37/38/39 weeks for delivery?

[prufrock]

Well I think the OC is back (LFT?s still within normal range but elevated from my baseline, bile acids due on Friday and itching to b*ggery). Good news is I spent Friday evening at the hospital with a wonderful wonderful midwife, who has got me transferred to the nicest consultant in the hospital.
He however doesn?t believe in delivering OC babies at 37 weeks (which is the received wisdom) but instead does scans of the foetal aortic flow and tries to get the pregnancy to last as long as possible. I?m slightly concerned about this ? everything else I know about OC stresses the increased risk of stillbirth due to foetal heart failure after 37 weeks.
So my question, does anybody have any facts on the relative benefits of continuing a pregnancy after 37 weeks. Will my baby be any better off being delivered at 38 or 39 weeks than at 37 (I?m having an elective caesarean whatever ? even pupuce agreed it would probably be the best type of delivery for my circumstances). If the extra 2 weeks inside don?t help, I?m not sure I want to run the slight increased risk of stillbirth.

I have no facts. I do however have a baby born at 37 weeks, ditto a sister, and they are both utterly splendid (my sister was under 5lb but fine, dd2 was a sturdy six-pounder). My gut feeling FWIW is that you are right.

Been having a check - trying to keep me occupied and found these websites - as far as I can see they all say that you should have the baby early - you have probably looked into this so I am sorry if I am wasting your time Sorry to hear that you have started to feel crappy

www.babycentre.co.uk/refcap/552042.html#6

www.britishlivertrust.org.uk/content/diseases/obstetic_cholestasis.asp

www.thenhs.com/cats/library/bwq08005.htm

www.wmpi.net/reviews/oc/oc_management.htm

www.eastquaymedicalcentre.com/pils/obstetric_cholestasis.htm

omni.ac.uk/whatsnew/detail/3009430.html

I am sorry but I have no idea how to do links!!

I don't have the latest medical reseach to hand but my son was born at 371/2 weeks - they wanted him born on the 13th but in a rare moment of superstition I asked for it to be the 17th. He was a staggering 8lb8oz ('It's a little - er, no, a BIG boy!" and very healthy. However, due to the blood loss from my c-section (excessive because I had placenta praevia) and, also, I think because he was a little early, my milk was delayed for a couple of days, which I found distressing. However, happily, when it came in, it really came in and I b/fed for over a year. I always understood that 37weeks+ was considered term so am surprised if drs really think that an extra two weeks is that important if there is any risk to the baby. If I had no medical condition that put me and the baby at risk but needed a c/s again I would prefer to go to 39 weeks esp as I suspect that I would naturally have gone over 40 weeks with ds as I hadn't had so much as a hint of a Braxton Hicks or anything by 371/2 so maybe it was up to five weeks early for my mite. But in your circs I would also be concerned about waiting. Is there an OC helpline or support group who can help you at this point? I'll look on the web for you. And lots of sympathy, it sounds nasty and scary.

You can take Piriton, I believe, for the itching.

what's his rationale? Is he a specialist in this area?

You can take Piriton, I believe, for the itching.

I found this on the net: This drug sounds fantastic.

"With regard to drugs, two are currently used to manage the condition. Ursodeoxycholic acid is favoured in the specialist centres for OC and has been used on over 400 women. As it is unlicensed for use in pregnancy it is prescribed on an informed consent basis, that is, mothers take it knowing that it has not been rigorously tested. It appears to eliminate or reduce the itching and can result in the liver function and bile acid results coming back to normal. Results so far look promising. Steroids (in particular oral dexamethasone) can also be considered, but will need careful management.
Mothers with OC (and in rare cases the baby) may be at risk of bleeding. For the mother this is after the birth. This can happen because bile is needed for the absorption of vitamin K from food, and vitamin K helps the blood clot. So in some hospitals the mother is given oral vitamin K daily until delivery to protect her and her baby from the small risk of bleeding.
As far as the baby is concerned, the principal aim of treatment is to eliminate the risk of stillbirth by delivering him as soon as his lungs are mature enough to survive outside the womb. It is not easy to know when to plan the delivery although, at present, doctors think it best to deliver the baby at about 37 to 38 weeks. If women with OC have their labours induced early, their babies are very likely to survive, while if pregnancy is allowed to continue to 40 weeks the risk of stillbirth increases.
Your baby will need an injection of vitamin K shortly after birth, to reduce any risk of bleeding.
For more information on OC contact the Obstetric Cholestasis Support and Information Line."

This certainly seems to support your view, prufrock. Good luck.

I found this on the net: This drug sounds fantastic.

"With regard to drugs, two are currently used to manage the condition. Ursodeoxycholic acid is favoured in the specialist centres for OC and has been used on over 400 women. As it is unlicensed for use in pregnancy it is prescribed on an informed consent basis, that is, mothers take it knowing that it has not been rigorously tested. It appears to eliminate or reduce the itching and can result in the liver function and bile acid results coming back to normal. Results so far look promising. Steroids (in particular oral dexamethasone) can also be considered, but will need careful management.
Mothers with OC (and in rare cases the baby) may be at risk of bleeding. For the mother this is after the birth. This can happen because bile is needed for the absorption of vitamin K from food, and vitamin K helps the blood clot. So in some hospitals the mother is given oral vitamin K daily until delivery to protect her and her baby from the small risk of bleeding.
As far as the baby is concerned, the principal aim of treatment is to eliminate the risk of stillbirth by delivering him as soon as his lungs are mature enough to survive outside the womb. It is not easy to know when to plan the delivery although, at present, doctors think it best to deliver the baby at about 37 to 38 weeks. If women with OC have their labours induced early, their babies are very likely to survive, while if pregnancy is allowed to continue to 40 weeks the risk of stillbirth increases.
Your baby will need an injection of vitamin K shortly after birth, to reduce any risk of bleeding.
For more information on OC contact the Obstetric Cholestasis Support and Information Line."

This certainly seems to support your view, prufrock. Good luck.

The number for the support group is 0121 353 0699 - they say specifically that they offer support and research information when your medical support do not realise there is a risk to the foetus! They say they aren't there all the time but will respond promptly to any messages left on the answerphone. I'd definitely call.

Thank you very much Aloha - I am in contact with the support line (and going to be taking part in their research). I am also fortunate that Urso agrees with me (brought my LFT levels from 350 to 90)- I should be starting it soon but as the article said it's not licensed or fully tested so doctors are loath to prescribe it this early when the baby is still developing. Piriton definately doesn't work (wrong chemistry) OC itching is caused by body trying to eliminate toxins, not reacting to allergens.

I think this guy is a specialist - but in foetal monitoring. And I'm not sure how much his desire to research the condition further (they don't really know what causes the stillbirths but think it's heart failure) is driving his advice to try for a later delivery. And if there isn't really any benefit to the baby of spending that extra 2 weeks inside, I don't really want to take the risk just so he can do his research. (Am I being v. cynical about his motives here)

Hi Prufrock.... I can't answer your CO question specifically. But I can say that I work a lot with (elective) caesarean mums (babies usually born at 38 or 39 weeks) and it never ceases to amaze me how much younger they "feel" to me (usually BF is trickier to establish, very sleepy babies, smaller babies too - of course they catch up). This is NOT me having a go at caesareans by the way - mumsnetters who know me I'm sure would confirm
And this is not about you not getting the C at 37 weeks... just trying to explain why it is seen as better (if you can safely) to wait to later.

On some of the websites I looked at they thought risk of stillbirth was down to blood supply from placenta being interupted or placenta shutting down - not sure why this would happen though?

Just wanted to say poor you Prufrock, OC sounds really awful.

I can understand your fear. Stillbirth is a hell of a nasty thing to contemplate. I instinctively wanted to wait as long as possible for my ds to be born but labour would have been so dangerous for pp that they really didn't want to risk it happening. I was happier at 37+4 than I was at 37, but had there been a risk of my baby dying then I would have been like you, keen to do it at 37 weeks. I think you need to talk to him again and really express your worries. You seem extremely clued up so he should respect your views IMO.

Just a little reassurance my ds2 was born at 37 weeks, was absolutely fine and weighed in at 8lb 13oz.I think i would worry so much in your case that i would want to be delivered at 37 weeks as surely the stress on you wont be good for the baby while inside anyway.Take care hope all goes fine.

Agree with Aloha and others re 37 weeks being term and your own mild suspicion that some further research into foetal monitoring is being done here, however much of a sweetie he might be as a person. My own history with consultants is that you can love them and trust them implicitly but still get lumbered with their noodle-headed SHO if something arises outside 9-5.
Was dd a bouncing baby? It might add grist to your mill if there is evidence your baby will be a good size at 37 weeks.
Also, Prufrock, just wanted to say how sorry I am that it has come back and you are feeling so crappy. Hugs and good luck.

Prufrock, I've nothing to add by way of advice but just wanted to send you my best wishes. How far along in pg are you?

Prufrock - I think you should trust the specialist - he will be monitoring the baby's heart throughout. The fetal heart failure is something that was unable to be monirored in the past - fetal medicine has really advanced and specialists are just that. He will not take a risk with your baby. The risk of an elective C/S at 37 weeks is not negligable. Babies are often admitted to special care with respiratory problems at that gestation and that in itself can be very problematic.
I know how you feel because in my last pregnancy my antibody levels were rising steeply and again there is a risk of heart failure for the baby. I wanted to deliver just before 36 weeks but was encouraged to wait by the consultant. DD was induced at 37 weeks and 5 days and thankfully had no breathing difficulties. She had a lot to go through with blood transusions and that would have been harder on her if she was born earlier.
Trust him.

hi prufrock, sorry to hear you are having such a miserable time. what a worry this must be for you. my only (and rather obvious) suggestion is that you seek a second opinion from a dr whose specialism is OC rather than foetal monitoring. is that possible?

hang in there until you can start taking your drugs at least you will feel a bit better then.

Sounds like a great idea from bk Prufrock. Can the OC people supply some stats too about the risks over 37 weeks?

Prufrock - have reread this post and realise you are worried that he will try and extend the pregnancy as long as possible ie 42 weeks . I think he would have meant that it was best to get the baby closer to 38 weeks rather than delivering at 37 weeks ( ie as long as possible with this conddition). A week can make a great dealof difference to an elective C/S baby particularly. I do not think he meant longer than that. If all is well, a C/S at 38 weeks is the way to go.

It's all a bit political. The recommended course of action from the OC people is delivery at 37 weeks (36 in Australia) but apparently that is just an arbitary figure based on when lungs are usually mature. There isn't really any data on real risks of a properly managed OC case going past 37 weeks, because they haven't let anybody do it for quite a while.
But this consultant is trying to change that. I am going to ask for specifics on how succesful the scans are in picking up problems ie, if all is normal I have 48 hours safety say.
I suppose I was just lucky last time. DD was finally born at 37 +1. She definately wasn't ready to come, but didn't have any probs. My milk came in after 3 days, and tbh I quite enjoyed the fact that she was quite sleepy for the first 10 days or so!
In a way it is reassuring to know that any extra days we can last out are worthwhile - at least it means the consultant isn't telling me lies (wierd isn't it how I trust an anonymous midwife who I've never met more than my consultant)

I insisted on my ds being born at 37 weeks. I'd had dd1 at 38 weeks, dd2 at 34 weeks. I had a problem with antibodies and weas constantly going backwards and forwards to the hospital (miles away). At first they said 39 weeks but if the antibodie levels got high they would deliver at 37 weeks. There weren't really any probs but at 37 weeks i was fed up of being P**d around so I insisted.

I am glad that was helpful Prufrock. It is a balance of risks. If your condition worsens and you need delivered at 36-37 weeks, you will be. In that circumstance the risks of C/S at 37 weeks are far outweighed by the risk of the baby staying put.

I can truly empathise with you. Rhesus disease that I had can result in stillbirth too. My rhesus antibodies soared in my third pregnancy and ds was induced early at 35weeks + 4 days because it was thought he was better out. However, despite being a good weight (6lb 1oz) he had severe breathing problems and was ventilated for a week. I still remember the consultant paediatician advising me that he might not survive.

With number 4, dd1, the pregnancy was monitored closely and I was induced at 37 +5 weeks. She did not need ventilated but did need exchande transfusions which she was in a better condition to tolerate. I did have a wobbly the week before and asked to be induced then. My consultant reassured me that it was better to wait another week and I am glad I did.

All the best, mears

Prufrock, my ds was delivered at 37 weeks and 4 days. I said it was superstition that made me insist on the 17th instead of the 13th, but I was also I have to admit instinctively keen to keep him inside for as long as was compatible with health and safety. He was, I suspect, better off for being a few days later (8lb 8oz!) Good luck