Obstetric cholestasis at 38 weeks - hospital won't induce; I'm still wondering about home birth

[MiniPenguinMaker]

I'm 38 weeks and 4 days. Last week I was diagnosed with obstetric cholestasis (intrahepatic cholestasis of pregnancy).

My bile acid levels are 22, ALT is 83 and ALK is 441. I'd been planning a home birth but assumed from the research online that it is standard practice to induce at 37-38 weeks... turns out that although this was the case until last year, my local trust don't do this any more. I won't be induced unless my levels rise.

Have been prescribed Urso and vitamin K. They will check bloods again tomorrow.

I'm just a bit concerned because I don't know what research this decision is based on. The registrar got a number of facts wrong (eg that the risk of stillbirth is pretty much the same with ICP as it is with a normal birth without complications - I am pretty sure that this is only the case if it is "actively managed" which usually includes induction at 37-38 weeks). Also that stillbirth is conclusively linked to bile acid levels over 40 and poor fetal movements - I have read several research papers that state very clearly that stillbirth cannot be predicted from either bile acid levels or fetal monitoring, but is usually a complete surprise after 38 weeks. There seems to be very little known about the stillbirth rate WITHOUT induction at

Bump - anyone?

I was diagnosed with Obstetric cholestasis at 38+3 (the week before last).The hospital didn't let me go home and induced the same day. My birth plan went completely out of the window (as I'm told they often do) but I was much more content to have continuous monitoring for the baby as a reassurance. The consultant was fantastic, and I was glad to be in a hospital where help would be there immediately if we needed it.

The conclusion the medical team seemed to reach about the research is that the stillbirth risk isn't conclusive, but that they didn't want to take the chance, hence the induction. Interesting that different PCTs come to different conclusions - although from what I remember my results were quite a bit higher than yours. Good luck with whatever you decide.

I'll tell you about my recent experience. I'm 37 and just delivered DCDA twins at end of May. I had severe obstetric cholestasis. My levels rose weekly, and I had a semi-planned section at 36+3. My final bile acids were 107 and my ALT peaked at around 220.
The consultant talked about delivering earlier but wanted to wait for lung maturity. Can't see much reason to wait in your case at almost 39 weeks.
As far as I could tell, risk of meconium liquor is higher and still birth risk too if bile acids over 40.
To reassure you, the twins were fine. I personally would never consider the risk involved in a home birth, but I work in the medical field so my views may be biased.

MiniPenguinMaker I looked into this a bit when I had tests run due to itching (turned out not to be anything other than itching but hey ho) and as far as I could see there isn't really much evidence that you should be induced/prescribed urso either.

So, in the absence of much evidence for any particular course of action it will come down, to a large extent, to your personal preference.

If you have an induction you'll prob be have to (because they can't do all types of induction elsewhere) be in consultant lead.

Obviously no induction does give you more options.

Consultant lead doesn't have to mean non-active though. You will need to get midwife/birth partner to help with the monitoring equipment if you have it though as it doesn't always stay on so well when you move around.

I was diagnosed with OC at 35 weeks, not dissimilar levels to yours. But was in the opposite situation. The hospital policy here was to induce at 37 weeks (regardless of levels). Having done a lot of reading on it I challenged them about the their blanket policy and the consultant compromised for induction to be at 38 weeks. I really wanted to try and go full term (with lost of monitoring) but the consultant strongly advised against it. I think the problem is that levels can dramatically change at any point? When I was pushing them with 'research' etc the consultant just kept saying their policy was based on their Trusts's outcomes? Not sure exactly what that meant but I was happy with the compromise in the end. It felt like the right decision for me.

Although I was induced (and therefore monitored) I managed to have a fairly active birth (using birthing ball for most of the labour plus gas and air). The midwife could see that me and DP were doing OK together most of the time and pretty much left us to it till the pushing stage! She would pop in periodically to check on us. The good thing about being 'high risk' is that you get assigned the most experienced/senior midwives who are considered to be a safe pair of hands! (generally).

I do understand your preference for home birth etc. I felt the same. And, chances are you would probably be absolutely fine with home birth. But once something like OC has been identified you have to be treated as high risk. Just because of the slim chance of things not being OK (even though this is highly unlikely). I think I was happy to err on the side of caution in the end.

Not sure this helps? I found it all very stressful at the time, especially since my pregnancy had been pretty straightforward till that point. I felt like it was all too much by then. Work were not impressed with me disappearing for blood tests every other day... Plus, no one I knew or worked with seemed to have ever heard of it.... I felt a bit freakish. Why me?

Wishing you all the very best, whatever you decide!

Thank you very much everyone.

To be honest I was really surprised that they didn't want to induce me right away when I went in at 38 weeks - it sounds as if it's policy at most trusts.

It makes me feel as if they don't take the risk very seriously and I can't tell whether this is for a good, evidence-based reason or not unless they tell me. I am going to try to insist on speaking to a consultant tomorrow when I go in for monitoring, as otherwise I will just spend more time stressing out and worrying about this.

As I understand it, the major risk is with intra-uterine fetal demise (eg baby dies inexplicably while still inside, usually after week 37/38), not with labour itself. So I'm surprised that they aren't taking that risk seriously, while expecting me to take it very seriously and be in hospital 'just in case' for labour, when that seems to me to be the less risky time.

Oh and btw obviously if I had any distress signs in early labour, like meconium in the waters, or anything unusual picked up on the doppler, I'd be in hospital like a shot in any case....