Obstetric cholestasis and induction

[Catlover1812]

I'm 34w 6 days and yesterday was diagnosed with obstetric cholestasis (pregnancy related liver condition). The symptoms were severe itching on my hands and feet. I suddenly went from being low risk and under midwife care, to high risk and under consultant care. I have to go in to hospital once a week for bloods, monitoring, growth scans and to see the consultant, whilst being put on medication. He mentioned that they don't like to let anyone with this condition go over 38/39 weeks, but said it is more likely to be an induction at 37 weeks (we will just take it week by week, which is realistic). I just wondered if anybody else has suffered/is suffering from this and when you were induced, or what you have been told. It's all a bit overwhelming x

Hi, and yes!

I was diagnosed with OC in my first pregnancy, with similar timing to you. It will depend somewhat on your bile levels, but actually it turns out that different hospital trusts have different policies on OC treatment, so you may have more options that you think. I was at a hospital where they don't induce as a matter of course until over 40 weeks. Apparently being induced at 37 weeks by default is NOT necessarily evidence-based. You may want to question your consultant about this. I was however told that it was the norm at many other hospital trusts (indeed, now pregnant with #2 and in a different city, I've been told I 'won't be allowed' to go over 37 weeks!).

Definitely do take up the regular bloods, monitoring and growth scans as these are reassuring and helpful indicators. Have a look at the bile acid levels. If yours are high, you may feel positive about an early induction. If your bile levels are relatively low, though, you may prefer to refuse an induction until your due date.

There is no actual evidence showing that the urso medication has any effect, but there's also no evidence that it does any harm, so I decided to take it just in case!

I was obviously anxious about the increased risk of still birth so I did question the lack of induction, but felt confident that the consultant was knowledgeable and that their policy was evidence-based. This has made me sceptical of the 'must induce at 37 weeks' brigade! It obviously isn't as cut and dried as some consultants make out. You may want to contact some trusts that have a different policy to ask about why. I did however ask for sweeps once I was over 38 weeks, and gave birth at 38+5 after labour started naturally.

I started out having a home birth, but transferred into hospital when my waters broke (at 9cm dilated!) and there was meconium in them. I also had an anterior lip on the cervix which was slowing progress, so midwife suggested hospital and I trusted her. Ventouse birth at hospital, having done a bit more pushing to get the head into the birth canal. Healthy happy baby. Meconium in the waters is quite common with OC, apparently. Many OC babies also come a bit early naturally.

I will have bloods taken regularly in this pregnancy to see if the OC develops again (it recurs in 40-90% of women who've had OC in a previous pregnancy). I have also tried to cut down on fats and sugar, drink extra water, and I am taking a herbal supplement called milk thistle that is meant to be good for the liver.

If all goes well, I will be refusing an induction at 37 weeks and going for another home birth unless there are other risk indicators (like very very high bile levels). I feel that induction is itself a type of risk, and I don't believe that there is clear evidence for it beyond 'lots of trusts do it, so we will'. I would however probably have an induction if I went over my due date or if my bile levels rose dramatically. And I will have sweeps again from 38 weeks onwards.

Hope this is helpful!

These guidelines from the Royal College of Obstetricians and Gynaecologists are written for clinicians but give a really good overview of some of the evidence base and pros/cons of induction:

www.rcog.org.uk/globalassets/documents/guidelines/gtg_43.pdf

Me too, twice! First time, it was undiagnosed despite me practically begging my midwife for help with the itching (I hadn't heard of OC). I was told it was just hormones and to basically get on with it. Anyway, at 40 +4 I went in to labour. Somehow they picked up on the OC and while in labour I suddenly went from low risk to action stations. It was terrifying as I had no idea what was going on, I was also having a back to back labour. I ended up with a forceps delivery. I was bf but my baby ended up in intensive care within the week through initial weight gain concerns but having read notes my conclusion was that it was due to salt in her blood. When the itching returned the second time around they didn't mess about. I was quickly diagnosed and, like you, monitored weekly. I was terrified. My levels were particularly high so when they suggested being induced at 37 weeks I agreed, I was so scared. But, it turned out to be a beautiful, relaxed and controlled birth experience and resulted in a healthy baby. I do wish I'd researched this more the first time around but I trusted the midwife. The second time around, with a new team of carers, decisions were made jointly. So I agree with the pp do a bit of research (don't scare yourself stay with trusted sources). It is scary but reassuring knowing they are closely monitoring you and baby, wishing you the very best.

Sorry, got my dates wrong. I gave birth at 39+4 after labour started naturally.

Inform yourself as much as possible and then go for what feels right to you!

@NotMyPenguin thank you so much, this is so helpful. My consultant has been great so far. He did actually mention not wanting me to go over 40 weeks. 37 weeks is if the bloods go off the charts, which I understand can happen sometimes, v quickly. My midwife said to expect it to be around 38 though, but the consultant is taking it a step at a time. That's great you were able to start off with a home birth. I've been told I have to go on the labour ward (birth centre was my preference but I'm fine with the labour ward tbh). OC sounds so dramatic, but once you know the facts and know you are being constantly monitored it doesn't seem as scary x

Had this condition in both pregnancies and was induced both times at exactly 37 weeks. Both babies were fine and good weights.

Monitoring is import and but my god I remember the itching....I used to scrape my leg on the wardrobe door at night 😕😄

As soon as babies were born, itching stopped and my bilrubin levels went straight back to normal... No lasting effects on me or babies ( who are now 4 and 6!)

@Phoenix76 thank you for this. I'm so glad your induction story for your second pregnancy was a good one as I'm feeling rather anxious about that. It must have all been so scary for you first time around. Luckily the hospital saw me straight away on Tuesday, after being up most of the night with itching (it really is the worst isn't it) and I got blood results yesterday so that, coupled with the nice doctors I've seen, has really put me at ease. Thanks all for your replies. It's good to have support as it can be quite isolating x

My bile acid levels were mental though, and thankfully due to the monitoring they picked up that they were rapidly increasing. I was going in every other day to be monitored at the end... Hence the 37 week induction. I begged the consultant in my first pregnancy to let me have another week and he was very firm in how he phrased the potential outcome, shall we say.... So go with the flow. Good luck OP! I'm pondering a third DC and the OC had to be factored in.....

I've had 2 OC pregnancies.
#1 diagnosed at around 28-29 weeks. Straight onto consultant led care with a consultant who encouraged induction at 40 weeks. Baby born at 40+2.
#2 not properly acknowledged until 37 + 4 despite weekly blood tests & twice weekly monitoring from about 32 weeks. I hadn't even finished work because I assumed I would still be fine to wait to 40 weeks per 1st pregnancy. Actually got called at work to go back to the hospital & they were trying to keep me in for immediate induction.
Waited til 38 weeks to go into hospital for induction but didn't need propess so just waited 2 days for delivery suite space. Dd2 born with no complications at 38 + 3.
There's a good Facebook site for ICP which is another term for OC
Good luck - and hope the itching isn't too unbearable

I was diagnosed with OC in my third pregnancy at 35 weeks, and weirdly though my bile acids were off the scale, I wasn't actually that itchy. I just happened to mention mildly itchy palms and as I was at Queen Charlotte's where they had a research project going on, they decided to test for it. They were going to induce a few days after diagnosis as the readings were so high but I went into labour naturally the day before. Funnily enough the earlier two babies were also early (35 and 36 weeks), and I wonder if they were also undiagnosed OC pregnancies. All were good weights (the OC baby was 8lbs 7oz!) and didn't need special care.