used to reduce inflammation. See the section on Topical corticosteroids in the CKS topic on Eczema - atopic for further information.
    • Offer a sedating antihistamine (such as chlorphenamine or promethazine) if itch is causing sleeping difficulties (off-label indication).
  • If the rash is particularly severe or unresponsive to treatment in primary care, refer the woman to a dermatologist. A short course of oral corticosteroids or phototherapy may be indicated.

Basis for recommendation

The recommendations on how to manage women with atopic eruption of pregnancy are based on expert opinion in narrative reviews  [Stefaniak, 2022; Adhikari, 2023; Kurien, 2024].

Natural history
Symptomatic treatment
  • The recommendations on the use of emollients, topical corticosteroids, and oral antihistamines in the management of atopic eruption of pregnancy are based on expert opinion in narrative reviews [Stefaniak, 2022; Adhikari, 2023; Kurien, 2024].
  • The UK Teratology Information Service (UKTIS) states that the sedating antihistamines for which there are most pregnancy safety data are chlorphenamine and promethazine [UKTIS, 2019a; UKTIS, 2019b]. 
Referral to a dermatologist
  • The recommendation to refer women with severe, refractory atopic eruption of pregnancy to secondary care is pragmatic based on what CKS considers to be good medical practice. Expert opinion in narrative reviews states that treatment with oral corticosteroids and phototherapy may be required [Stefaniak, 2022; Adhikari, 2023; Kurien, 2024].

How should I manage suspected pemphigoid gestationis?

  • Reassure the woman that the prognosis is good with treatment, but that the condition is likely to have exacerbations and remissions throughout the pregnancy (and will probably flare up at childbirth). There is also about a 10% chance of mild and transient skin lesions in the newborn baby.
  • Offer information and advice about pemphigoid gestationis. A patient information leaflet is available from the British Association of Dermatologists.
  • Refer the woman urgently to dermatology and also refer to obstetrics:
    • Treatment with topical corticosteroids and antihistamines will be required in mild cases.
    • Moderate and severe cases are treated by specialists with systemic corticosteroids. 
    • Additional antenatal surveillance may be advised owing to an increased risk of preterm birth and reduced fetal growth.

Basis for recommendation

The recommendations on how to manage women with pemphigoid are based on expert opinion in narrative reviews [Stefaniak, 2022; Adhikari, 2023; Kurien, 2024; PCDS, 2024].

Natural history
Referral to obstetrics and dermatology
  • The recommendation to urgently refer women with pemphigoid gestationis to a dermatologist is based on expert opinion in a review article [PCDS, 2024] and the recommendation to refer to obstetrics is pragmatic, based on what CKS considers to be good clinical practice:
    • This is a rare condition and so experience in primary care is likely to be limited.
    • Owing to the associated increased risk of preterm birth and low birth weight, additional fetal and maternal monitoring may be required [PCDS, 2024].
    • Dermatology referral allows for confirmation of the diagnosis, which may only become clear when the bullous stage becomes apparent [Paunescu, 2008], and administration of systemic corticosteroids where necessary [Kurien, 2024; PCDS, 2024].

What self-care advice should I offer?

  • Advise the woman about self-care measures to reduce itch.
  • When bathing, she should:
    • Reduce the amount of time spent in the bath to less than 20 minutes.
    • Bathe less frequently, if possible, as washing dries the skin. The axillae, genital area, and under the breasts can be washed daily, but other skin areas can be washed 2–3 times weekly.
    • Use cool or lukewarm water (hot water can be drying).
    • Avoid bubble bath, soap, and perfumed products. Mild, alcohol-free cleansers should be used, or an emollient used as a soap substitute.
    • Avoid vigorously drying the skin, and pat it dry instead.
  • A cool shower may offer immediate short-term relief from itch, but excessive showering should be avoided as this may dry the skin.
  • Nails should be kept short to minimize any skin damage from scratching. Rubbing rather than scratching is advised if the urge to relieve the itch cannot be ignored.
  • The indoor environment should be kept cool (particularly the bedroom); humidifying the air may help, particularly during cold winter months.
  • Clothing that does not irritate the skin (for example cotton or silk) should be worn, avoiding wool or synthetic fabrics.
  • Spicy foods, alcohol, and caffeine should be avoided as they may cause vasodilation, which can worsen itch.

Basis for recommendation

Recommendations for self-care are based on expert opinion in a narrative reviews [Rupert, 2022; Stefaniak, 2022; Adhikari, 2023].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Emollients

  • For information on how to prescribe and use emollients, see the section on Emollients in the CKS topic on Eczema - atopic.

Corticosteroids

Chlorphenamine

Dosing information

  • Prescribe chlorphenamine 4 mg; to be taken at bedtime (note: as chlorphenamine is being used for its sedative effect, CKS advises the use of a single dose at night).
    • People should be advised not to drive or operate heavy machinery if sedation is an ongoing adverse effect.

[EMC, 2023; BNF, 2025]

Contraindications and cautions

Chlorphenamine is not contraindicated in pregnancy (but is not specifically licensed for use in pregnancy). Use around the time of delivery may cause irritability, paradoxical excitability, and tremor in the neonate.

  • Chlorphenamine should be used with caution in people with:
    • Hepatic impairment — avoid sedating antihistamines in severe liver disease (obstetric cholestasis does not qualify as severe liver disease).
    • Renal impairment.
    • Severe hypertension or cardiovascular disease.
    • Raised intraocular pressure or glaucoma.
    • Pyloroduodenal obstruction.
    • Epilepsy — avoid antihistamines if possible, as they reduce the seizure threshold.
    • Asthma, bronchitis, or bronchiectasis.

[EMC, 2023; BNF, 2025]

Adverse effects

Adverse effects of chlorphenamine include:

  • Neurological — dizziness, restlessness, tinnitus, psychomotor impairment, headaches, sedation that can persist for up to 12 hours (affected people should not drive or operate heavy machinery), and muscle twitching.
  • Anticholinergic effects — blurred vision, dry mouth, and urinary retention.
  • Skin — urticaria, rash, exfoliative dermatitis, and photosensitivity.
  • Gastrointestinal — nausea, vomiting, abdominal pain, diarrhoea, dyspepsia, anorexia, and hepatitis.
  • Cardiovascular — palpitations, tachycardia, arrhythmias, and hypotension.
  • Neuropsychiatric — depressed mood, excitation, irritability, nightmares, and confusion.

[EMC, 2023; BNF, 2025]

Drug interactions

  • Use of chlorphenamine is contraindicated where treatment with a monoamine oxidase inhibitor (MAOI) has occurred within the last 14 days — the anticholinergic properties of chlorphenamine are intensified by MAOIs.
  • Combinations requiring caution include:
    • Hypnotics and anxiolytics — may cause an increase in sedative effects.
    • Phenytoin — Chlorphenamine inhibits phenytoin metabolism and can lead to phenytoin toxicity.
      • If symptoms of toxicity are present (confusion, blurred vision, nystagmus, ataxia, or drowsiness), monitor serum phenytoin levels and reduce the dose if necessary.

[EMC, 2023; BNF, 2025; Preston, 2025]

Promethazine

Dosing information

  • Prescribe promethazine 25 mg; to be taken at bedtime (note: as promethazine is being used for its sedative effect, CKS advises the use of a single dose at night).
    • People should be advised not to drive or operate heavy machinery if sedation is an ongoing adverse effect.

[EMC, 2024; BNF, 2025]

Contraindications and cautions

Promethazine is not contraindicated in pregnancy (but is not specifically licensed for use in pregnancy). Use around the time of delivery may cause irritability, paradoxical excitability, and tremor in the neonate.

  • Promethazine should not be used in people with central nervous system (CNS) depression of any cause.
  • Promethazine should be used with caution in people with:
    • Hepatic impairment — avoid sedating antihistamines in severe liver disease (obstetric cholestasis does not qualify as severe liver disease).
    • Renal impairment.
    • Severe coronary artery disease.
    • Urinary retention, narrow-angle glaucoma, or pyloroduodenal obstruction.
    • Epilepsy — avoid antihistamines if possible, as they reduce the seizure threshold.
    • Asthma, bronchitis, or bronchiectasis — promethazine may thicken or dry lung secretions and impair expectoration.
    • In addition, the manufacturer advises that phenothiazine derivatives may potentiate QT interval prolongation, which increases the risk of ventricular arrhythmias, including Torsade de pointes. QT prolongation is exacerbated, in particular, in the presence of bradycardia, hypokalaemia, and drug-induced QT prolongation. The manufacturer suggests that if the clinical situation permits, medical and laboratory evaluations should be performed to rule out possible risk factors before initiating treatment with a phenothiazine derivative and when necessary during treatment.

[EMC, 2024; BNF, 2025]

Adverse effects

Adverse effects of promethazine include:

  • Neurological — dizziness; restlessness; headaches; nightmares; sedation that can persist for up to 12 hours (affected people should not drive or operate heavy machinery); muscle spasms and tic-like movements of the head and face; and extrapyramidal effects.
  • Anticholinergic effects — blurred vision, dry mouth, and urinary retention.
  • Skin — urticaria, rash, pruritus, and photosensitivity.
  • Gastrointestinal — anorexia and gastric irritation.
  • Cardiovascular — palpitations, hypotension, and arrhythmias.

[EMC, 2024; BNF, 2025]

Drug interactions

  • Use of promethazine is contraindicated where treatment with a monoamine oxidase inhibitor (MAOI) has occurred within the last 14 days — the anticholinergic properties of promethazine are intensified by MAOIs.
  • Combinations requiring caution include anticholinergic drugs, tricyclic antidepressants, sedatives, and hypnotics — promethazine enhances the action of these drugs.

[EMC, 2024; BNF, 2025; Preston, 2025]

Supporting evidence

This CKS topic is based on the Royal College of Obstetricians and Gynaecologists guideline Obstetric cholestasis [RCOG, 2022], guidance from the British Liver Trust [British Liver Trust, 2024], the Primary Care Dermatology Society (PCDS) [PCDS, 2022; PCDS, 2024], the charity ICP Support [ICP Support, 2024], and on expert opinion in narrative review articles [Stefaniak, 2022; Adhikari, 2023; Chouk, 2023; Kurien, 2024; BMJ Best Practice, 2025].

A brief summary of the evidence is given in the relevant Basis for recommendation sections. The evidence for specialist management strategies is not discussed as they are beyond the scope of this CKS topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on the primary care management of itch in pregnancy.

Search dates

April 2020 - March 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 20th April 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S19    S8 OR S15 OR S16 OR S18 
S18    S7 AND S17 
S17    S9 OR S10 OR S11 OR S12 OR S13 OR S14 
S16    AB ( pemphigoid gestationis or herpes gestationis ) OR TI ( pemphigoid gestationis or herpes gestationis ) 
S15    (MH "Pemphigoid Gestationis") 
S14    AB atopic eruption OR TI atopic eruption 
S13    AB ( toxic erythema or toxemic rash* or toxaemic rash* ) OR TI ( toxic erythema or toxemic rash* or toxaemic rash* ) 
S12    AB PUPPP OR TI PUPPP 
S11    AB polymorphic eruption OR TI polymorphic eruption 
S10    AB cholestasis OR TI cholestasis 
S9    (MH "Cholestasis+") 
S8    S3 AND S7 
S7    S4 OR S5 OR S6 
S6    AB ( pregnan* or obstetric* or gravid* or trimester or gestation* ) OR TI ( pregnan* or obstetric* or gravid* or trimester or gestation* ) 
S5    (MH "Pregnant Women") 
S4    (MH "Pregnancy+") 
S3    S1 OR S2 
S2    AB ( (prurit* or prurigo or itch*) ) OR TI ( (prurit* or prurigo or itch*) ) 
S1    (MH "Pruritus+") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Adhikari, B., Hall, H. and Carlson, K. (2023) Pruritus in pregnancy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov [Free Full-text]
  • BMJ Best Practice (2023) Assessment of pruritus. BMJ Publishing Group. https://bestpractice.bmj.com/info
  • BMJ Best Practice (2025) Intrahepatic cholestasis of pregnancy. BMJ Publishing Group. https://bestpractice.bmj.com/info
  • BNF (2025) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • British Liver Trust (2024) Intrahepatic cholestasis of pregnancy. British Liver Trust. https://britishlivertrust.org.uk [Free Full-text]
  • Chappell, L.C., Bell, J.L., Smith, A., et al. (2019) Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial. Lancet 394, 849-860. [Abstract] [Free Full-text]
  • Chouk, C. and Litaiem, N. (2023) Pruritic urticarial papules and plaques of pregnancy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov [Free Full-text]
  • EMC (2023) SPC for piriton allergy tablets (chlorphenamine maleate 4 mg). Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024) SPC for phenergan 25 mg tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • Fleminger, J., Seed, P.T., Smith, A., et al. (2022) Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a secondary analysis of the PITCHES trial. British Journal of Obstetrics and Gynaecology 128(6), 1066-1075. [Abstract] [Free Full-text]
  • ICP support (2024) ICP support. ICP support. [Free Full-text]
  • Kurien, G., Carlson, K. and Badri, T. (2024) Dermatoses of Pregnancy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov [Free Full-text]
  • Odabaş, R.K., Sökmen, Y., Dünder, E. and Taşpınar, A. (2024) The incidence of intrahepatic cholestasis of pregnancy and its Mmaternal, fetal, and neonatal adverse outcomes: a systematic review and meta-analysis. Journal of Midwifery and Womens Health 69(3), 370-382. [Abstract] [Free Full-text]
  • Ovadia, C., Seed, P.T., Sklavounos, A., et al. (2019) Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet 393, 899-909. [Abstract] [Free Full-text]
  • Parfene, C.G., Bohiltea, R.E., Mihai, B.M., et al. (2021) Influence of pemphigoid gestationis on pregnancy outcome: A case report and review of the literature. Experimental Therapeutic Medicine 23(1), 23. [Abstract] [Free Full-text]
  • Paunescu, M.M., Feier, V., Paunescu, M., et al. (2008) Dermatoses of pregnancy. Acta Dermatovenerologica Alpina, Pannonica, Et Adriatica 17(1), 4-11. [Abstract]
  • PCDS (2022) Polymorphic eruption of pregnancy (syn. pruritic urticarial papules and plaques of pregnancy). Primary Care Dermatology Society. https://www.pcds.org.uk [Free Full-text]
  • PCDS (2024) Pemphigoid gestationis (pemphigoid of pregnancy). Primary Care Dermatology Society. https://www.pcds.org.uk [Free Full-text]
  • Pillarisetty, L.S. and Sharma, A. (2023) Pregnancy intrahepatic cholestasis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov [Free Full-text]
  • Preston, C.L. (2025) Stockley's Drug Interactions. Medicines Complete. Pharmaceutical press. https://www.medicinescomplete.com
  • RCOG (2022) Intrahepatic cholestasis of pregnancy. Royal College of Obstetricians and Gynaecologists. https://www.rcog.org.uk/guidance [Free Full-text]
  • Rupert, J. and Honeycutt, J.D. (2022) Pruritus: diagnosis and management. American Family Physician 105(1), 55-64. [Abstract] [Free Full-text]
  • Stefaniak, A.A., Pereira, M.P., Zeidler, C. and Ständer, S. (2022) Pruritus in pregnancy. American Journal of Clinical Dermatology 23(2), 231-246. [Abstract] [Free Full-text]
  • Summey Jr, B.T. and Yosipovitch, G. (2005) Pharmacologic advances in the systemic treatment of itch. Dermatologic Therapy 18(4), 328-332. [Abstract]
  • Taylor, D.,  Pappo, E.,  Aronson, I.K. (2016) Polymorphic eruption of pregnancy. Clinics in Dermatology 34(3), 383-391. [Abstract]
  • UKTIS (2019a) Use of chlorphenamine in pregnancy. UK Teratology Information Service. www.medicinesinpregnancy.org [Free Full-text]
  • UKTIS (2019b) Use of Promethazine in Pregnancy. UK Teratology Information Service. http://www.uktis.org [Free Full-text]
  • UKTIS (2024a) Treatment of intrahepatic cholestasis of pregnancy (obstetric cholestasis). UK Health Security Agency. https://uktis.org [Free Full-text]
  • UKTIS (2024b) Use of ursodeoxycholic acid in pregnancy. UK Health Security Agency. https://uktis.org [Free Full-text]
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