44. Navigating Pregnancy with Shanda Dorff, MD

Episodes have been transcribed to improve the accessibility of this information. Our best attempts have been made to ensure accuracy,  however, if you discover a possible error please notify us at info@bendybodies.org

00:00
Jennifer Milner
Welcome back to Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility, focusing on dancers and other athletic athletes. This is co host Jennifer Milner, here with the founder of Bendy Bodies, dr. Linda Bluestein. 

00:17
Dr. Linda Bluestein
Our goal is to bring you state of the art medical information to help you live your best life. Please remember to always consult with your own healthcare team before making any changes to your routine. 

00:27
Jennifer Milner
Our guest today is Dr. Shanda Dorf, founder of Complex Cares, an organization that focuses on connective tissue diseases, mast, cell diseases, pots, and dysautonomias. Hi, Dr. Dorff, and welcome to Bendy Bodies. 

00:55
Dr. Shanda Dorff
Hi, it's a pleasure to be here, and thanks for inviting me. 

00:58
Jennifer Milner
Absolutely. 

00:59
Dr. Linda Bluestein
We're thrilled to get to chat with you. 

01:01
Jennifer Milner
Yes, we are. Can you start out by telling us a little bit about yourself? 

01:07
Dr. Shanda Dorff
I grew up in a small town in southern Missouri where I had no idea that being double jointed was abnormal just because always was around like my mom and other family members who could do the exact same things that I could. So it very much seemed normal. I now know that just means genetic, but I was also a kid that was often very sick and thought there had to be a better way. And so it was at that point when just dealing with a lot of illnesses as a child that I then decided at age seven that I was going to be a physician. But it was when in residency and rotating with various different specialists who were screening some of their patients for connective tissue disease and hypermobility. In particular the sports medicine doctors, the dermatologists and even did some electro rotation with the geneticists that I found it kind of strange that when they would ask patients to do various different hypermobility exam type of testing assessments, and the patients look at them really almost grossed out, like, what are you talking about? 

02:04
Dr. Shanda Dorff
What is this? And to me, it just seemed like, oh, come on, surely you can let's move on. Come on, just bend it back this way. Let's move on to the next thing. And the ones that I was rotating with would kind of whisper to me suddenly, like, you need to get that checked out. So I got to thinking, I was like, well, wait a minute, maybe these things aren't as normal as what I was expecting growing up. When I went in for my just regular annual checkup with my physician that first year in residency, after I'd had at, that .3 different people telling me I need to get evaluated for it. I just asked and was told that it was something that would only make a difference if you're going into the NFL. And then asking me if I was changing careers. I was never particularly good at football, although I do think it's fun to watch. 

02:45
Dr. Shanda Dorff
And so it's like, no. And just, okay, didn't really give it too much more thought. But then as I got back into working with some of the patients and other rotations, it kept coming back into my mind that, well, maybe there's more to it than just being told that, hey, this isn't going to make a difference or this isn't going to matter. And so that's when I started reading a lot more into it, working a lot more with it. And in part due to my own curiosity, due to potentially what I thought of at the time, might even be a little bit of selfish reasons of wanting to try to find out for myself or is there a way that I could prevent a potential problem in myself. But also as was identifying things not only what to look out for, how to try to prevent things, how to kind of retrain the muscle memory, retrain the body. 

03:28
Dr. Shanda Dorff
It was at that time that I was also applying what I was learning to any patients that I felt could potentially benefit from it. And over the years, more and more patients, including sometimes four or more generations of the single family I was working with and it really just became more and more of a passion. And by this point I had already been found to have the classical type of Eds. I was also really surprised when I was pregnant and I'd also been found to have mast cell disease too. That especially during my pregnancy with my daughter, she's my second child, the oldest daughter of a second child, that it was really surprising people whenever was having a problem or difficulty from the mast cell disease to say, well, wait a minute, you're pregnant. We don't know what to do, so we can't do anything. 

04:19
Dr. Shanda Dorff
I was like, well, I guarantee that every single patient is the result of someone being pregnant at some time. And I'm sure that I'm not the very first patient who has been pregnant and has had mast cell disease at the same time. And they were very quick to my well, there was nothing that they could go from to have any reference, but I knew all the information, but therapy just would piece it together. It just maybe wasn't in a single concise source. And so that's when I was pregnant, I decided, you know what, once I've had this baby, because it was a very difficult, challenging pregnancy for me, that I was going to make sure that others wouldn't be without resources or wouldn't be without the information out there. And that's why I started gathering up a lot of data, more research stuff. Didn't actually initially put the pen to the paper or the fingers to the keyboard, so to speak. 

05:06
Dr. Shanda Dorff
To start writing the article right away. Started with more data gathering ideas, notes, things like that, before I actually went to construct the paper itself or for that matter, the Disjointed book chapter. But it was because I knew what it was like to feel like needing help but then others not knowing where to go to get the information to guide them and not wanting to risk doing something wrong and then just sound like you were stuck. So that's why not only continued with the passion of working with connective tissue disease and with women's health prenatal cares and things like that, but wanting to make sure that hopefully be able to help many future generations of people worldwide, not even just in my community. Ultimately, it was in working with these patient populations, because these conditions are ones that don't just involve something that's very quick, simple, straightforward. 

05:57
Dr. Shanda Dorff
It's not like, do you have strep throat? Yes or no, just waiting for a quick lab test, that type of thing. It was one that does involve multiple different body systems and especially for a new patient visit. I found that no matter how hard I tried, I was never able to consistently be able to get it all captured, to be able to feel like I was reviewing everything, answering all their questions, everything within a typical 15 to 20 minutes doctor's appointment. I tried for years and I always felt like I was missing something or always having to play catch up. And so now that I am my own separate entity at the Complex Cares LLC, I actually get to feel pretty spoiled that it lets me be able to have as much time as needed to be able to ensure getting to hear each and every person's unique story. 

06:40
Dr. Shanda Dorff
And some may have more kind of detours to their life adventure path, others it may be more of a straight shot. But it's one that no matter what, every story is important, every story is unique and every story deserves and needs to be told in this way. With me not having this time limits that the more typical practices had like what I was trained in when working with insurance, that it now allows me to be able to really get to know their stories. 

07:10
Jennifer Milner
I love that and I love hearing through your story that it seems like your whole life you've been a problem solver and that from a very early age you wanted to do medicine. Like you knew that and you had this passion for it. And every time you move forward you see a problem and you're like, well that's a problem, let's solve it. I don't feel good. There's reasons, let me look it up, let's solve it. Like you have just sort of instinctive, not only detectiveness to you, but also an instinctive desire to fill that hole and to fill that space. If you see a wrong you want to right it or if you see an emptiness, you want to fill that. And it sounds like the research that you've done for yourself and sort of putting together your own connective tissue disorder program right as you move forward has really helped you with your own health, but then your health has spurred you forward to help other people. 

08:04
Jennifer Milner
And you've seen this hole with pregnancies and postpartum and sort of beyond with women's fertility health and thought well, somebody needs to do something about that, I think it's going to be me. It's so fantastic to meet someone like that and to meet someone who continues to feel that passion and continues to feel that drive to move forward. And it's great to see how your story brings you to this really interesting place that makes you uniquely qualified to help all of these people. So when we're looking at like when we're talking about if someone is contemplating pregnancy and they have Eds or another connective tissue disorder, what are some important considerations for someone like that? 

08:49
Dr. Shanda Dorff
First, I just want to say thank you. Some things for them to keep in mind initially is something that's true for everyone, regardless of connective tissue disease. The fact that it's important whenever possible to be able to try to make sure that you are at your healthiest before would be actively trying to get pregnant as well as trying to minimize and try to get off. Of or transition change to medications that would not potentially be harmful or dangerous to a pregnancy or to the delivery whenever possible in advance of trying to get pregnant. Also, it's very important to remember that not everyone is able to get pregnant the very first time they try and they actually only consider it abnormal or they want to do further investigation. If they anticipate, the mom would be under 35 years of age at the time of delivery, after a whole year of trying, without being able to successfully conceive versus they would start investigating after about six months. 

09:48
Dr. Shanda Dorff
If they anticipate, the mom would be age 35 or older at the time of delivery. Just from a risk stratification standpoint, but specifically with regards to Eds or hypermobility spectrum disorder, while there is a very wide range of potential complications that can happen for it doesn't mean that one person is going to have all of them. Some people may not even actually fully experience any complications at all, just the potential for them. So it's important to have it on the radar screen, but to also not let it overwhelm you, not let you feel like it would be impossible. I could never get pregnant, but cause of every possible thing that could happen because in life there's an infinite number of things that could happen even completely unrelated to hyperbole and Eds. But we're fortunate in the fact that we don't experience everything altogether. We just want to make sure that we know what to look for. 

10:41
Dr. Shanda Dorff
We are monitoring. We're working to try to prevent things whenever possible, being careful, but also working with ones who are aware of the things that can be very helpful for us to make sure that if something were to develop, it's able. To be identified sooner, to be able to be taken care of sooner, to make sure that it does not risk end up causing problems or doesn't risk potentially spiraling for you. Also, don't be alarmed just being told that the pregnancy would be considered high risk because many pregnancies are considered high risk. In the US. For example, pretty much anytime woman has a diagnosis before she gets pregnant, it would make it considered high risk. And there's a wide range of severity within that high risk category, some much more severe than others. But even if a woman has a BMI of 30 or above before conceiving, then that would mean technically is obese. 

11:33
Dr. Shanda Dorff
Even if has no other health issues whatsoever, they would consider that higher risk because a higher potential risk for gestational diabetes and things like that. So they just want to make sure they're watching it closer. It doesn't mean that there's going to be a problem, it just means they want to watch closer. Now there are definitely some other conditions that are much higher risk within that high risk category, but those are ones that are usually separate from a connective tissue disease. Also make sure whenever possible that you get a chance to try to meet with a prenatal provider, whether it be obstetrician, family physician, midwife in various different countries, there's different ones that work to do with the prenatal cares and deliveries whenever possible to try to do planning beforehand. Also may want to meet with a genetic counselor just to be able to discuss risks potentially not only to the mom but risks for the baby inheriting it. 

12:27
Dr. Shanda Dorff
Most types of Eds, but not all, but most types including but not limited to the most common type being the hypermobile are ones that are inherited what they call an autosomal dominant pattern. So it means it doesn't matter which gender the parent is that the baby would only necessarily need to inherit it from just one parent in order to have it with it being a dominant trait. It's not something that would skip a generation, it's one that if it's there. And so it wouldn't be kind of hiding out or things like that. I tend to think of it similar to dark hair, is dominant to blonde or red hair. Sometimes blonde or red hair may kind of skip a generation, but the dark hair provided it's their natural hair color, not some beautiful bottles styles on. There are ones that one wouldn't tend to skip a generation. 

13:15
Jennifer Milner
That makes sense. So it sounds like you're saying, first of all, try to be in good health, right? If you're considering being pregnant. So in your best possible health, like no one's ever going to be in perfect health and it means something different for everyone, especially a lot of our listeners. So try to be in good health, don't panic, right? Don't let all the possibilities overwhelm you and consult with some experts, like you said, a geneticist. So that seems doable. That seems manageable. Thank you. 

13:47
Dr. Linda Bluestein
And I wanted to ask, in the Disjointed book, we focused on hypermobile Eds and hypermobility spectrum disorder. Would your advice be different if in the rare case that they were already diagnosed with classical or vascular or one of the other we know much more rare forms of Eds, would your advice be different? 

14:06
Dr. Shanda Dorff
The risk is the greatest by far with the vascular type, and that is one that without a doubt, absolutely essential, not just may want to consider, but absolutely essential to be meeting with geneticist or genetic counselor. Not everyone may have access to a geneticist because I think there are far too few of them out there, but that may just be my own bias as well. But it's one that type not only was the first one they had reliable genetic markers for, so it's much easier to be able to screen for, but it's also the only type associated with dying young. The greatest risk to mom and unborn baby during pregnancy because uterus itself is a very highly vascularized organ. And during pregnancy, you have to have increased what they call vasodilation, where the blood vessels get a little bit bigger to accommodate more blood flow because it has to be able to have enough to be able to cross the placenda to be able to feed the fetus or baby. 

15:00
Dr. Shanda Dorff
And so when you're dealing with a vascular type, when the blood vessels themselves are the most fragile and they're having to get stretched out, much greater risk for them to shred versus much greater risk for uterine rupture. And that's why it's very difficult for a vascular Eds pregnancy to ever go to full term, especially to the due date, and technically the due date or your full term three weeks before the due date itself. But it's one that they usually actually don't allow them to be able to go to the due date because they know that it puts so much strain on those vessels that the risk or it could potentially result in rupture shredding that could result in loss of both mom and baby is extremely great. That's why they usually try to make sure they are able to give some steroids to the mom to be able to cross the placenda to ensure baby's lungs develop in time, and then usually whenever possible, try to deliver around 36 weeks if they're able to. 

15:57
Dr. Shanda Dorff
With the classical type, you have a higher risk for the uterine rupture, especially if they've had a prior c section. If they haven't had the prior c section, then the risk goes down much lower, and it's still not anywhere near as high as the risk with the vascular type in general, for the uterine rupture risk. But with the classical type, it's the skin and soft tissue that has a much greater impact to it. And so if you have a scar across the uterus. And for the individuals with the most common types of C section these days is what they call a low transverse, which is where they just go horizontally across the bottom part of the uterus, a little bit above kind of what would be like the pubic bone, if you're kind of imagining kind of going deeper down inside there. And that's one that as things stretch as the uterus is growing, it kind of ends up going from looking like a flattened out little balloon to like a hot air balloon on there. 

16:55
Dr. Shanda Dorff
And sometimes it feels like it could be as big as a hot air balloon as the pregnancy expands. Maybe that was just my experience as well. But it's one that could also be stretching out at the scars and ones with a classical type, much more so than individuals with the hypermobile. But it still happens with the hypermobile, can have problems with scarring. Not only can it become a lot widened, sometimes it can become a lot thinner, sometimes it can become really uncoordinated type of healing with the skin whenever it tries to. And the same is true for the deeper tissues such as the uterus. And so if it's stretching out there and it's becoming thinner and then especially, also if your body starts trying to go into labor, it might end up getting a little confused. It might start thinning at the scar site instead of at the cervix itself. 

17:38
Dr. Shanda Dorff
So the cervix is that bottom one third of the uterus that's supposed to be changing when a woman is going to be getting ready to have a baby, where it becomes thinner, it becomes more opened up, getting ready for a baby to pass through. But if all of the body's forces are going right at that scar site instead of the cervix, it's thinning trying to open up. And then you can even tell an ultrasound where it's and I know this firsthand because I've had it twice, where if they do the ultrasound, the lower uterine segment, which is right over where that scar site was, it's called the myometrium, which is the muscle wall of the uterus. When you develop a uterine window where you can see through it, literally, you can actually see through it. If you had the skin part opened, you can actually see through because a muscle is gone. 

18:23
Dr. Shanda Dorff
And on the ultrasound you'll notice no longer having the wall layer of the muscle going all the way down across the entire front of the uterus. And you'll see whenever the baby moves or kicks the part that doesn't have that myometrium or muscle wall, it just kind of floats on the ultrasound. And the uterus itself is not supposed to be looking like someone is. My son describes them as like a wobbly man. Those little inflatable balloons you might see like marketing things like that, but that's what it looks like there versus on the operating table when they open up the skin incision, make sure they can see everything in the uterus. When the myometrium is gone, you can actually see through with your own eyes the uterus itself before you've even cut it because it's usually down to only about two or three cells deep. 

19:11
Dr. Shanda Dorff
I know in the case with my daughter, who is my second child, I remember being on the operating table and then going Interesting, and just being like, what? And they go, oh, your scar from your last C section, I can actually see your daughter moving right through it and it's like, you're not supposed to see those followed organs. And then I go, oh, I'm like now. And then come to find out, all they had to do is just barely touch with their sterile gloved hands the uterus itself. They hadn't got a chance to actually get the scalpel to the incision, they just touched it to try to get ready to apply the scalpel and it completely split open at the scar site. Wow. Because it thinned out so much. And so it actually made me really grateful that I was right there and was already going to be getting ready to meet my now amazing teenager. 

19:59
Dr. Shanda Dorff
But it's the one that because of the classical type, we knew to expect there could be challenges and problems with the scarring. Now not everyone with the classical type will experience that. It's just something that they want to make sure they're able to watch and monitor for. And so that's why in my third pregnancy with my now toddler, they were closely monitoring that segment and it went really smoothly. So much nicer, so much easier, because as soon as the change happened, able to be addressing things right away. 

20:28
Dr. Linda Bluestein
That's fascinating. I've been in many C sections, I've never seen that before. As you're describing, I could have this visual of the nice thick uterine wall and how it normally looks before they make that incision. So that's really interesting. Thank goodness. The classical type and the vascular type and the other subtypes are so much more rare than hypermobile Eds and HSD. I just want to reiterate that because oftentimes when we start talking about those and people will hear little bits of themselves in other parts of the story and while for the person that has it, like in your case, it doesn't in a way matter how rare it is because you have it 100% right. But just for the other people listening, just so that they realize that those conditions are much more rare than the hypermobile Eds and HSD, it is definitely. 

21:26
Dr. Shanda Dorff
Very much more rare and very uncommon even for those with the classical type to experience that. But it's one that just something to be having on the radar screen. That's why it's so important to make sure that whomever is the clinician working to be able to help guide and care for the listeners or anyone else's pregnancy. That it's. Ones that they're able to know the health history. Of the patient and be able to feel comfortable knowing what to look out for, understanding what types of risk, precautions, monitoring, because that can make for such a huge difference, and it can really result in what could have been potentially a very tragic experience becoming a very beautiful, wonderful one, like in the case with my amazing daughters. 

22:11
Dr. Linda Bluestein
That's great. What other things during pregnancy should people be watching for? Whether they have an actual diagnosis or they suspect that they fall into the category of one of these diagnoses, what should they be looking for? 

22:29
Dr. Shanda Dorff
Well, initially, some of the most common things that are present in ones with hypermobility, whether it be fulmanant Eds or just on the hypermobile spectrum, is that you can experience more challenges from instability, the progesterone, the pregnancy hormones that are designed to allow for the pelvis to change to accommodate a growing uterus. They don't tend to say, well, we're only going to do this just at a certain moment in time, and especially if things are already extra flexible or lax or hypermobile to begin with, might start noticing those changes even earlier on. And so you might be needing like an si belt or a sacral iliac belt because it could be noticing the muscles around the pelvis starting to get sore because the bones inside the joints in there could be kind of slipping a little bit. Sometimes you can get spasms, sometimes you can get discomforts. 

23:14
Dr. Shanda Dorff
I know for myself, I was actually kind of surprised when the si joints came out because I remember being told in med school that was one of the few joints in the body that doesn't actually move. I now know that it does move, but that was something they initially had told us in schools that it doesn't. And I remember thinking like, what is this pain? Because it felt like it was just kind of farther back, deeper back than what would be in alignment with the ovary, even though it wasn't actually like the ovary itself, but it was actually the si joint. It once literally was able to hear the pop. It was like instantly the pain went away despite all kinds of imaging and ultrasound. Well, there was no cyst on there, but it was just because of the si joints. The pubic bones likewise can also shift and move around. 

23:53
Dr. Shanda Dorff
So that's where it's helpful to work with physical therapists. Like I said, having the si belts, making sure might have a need for a back support because you can notice like, back spasms pain. Scoliosis can be worse during pregnancy. You can have more need for a chiropractic adjustment or osteopathic adjustment as well. Also there is a higher risk for breakthrough bleeding, which would be like spotting and things like that during pregnancy or potential miscarriage risk. But that miscarriage risk is much more so individuals with the vascular type, like we had talked about being very rare earlier, or individuals with the classical type, especially if they have had a prior what's called a leap or cone procedure, which is procedures where after a woman has had an abnormal PAP smear, they might need to have multiple biopsies of their cervix or different treatments to try to remove any cancerous or precancerous cells from the HPV virus on there. 

24:48
Dr. Shanda Dorff
And that can result in being a little bit thinner or may need what's called a circlage, which is where they put a stitch in there to kind of make it loop up almost like a drawstring, keep the cervix closed until ready to be able to have a baby. And they can just remove the ish. And it works to be able to contain pregnancy, to allow it to be able to be viable and do well. Also increased risk for swelling. The mouse don't really have a lot of cardiovascular effects or problems from it. In fact, it's really interesting that many patients with Pots, and I believe it's around 70% of the Pots patients, actually find themselves feeling better during pregnancy because of the increased fluid volume that's needed just to accommodate the growing fetus or in some cases more than one on there. And it's one that has all the additional fluid volume of fluid flow can be really helpful for them. 

25:37
Dr. Shanda Dorff
It can help to really reduce a lot of their plot symptoms and sometimes even reduce the need for some of their medications. But even though someone could have Eds or hypermobile spectrum, they also need to make sure they don't risk ignoring or forgetting about some of just the general pregnancy things that you want to make sure that you're on the lookout for to make sure to let your doctors know. Such as if you all of a sudden you've been noticing and feeling baby move, fine. But all of a sudden noticing baby move anymore. Not being able to feel baby move. If you're having significant amount of vaginal bleeding, which would be more than, like, spotting, if you're noticing a large amount, if you're noticing the water breaking or amniotic fluid leaking, like early or large gushes if you're noticing the contractions happening, even if it's when you'd be expecting to be having a baby, it's still important to make sure monitoring and letting them know and being able to get to the place where you can have the baby there. 

26:25
Dr. Shanda Dorff
If you're having severe pain, if you're having severe headaches, if your blood pressure is becoming dangerously high or super high, those are all things that's still really important to be on the lookout for. Just for anyone who is pregnant with or without a connective tissue disease or suspected connective tissue disease, that's a fabulous list. 

26:43
Dr. Linda Bluestein
That's such great information. And what about during delivery? What are some of the complications that can occur during delivery and how do you recommend preparing for them? 

26:53
Dr. Shanda Dorff
Well, the. First way to prepare, I recommend whenever possible, is to try to plan to deliver someplace that has the ability to perform a C section if needed. Now, it does not mean that someone would have to have a C section. It doesn't mean that anticipator that people with hypermobile should just go straight to a C section because that is definitely still considered more physically challenging for the body than for a vaginal delivery. However, even in people without any other known health issues whatsoever, sometimes surprises happen, sometimes emergencies can happen. So that's why, whenever possible, to try to deliver at a place where if an emergency were to happen, they could do a C section if needed. But specifically, with regards to Eds, connective tissue disease or hypermobile spectrum, there can be a higher likelihood for a breach presentation, which is where the baby is kind of in the same direction as the mom, where the head is up higher and the bottom is down lower. 

27:48
Dr. Shanda Dorff
And usually babies, especially when the mom has hypermobility as well as the baby, they're a lot more able to keep twisting, turning, moving around, whatever position they're wanting to be in, whenever they are wanting at their own discretion. They are showing their own personalities already early on, because the uterus is more flexible, better able to accommodate, they're more kind of bendy, more flexible, so they can twist themselves to get around however they're wanting to be. So it isn't necessarily someone where you can assume that just because a baby happens to be head down at one doctor's visit that they're going to stay that way. Likewise, if they happen to be breached where their bottom would be first, it doesn't necessarily mean they would stay that way. And sometimes, even if they do, what's called aversion, where they're trying to turn the baby to be able to make sure the baby would be more of a head down, which is the less challenging way to deliver a baby vaginally because it's a smaller size for the head than it would be for their bottom of their buttock. 

28:44
Dr. Shanda Dorff
And so you'd have a higher tearing risk if they were delivering with their cheeks first, their buttock cheeks, as opposed to their facial cheeks and their beautiful faces. Also, there is increased risk for tearing. Now, sometimes they will do what's called a peziotomy to try to allow for the passage of a baby through the birth canal, where they have better what they consider more controlled tearing by actually just making a cut to try to open up the amount of space for the baby to go through. And there's a couple of different approaches to it. The original types of peziotomies were in what they called a midline one, which is where if you can kind of imagine like a clock circle face is going straight down around the 06:00 position. And the biggest challenge with that, especially in people with hypermobility or connective tissue disease, is if that were to extend, it extends straight back right down into the anus and can result in what's called a fourth degree tear. 

29:36
Dr. Shanda Dorff
And that's the most severe type of tear from a delivery where it tears all the way through the wall of the vagina into the rectum, versus if they do a medial lateral one where they're kind of going around a 45 degree angle. That's one where if it were to extend, it will extend out towards mom's thighs, but not down towards the rectum. So it's one that it doesn't risk the severe, most severe types of vaginal tears, but sometimes it can be more painful as it's healing, because it is cutting across some of the skeletal muscles there, but it can definitely still heal. It just doesn't cause as much of the vaginal wall severe tears tearing on there. Also a fourth degree tear is a higher risk in general, even without a Pcotomy for once with that very rare vascular type of Eds, especially if it happens to be a really rapid delivery. 

30:23
Dr. Shanda Dorff
And ones with connective tissue disease in general can have a faster delivery, especially after the water break. Sometimes it's like, all right, free flow, let's go, just because things can stretch a lot quicker and a lot easier. But they don't have as much of the risk of the fourth degree in any non vascular type. And so that does still provide a little bit more reassurance for ones because the vascular type is very rare. But it's also one that the other types, while you can have tearing and many do, not all but many do have tearing, there's a wide range of tearing. Some of it might just be more superficial. Some of them, they might just need a stitch or two or just a little bit. But it's extremely rare for it to actually be that fourth degree where they have to rebuild up that partition or the wall between the vagina and the rectum. 

31:06
Dr. Shanda Dorff
Also you can have something called prom or p prom, and so it isn't referring to a dance or things like that. Those can be very lovely and perhaps the baby may experience one of those later on. But this one is referring to premature rupture of membranes. So where the water breaks before an active labor in the case of prom, is where you're full term, but your body isn't having the cervix changing and contracting consistently to make those changes. Versus pre prom or preterm premature rupture of membranes is where the water breaks before you're going into labor. And you're not full term yet either. That's more common in ones with the classical type, which is still rare, not as rare as a vascular type, but much more rare than the hypermobile type or just the hypermobile spectrum in general. With regards to anesthesia and analgesia, some patients with connective tissue disease have difficulty being able to find something that works quite right to be able to numb them. 

32:03
Dr. Linda Bluestein
What about in the immediate time after delivery or in the subsequent weeks? Are there certain things that you would tell people to be looking for doing so? 

32:17
Dr. Shanda Dorff
Key things are you wanting to make sure to be avoiding doing a lot of heavy lifting, especially for ones with hypermobility because you don't want to have to add to the increased risk for pelvic floor prolapse. And that's one that can happen in general with hypermobility and connective tissue disease. A greater risk in women, especially after they've had multiple vaginal deliveries. But if you do a lot of heavy lifting, that can be a challenge too. And that's why their doctors advise everyone to not be doing heavy lifting immediately after they've had a baby. But not everyone follows all the advice that they're given. Freedom of choice in there. But in particular with regards to the pelvic floor, there's multiple different aspects of it. Not only is it just involving the muscles along the base and kegel exercises that are not strictly just for right after delivery to try to help things stay strong. 

33:03
Dr. Shanda Dorff
It's actually good practice to do at all times, but can also develop what's called a cystoceal, which is where the bladder kind of falls backwards against the front or anterior walls of the vagina. So sometimes it can make it difficult to be able to empty out the bladder. You can have what's called a rectus seal, which is where the rectum kind of falls forward against the posterior wall of the vagina. And so then it can be tough to empty out the rectum or tough to be able to have a bowel movement because the walls of the vagina are made also of defective tissue when it's someone with connective tissue disease and so they're not able to be as strong in general. And you can also have prolapse where they're actually kind of falling more towards the outside world. And that's even true for the uterus itself. 

33:45
Dr. Shanda Dorff
And so like the prolapse where it's actually going down versus the seals where it's kind of falling into the vagina on there, scarring can be a challenge. You can have problems with excess scarring. It just can become a big tangled mess. It can become really wide and it can thin out. It can develop keloid. Scars can have problems with dehyssence, which is where it pops open, kind of like what we talked about from my own personal experience with regards to the uterine scar from a prior C section where it kind of opened up on its own. And that was just where the scar itself had just kind of thinned and thinned because the uterus stretching out farther and farther due to the response of hormones into a subsequent pregnancy after that. Also you want to avoid this is more for the clinician, whether it be a physician, whether it be midwife, nurse practitioner, physician assistant. 

34:34
Dr. Shanda Dorff
You want to make sure to be avoiding pulling too tight with the stitches and that's whether it be on a C section, whether it be a vaginal suture or anything. Because once with connective tissue disease, if you pull it'll just shred, it just tears right through. And sometimes that can be a big challenge or problem as well as you want to make sure that you pull it tight enough where things are able touch, but not where it feels like it's super glued for life on there. Pull it where it touch, put them closer together. Sometimes they need to do multiple layers of them to provide that added support, but with that way it doesn't risk shredding the tissue that you've got already. Allow more time for them to heal. Kind of more of a slow and steady wins the race. You are able to get to the same goals, outcomes, you're able to be doing the things that you want, getting back to the way things were, but just remember to have patience, be able to allow your body the time that it needs to heal. 

35:24
Dr. Shanda Dorff
Also may need to avoid adhesives if a person has an adhesive allergy, whether it be glue, some do sterry strips, things like that, may need to avoid those if they have adhesive allergy if a person has problems with bleeding or postpartum hemorrhage. And the risk for that does go up individuals with Eds or hypermobile spectrum disorder compared to the general population. In the general population is about 3% versus the ones with connective tissue disease it goes up to 5%. So still around 95% of the time that is not an issue, which is really reassuring. It's just slightly higher risk going from three to five in ones who have Eds or hypermobile spectrum. And so that's where making sure the ones that are there doing the delivery are prepared to be able to manage it. Those common management strategies include things like Oxytocin or some to call it Pitocin, that's usually done in the IV I pull. 

36:17
Dr. Shanda Dorff
They usually start it right after the baby, right after the placenta has been delivered to be able to help the uterus contract down to try to stop bleeding. Misoprost, or some call it side attack, which is a little tablet that can be placed in the rectum that the woman just able to absorb that way to try to help reduce bleeding. DDAVP is another great option that can be used a lot of times. It's also very helpful with Pots as well and that's something that the anesthesiologists are usually very familiar with and have on standby. I have also seen some where it was more of a prolonged postpartum bleeding that resulted in hemorrhage for the cumulative volume. Not the immediate right after delivery time frame, but when it was prolonged in mast cell patients. Where? They might end up using some transvaginal mast cell medications, such as a diphre diphenhydramine, which is the active ingredient of Benadryl or chromalin inside the vagina. 

37:11
Dr. Shanda Dorff
But that's one that if you're wanting to be able to know, is the bleeding or challenge strictly related to mass cells as opposed to a typical gynecologic obstetric source? If it's related to obstetric gynecology, the chromalin or diphenhydrome is not going to do anything. This relates to the mass cells. You'll get a response right away. So that makes it really fast and simple. But those are ones that would not be expected to be the issue right there immediately after delivery. That'd be more if it was kind of prolonged because immediately after you have to first make sure is the uterus being able to clamp down, was there an additional tear or bleeding source that you maybe had missed or things like that? You might need to either cauterize, if you're in that C section, might need to have other stitches placed, things like that. Those are things that will be right then and there right immediately at the time where they can still be doing the oxytocin at the same time as they're taking care of the bleeding source or they can still use the cytotech, for example, or the DDI AVP. 

38:05
Dr. Shanda Dorff
But those are ones that would be separate or unrelated from mass cell disease. And you can have potential more, I think, about a risk for hip, pelvis, si, joint back instability just from delivery, from the position that you're in when you're trying to push the baby and things like that. That can be a challenge for some knees, hips, lower back, especially individuals that are hypermobile. 

38:27
Jennifer Milner
And I think it's worth mentioning again that we are having this conversation with Dr. Shanda Dorf about all possible complications that could happen during pregnancy and delivery and postpartum. So it's important as listeners listen to this that they not think all of this is about to happen to me. Right. As you mentioned earlier, Dr. Blusin, you can see pieces of yourself in some of these stories, right? And that's really easy for us. So it's just a reminder. We are trying to pick Dr. Dorf's brain because she is such a wealth of knowledge. So we are trying to get all of that information that she is a huge specialist on. We're not saying this is what's going to happen with every single hypermobile person who becomes pregnant, right? So it just bears saying most do. 

39:17
Dr. Shanda Dorff
Not have a lot of problems. Most do quite well and really great. Matter of fact, the majority of pregnancies, even ones that are connective tissue disease, the vast majority of those pregnancies go beautifully without problems, which is so great. 

39:32
Jennifer Milner
To hear, of course, for anybody who's considering pregnancy or is pregnant, I want to get to breastfeeding. But really quick, I just wanted to ask because most of our population that listens are dancers or other artistic athletes. Are there special contraindications or precautions that you would take for exercise with this population during pregnancy or after pregnancy or would you not consider that to be very different from other precautions for most pregnant people. 

40:01
Dr. Shanda Dorff
I would try to make sure those individuals that they have good supports for the pelvis when they're doing some of their activities, whether it be with an Si belt or pregnancy belt, things like that. Because not only are they in general tend to be very toned, muscle strength is excellent, strong. They are very skilled for many of the dancers and athletes out there. So it isn't as though they would be going from a very sedentary lifestyle to then all of a sudden wanting to be doing like a Cirque du Soleil or something like that or very acrobatic or things like that. These are ones that are very still, very trained. They also know their body very well. But don't be afraid to let yourself have just a little bit of additional support when you're doing some of the movements or activities, so that way you can still be enjoying the dance that you love without it risking potentially having the added challenges from the hormonal influences that could make something go out of joints a little bit easier. 

40:55
Dr. Shanda Dorff
That could limit some of the ability to do the dancing that you want or some of the other activities and that could potentially cause discomforts or pain too. Excellent. 

41:03
Jennifer Milner
Thank you. So, moving to breastfeeding, are there any special considerations that people with hypermobility should take during that time? 

41:14
Dr. Shanda Dorff
Yeah, and a lot of it depends on which type of connective tissue disease you have. For example, with the classical like or dramatosphoraxis type, a much greater risk for it to seem like the skin of the breast tissue or the areola is very lax or hyperextensible, where it might actually seem like the mammary glands, or what they tend to think of as the breast tissue itself isn't actually starting until lower down and just kind of looser excess skin up top where it might have to feel like kind of lifting things up on there or may have the areola more flattened out or might be able to not really stay back. When a baby is trying nurse, it might kind of fall forward across the baby's mouth and nose. And so might just need to just have a gentle hand placed on the breast tissue or feed through a nursing bra. 

41:59
Dr. Shanda Dorff
So that way it works to kind of hold the looser or hyperextensible skin out of the way so a baby is still fully able to breathe, be able to nurse, things like that. Some things that can be helpful if happen to have more of a flattened or inverted nipple is if you have a little bit of either a nipple shield or use a breast pump first because that can use a little suction work to kind of draw things out. Now, sometimes that can be very tender, especially in the beginning. And many moms, even if it's not their first time they've breastfed when their body is first starting to be lactating and getting that colostrum that tends to look more like egg yolk coming out before it ends up looking like what they tend to think of as milk on there. The more white tones it's one that it is pretty sensitive on there and it can be sometimes very painful for some others just more sensitive on there. 

42:48
Dr. Shanda Dorff
Then your body does work to adjust but don't be afraid to ask for help whether it be from a lactation consultant, a breastfeeding medicine specialist, the clinicians who deliver the baby or babies the baby's doctor. There are lots of resources out there, you are not alone. There are also many support groups even that are just made up among a lot of moms and stuff too because wanting to be able to make sure that both mom and baby are able to have a successful breastfeeding journey. Also sometimes the babies may seem like they're able to be latching on and latching is just where they're trying to be able to suck from the nipple on there. But tongue tie can be a challenge for them and especially if the baby happens to have some high probability. It may seem like your tongue is able to stick out just fine because things are really stretched but may not really be able to suck as well as what would be needed to draw the milk out. 

43:37
Dr. Shanda Dorff
And a way that you can kind of check for that is just put a little finger in baby's mouth and the baby should then be able to just immediately, automatically through a reflex start trying to suck on to try to draw milk out and that is what the baby is supposed to do. It is not as though you're trying to tease the baby or things like that with the finger. No, that's just actually checking to make sure the reflexes are working properly. And if they're not able to have a strong grip to be sucking your finger, where if you can easily just slide your finger right out as opposed to feeling that resistance because the baby has kind of gripped on. Trying to suck on your finger, then might need to be able to get checked to see if baby's having a little bit of a tongue tie and to be able to take care of it's. 

44:13
Dr. Shanda Dorff
Actually a really simple usually able to be done in office procedure where they just use little sterile scissors. Just able to snip the little extra tissue that's kind of holding the tongue down a little bit and then it's free and entirely fine. Raynauds of the nipple can also happen and raynauds much like when you think of it for the fingers or toes where it can make things get discolored sometimes like blue, purple, sometimes bright, sometimes super pale where a cuff blood flow it can be really painful. That can also happen to the nipple. And in particular with the nipple, you tend to notice it either right after the shower, because the warm moisture of the shower right after baby has been nursing, because the inside of baby's mouth, its body temperature and it's moist with saliva. And as soon as get exposed to regular room temperature, it's like an immediate feels really cold coming to, which can constrict the blood vessels. 

45:01
Dr. Shanda Dorff
And sometimes that can cause a lot of pain, which can limit the ability of the mom to feel comfortable doing the breastfeeding. And so in those settings, maiden needing a small amount of some nifetapine, which is just a calcium channel blocker that's been around for a really long time. That can help with rain. ODS on there to allow to open. Up the blood vessels, good circulation, but you just want to make sure again, checking with your doctor to make sure that it would be a safe potential medication for the individual patients on there. 

45:27
Jennifer Milner
Excellent, that's a lot of really helpful information on that. I know that with all the work that you do with connective tissue disorders, you also have been working with the different comorbidities that are often common with some of them. So what might some special considerations be during pregnancy for mast cell disease? 

45:49
Dr. Shanda Dorff
Key things are check the safety categories of the medicines you're taking, whether it be the mast, cell specific meds or other medications for both the pregnancy safety as well as afterwards for any lactation safety on there because you always want to make sure doing safest for you as well as baby whenever possible. Sometimes a surprise may happen. Not everyone is always able to fully plan every pregnancy. We fully understand that. But want to make sure that whenever are aware of one, or whenever have the chance to plan to try to make sure having the safest medications and the safety categories are out there widely available. And your doctors are able to help guide you through those as well by kind of like even if you were to ever have a surgery, they go through your list of medication on what's safe to take for a procedure. 

46:34
Dr. Shanda Dorff
The same is true with any type of pregnancy as well. And in general from a medication standpoint, in general, whenever someone is pregnant, what's best because there's not really able to get a ton of what they call the gold standard double blinded studies for when someone is pregnant. From just a general medical ethic standpoint, usually the being more kind of after the fact observational someone had to have the medicine they couldn't go without it. And so you just want to be able to have as low of an amount of medication as possible to allow you to be able to remaining functional. You may not be feeling like you're on top of the world, but you still need to be able to be doing the things that you need to do, but just with the lowest amount possible, because that makes the least chance for it to potentially even have a chance to be able to affect the baby across the placenta or anything like that. 

47:22
Dr. Shanda Dorff
Also make sure that have a prenatal and delivery team in place that understands your needs. Make sure that they understand, for example, what mast cell disease is. Some do, some don't. Sometimes it's helpful to have multiple people involved to be working together on there just to be able to make sure that if you were to have any type of reaction or problem, whether it be during pregnancy, during delivery or even afterwards, that they're prepared to be able to manage it. Sometimes it may end up need to be you bringing some of your own medications from home if you have to have something that's compounded, for example, not every hospital is able to have that readily available. But sometimes it's important to make sure your doctors know if you have to have things compounded because a lot of hospitals want to make sure that they're only administering the medicines that they feel comfortable that they know about. 

48:14
Dr. Shanda Dorff
So that's where they may need to understand why you might be needing something to be compounded. Also, if you have a reaction, depending on the severity of the reaction that determines how aggressive they need to be with the treatments. If it's something that's pretty mild, it doesn't really bother you. Maybe just a little bit more tired, maybe just needing a little bit of a nap on there versus are you having itchiness rash, are you having irritation? Might just need some additional antihistamine, h one, h two. Maybe needing a steroid, maybe needing epinephrine of having anaphylaxis, which hopefully would never do that. But at the same time we do know that some people may experience that. So it's always important to make sure that the ones in your care team know what symptoms to be on the lookout for you and that they know how to be able to address it if something were to happen. 

49:01
Dr. Shanda Dorff
And again, most of the time things go very smooth sailing and do great and don't end up needing to have those additional precautions in place. But it's always better to make sure that someone is prepared if the need were to arise rather than trying to figure out what happened. What to do in the midst of a moment when you could be struggling. Sometimes may not need to premedicate before, such as if you have meant to know in advance that might end up needing to have a C section because maybe the placenta is blocking the opening of the cervix in which case you cannot deliver a baby through that because you can't do the placenta first. Then we have to have a C section. There's some other reason why I would have to have a C section too, but that just like the placenta position is completely unrelated to the connective tissue disease. 

49:41
Dr. Shanda Dorff
But it's one that if you know in advance you might need it, then might want to premedicate by having an extra dose some of your medicines around an hour or so before just to try to reduce the activation of your mast cells, taking them from their overly aggressive mastostape to bringing them down to a more typical normal response. Also you can have increased bruising, bleeding, fatigue, rashes, like increased hyperbility instability, but in this case it's multifactorial. Not only do you have the progesterone affecting it, the connective tissue disease affecting it, the mass cells also release an enzyme called Elastase two which is something that works to make things extra stretchy as well. It can also affect mood, it can affect sleep both in terms of ability to fall asleep, comfort while you're sleeping, actually getting truly restful sleep on there. It's not simple, but then again pregnancy itself, it's not super simple and a lot of those things can be affected just from pregnancy itself and pregnancy is also a very specific limited duration of time. 

50:44
Dr. Shanda Dorff
It is not something that's indefinite. And I think it's really great because afterwards you get to see the result of all of that and it would seem like very disheartening of just continuously having that what seems like hot air balloon constantly expanding and never actually getting to be able to hold the baby or to be able to get to see the feet beyond the ultrasound. I never really thought feet were particularly cute until I got to see my baby's feet on ultrasound and I thought they were just absolutely adorable. 

51:10
Dr. Linda Bluestein
Absolutely. And obviously you have an incredible wealth of knowledge on these topics. Most people are not going to have access to you when they're pregnant or be able to get in to see you. So for people that are looking for someone to help care for them, do you have any suggestions if they have one of these conditions or one of the comorbidities of how they could find somebody that would be able to help them in the best possible way? 

51:42
Dr. Shanda Dorff
The Ehlers Danlo Society has a great list of a lot of resources on there myself. I know at least in the Twin Cities there's multiple different OBGYN and high risk specialists that have become increasingly more familiar, do really well with it and have been very receptive and very open to even doing peer to peer discussions, things like that. I have no problem also providing individuals with resources. For example, like the obstetrics chapter, the book Disjointed is one that I wrote and there's a bibliography in that chapter that lets you be able to see where in the medical literature a lot of the different information came from there's. Also in the journal Obstetrics and Gynecology there's the article that I was lead author and Dr. Lauren Saffron was our co author about managements of mast cell disease for pregnancy delivery. Postpartum Lactation tried to provide some helpful tables and resources. 

52:36
Dr. Shanda Dorff
To let those be available, hopefully to people anywhere, not strictly just that are able to come see me, but to try to have resources out there. Because at least a lot of the observation I've had is if you find clinicians that are really eager to try to be able to learn and try to help stuff. But if they've been searching, whether it be from 30 minutes to an hour, sometimes 2 hours they haven't found what they're looking for, sometimes they'll get frustrated and might stop looking. And so that's where wanting to try to make things really quick, easy to find and comprehensive resources. I know you were also one of the wonderful authors of the Disjointed book yourself and has been very handy for a lot of my patients, have really enjoyed your chapters and even like the perioperative management recommendations for ones with Ehler's analysis syndrome that you authored. 

53:25
Dr. Shanda Dorff
That journal article along with Dr. Pradeep Chopra is another amazing, excellent resource and it talks specifically about obstetric as well as other surgical considerations on there too. 

53:35
Dr. Linda Bluestein
Yeah, and just like both of those articles that you just mentioned, I think that those are things that they're not that long, probably, so people could print that and if they wanted to highlight a few things. And at least it would be something. Because you're right if some of those things are not found super quickly and we know everyone has limited time, So that's a great suggestion for people to look for those resources and take them in. 

53:59
Jennifer Milner
Well, I have learned a lot today and I'm really grateful for you coming on here. I feel like I have learned that there definitely are special considerations for people with connective tissue disorders who might be trying to get pregnant during pregnancy, postpartum breastfeeding, sort of dealing with all their comorbidities. And that it's certainly something to keep in mind as you're going through the whole process. And it's really helpful to find someone who understands this process and who can specialize. It also sounds like you've recommended some great resources, including the book that you and Dr. Bluestein have both contributed to as an easy way for people to at least find a place to start. Yes, Disjointed. And I know we talk about that book a fair amount of the time on our podcast, and I just have to say once again that the authors are not making money off of this, that the authors have contributed their time and their expertise in order to provide a wealth of information in one space for all things hypermobile related. 

55:12
Jennifer Milner
So every time we talk about it, Dr. Bluestein is not making a dollar. So it really is a great resource because it has amazing people like Dr. Bluestein and like Dr. Dorf. So finding a book like that going to the Eds Society's page and finding those referrals, it is possible to find people out there who can help. I do believe that the medical community is moving to where they're more amenable to sharing information and speaking back and forth with other specialists about a patient they might have in common. I think that we are definitely moving into that time. So there absolutely is help out there for people who are looking to go through a pregnancy with hypermobility and the other comorbidities. Dr. Dorf, where can people find you if they want to get more information? What's? Your website? Your instagram. What's the best way to find you and get more information? 

56:14
Dr. Shanda Dorff
I'm at Complex Cares LLC, which is in Shoreview, Minnesota. Our website is complexcaresmn.com. So cares with an S and MN for Minnesota.com. They can call, text or voicemail to 651-756-9596 and then I know we also have a clinic Facebook page but don't get a chance to be super active on it just because, super busy. More so with just a lot of the patient stuff. And I'm trying to remember because I don't get a chance to do a whole lot of actually looking up the details on Twitter, but when on Twitter, just not able to be on it very often it's at Cares complex on there and then something else. I just want everyone to be able to remember because this was a lot of stuff to try to take in. But remember, it does not mean they would experience all these things. Matter of fact, the vast majority go very beautifully, don't have any problems at all. 

57:14
Dr. Shanda Dorff
But if you're finding yourself feeling stressed or overwhelmed, I want you to take a chance to look in the mirror and specifically look at your shoulders and I want you to pay attention to the size of them, okay? There's a very limited amount of space between here and here. There is not room to carry the weight of the world on it. Lift up and unburden yourself. There is room for a shoulder to lean on, room for a hug, but there's not room to carry everything there. When you try to do that physically, you make your neck hurt, you make your back hurt, be uncomfortable, and can really disrupt your sleep and everything else. Just take a peek at your shoulders. Remember, okay, there's only so much space here. There's only just so much that I can do. It's okay that there's not more space there because our bodies aren't made that way. 

58:00
Dr. Shanda Dorff
Even though they're bendy, they can work to try to hold a lot of things. Want to make sure that we are allowing us to be able to feel that it's okay for us to say, I need to pause or we need to take a little break or things like that or okay, this is a lot for me right now. I just need to take a breath and that's just fine. 

58:18
Jennifer Milner
Thank you. That's so well said. And I'm probably going to go back and listen to that about once a week after this podcast comes out as my little daily affirmation. That was beautiful. Thank you so much. We do forget that we don't have to do everything and it is okay to take a pause sometimes. Well, you have been listening to Bendy Bodies with the Hypermobility MD, and today we have been speaking with Dr. Shanda Dorff, founder of Complex Cares. Dr. Dorff, thank you so much for taking the time to come on the Bendy Bodies podcast and share your amazing expertise with us today. 

58:50
Dr. Shanda Dorff
It was an absolute pleasure. Thank you for having me. 

58:54
Dr. Linda Bluestein
We love chatting with you. Thank you so much. 

58:57
Jennifer Milner
Absolutely. Thank you. And to everybody else, we will see you again soon. Bye. 

59:03
Dr. Linda Bluestein
Thank you for joining us for this episode of Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other aesthetic athletes. If you found this information valuable, please share it with a colleague or friend and leave us a review on your favorite podcast player. Remember to subscribe so you won't miss future episodes. If you want to follow us on Instagram, it's at bendy underscore Bodies and our website is WW bendibodies.org if you want to follow Bendy Bodies founder and co host Dr. Bluestein on Instagram, it's at hypermobilitymd all one word, and her website is WW dot hypermobilitymd.com. If you want to follow cohost Jennifer Milner on Instagram, it's at jennifer. Periodmillner milner and her website is WW dot. Jennifermillner.com, thank you for helping us spread the word about hypermobility and associated conditions. We want to hear from you. 

01:00:08
Dr. Linda Bluestein
Please email us at info@bendybodies.org to share feedback. The thoughts and opinions expressed on this podcast are solely of the cohost and their guests. They do not necessarily represent the views and opinions of any organization. The thoughts and opinions do not constitute medical advice and should not be used in any legal capacity whatsoever. This information is not intended to diagnose, treat, cure, or prevent any disease, as this information is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment, please refer to your local qualified health practitioner for all medical concerns. We'll catch you next time on the Bendy Bodies podcast.