STUDY QUESTION Does ursodeoxycholic acid reduce itching in intrahepatic cholestasis of pregnancy, and what is the effect of early term delivery on caesarean section rates? SUMMARY ANSWER Ursodeoxycholic acid significantly reduces pruritus, but the size of the benefit may be too small for most doctors to recommend it or for most women to want to take it. Individual women are likely to differ in whether they consider the benefit to be worthwhile. Planned early term delivery seems not to increase caesarean section rates. WHAT IS KNOWN AND WHAT THIS PAPER ADDS Intrahepatic cholestasis of pregnancy is associated with preterm birth and fetal asphyxial events. Ursodeoxycholic acid and early delivery are widely used interventions of unproved efficacy. This study, the largest of ursodeoxycholic acid in intrahepatic cholestasis of pregnancy, shows that the drug significantly reduces itching but that the size of the benefit is small.