 The meeting is now being recorded. I'll dislike then to welcome Sarah Hunter. Sarah is a Certified Midwife in the United States of America but is currently living in Canada with her family and is working as a clinical herbalist. She has two children and a third baby that's on its way. Ond mae'r newid o hyd o fynd o'r cyllid yn colystyried, o bobl colystyried, o bobl colystyried hefyd. Rydyn ni'n gofyn i'r gweithio ar hyn, ac yn fawr mewn cyffredinolaethol i mewn gwirio. Felly, yma arnyn i'n gwybod Sera. Rhaid e, rhe yn fyrdd i metre hyn. Efallai pethau'r confermosfyr lle mwy am hollwn. Roedden i ran hwnnw ben i'r cyflisiad. I'm really excited to be part of it. I'm trying my favorite topic, pole stages of pregnancy. So as Anna said, I'm pregnant with my third baby so if you hear me breathing too loud, I'm slightly out of breath already just early and I have to clear my throat a lot. So we'll just start off with the words. Interhapatic pole stages of pregnancy. It's also known as obstetric pole stages. It used to have a whole bunch of different names, including ecterus gravidarum, just meaning jaundice in pregnancy. A lot of people like to throw in an extra O after the first E in pole stages. They want to say co-leo stages because it sounds pretty nice, but it doesn't need pole last stages. So intermeeting within, hepatic meaning of the liver, a co-leo means bile and stages of course means stages. So the disorder is within the liver. It's actually not in the bowel duct, so if people have their bowel blooders removed, they can still have pole stages of pregnancy. So the etiology, there's going to be a few slides like this where they're kind of vague. It's like, well, we kind of don't really know much about this. Are there pole stages? It's kind of poorly studied. There are a couple of teams now working on new research in the UK specifically and also in Sweden. So there should be more stuff coming out, but as it is, we don't really understand very much about it. So as these quotes say here, the etiology of ICT is complex and not fully understood, likely to result from co-aesthetic effects of reproductive hormones in their metabolites. The etiology of fetal complications is also not well understood, possibly directly linked to the bile acid, which we will get into a little later. So I turned my mic up. I hear someone saying, I see someone saying my volume is not on my computer too, because it's a laptop with the mic inside it. So that was the etiology. The etiology is also very varied. So depending on what country you go to and what year the study is from, the rates vary incredibly widely from the study from China. The English rate is 0.05% of pregnant women have ICT, and then Tilly has the highest incidence, and I see my picture. It's not here all of a sudden, oh well. Tilly has the highest incidence at 10% with higher rates in women with aralcanian-Indian descent. Higher incidences are also reported in winter months, also with twin pregnancies. Of course hepatitis is a risk factor. Guy, I'm nervous. I'm talking really fast. Excuse me, I'm better with big groups of people that I can see. So commonly how beliefs about ICT signs and symptoms, and I'm realizing this is the old version of my slides, you guys. Anyway, that's okay. I can work from these. So in my travels around the internet and talking to my colleagues, this is pretty much what I thought until I started studying post-asus. This is generally what I see going around on listeners and on Facebook and whatnot. Peredus as a ponsensuals, i.e. itchee ponsensuals, gondas, onset in the third trimester, and these things kind of get thrown around everywhere you go. Someone's itchy, like really itchy, but if it's not on her ponsensuals, don't even look into the rest of the symptoms. I see this commonly. So does this sound about right to the middle eyes on the list in terms of signs and symptoms? Do you want to show me like a, I think you can agree or disagree with your status? There's a little man with his hand up on the top left. This is pretty much what I was taught and what I retained anyway until I started studying. Peredus with no rest, absolutely. So it's sort of the beginning of the symptoms. I'll skip to my next slide. So Peredus is often generalized. This is well known and is in even my 20th edition of Williams with Cetrix is lying around the house. Peredus is generalized. This is the basic symptom of ICP. It's commonly experienced on the lens. A rash may appear, but more likely from too much scratching. Exploration marks can also appear, so I had a picture here, too. And these symptoms worsen that night. Jaundice is incredibly rare. Well, not incredibly rare. Jaundice is relatively rare. If you're waiting for someone to get jaundice, you may wait forever. Dark urine. Dark urine is a fairly common symptom, sign, rather. Pale stools is another one that's not well known, but quite common. Right upper quadrant pain is an interesting one, I find. If you have a client with right upper quadrant pain, you don't have to jump straight to pre-quansia, another more serious thing, we can think about colostasis as well. Theodoria is an excess of fat in the stool, which can also be leaky and kind of gross. Anorexia is another symptom that we don't talk about. People with liver disorders often stop wanting to eat, and colostasis is no different. And the onset may be as early as eight weeks. So this is now found in the literature, the onset being that early, but a lot of studies keep repeating the onset and the third trimester myth. For myself, I've definitely found in my very first colostatic pregnancy, I was scratching from the second trimester and didn't recognize it as it had nothing to do with my hands or feet. Associated complications. There are quite a few associated complications. Excuse me. They're largely for the fetus from newborns. The preterm delivery is really common, either by a chrygenic or a spontaneous preterm delivery. Into partome, I suspect 60% of the infant, excuse me, I'm still nervous. Myconium staining is quite common. It could be 60% to 68% in medical analysis studies, as I did. And sudden IUFD. Sudden IUFD kind of deserves a slide of its own. As you can see, cluster is around 37 to 39 weeks, depending on the study, 10 to 15%. Thank you guys for the chat. So IUFD can be up to 10 to 15% of colostatic pregnancies. It's an extreme number. I start to get nervous as a care provider when my statistics go into the full percentage points. Once they get into the double digits, I'm terrified, especially when I've come to IUFD. It's worth taking a moment to think about anyone who's itchy during pregnancy. Of course, with active management, I'm looking at this one particular study by James Williamson in 2009, with active management, they found the rates would go down to about 3.5%. And then a study we're going to talk about a little later. The Glenn's Hepticology article, they actually managed to get the associated complication of IUFD down to less than a percentage, approximately to 1.6%, with a different kind of management as well. Low aptar scores at five minutes is another issue. RDS and postpartum hemorrhage. You'll notice most of these are issues for the baby and not for the mother. TTH being pretty much the only associated complication in chipartum. So lab tests, I find this is another place where care providers are either not educated or have forgotten what to do. Liberal function tests should be done. They're subordiff, but they are definitely not diagnostic. I know there's definitely places in the world where I live specifically where we only run LFTs and for a lack of the other testing being available, believe it or not. So you will see changes in the liver function tests, NALK, delivery of the NALT, ASD, et cetera. The only diagnostic test for ICP is the fasting fractionated serum bile acid test. There's some argument of whether or not it needs to be fasting. In different parts of the world, they do fasting or just random serum bile acid tests. So that's something we're looking into further research I mentioned. Prosperonbentine may be increased. This is something really good to know for midwives. If you're ever going to consider a home birth for a client who has colostasis, you'd be really good to know her for a long time before more seriously considering. The results of all of these tests may fluctuate and definitely need to be repeated as the pregnancy advances. The disease process can also worsen. It can and usually do worsen unless treatment is undertaken. So the fractionated serum bile acid test, when they're fractionated, they break them down into the colic acid, deoxy colic acid, and senodeoxy colic acid. The normal values depend on, of course, the lab and the place where you're living. A general lab value is, normal lab value is under 10 micromol for the total or 3.1 for colic acid. And a woman who's just starting a colostatic pregnancy with early on her symptoms may have a very normal total bile acid, but the colic acid will be the first thing to rise. So that's why it's with fractionating them and not using the whole, the total value. So depending on a lab, like I said, 10 is a general line that the lab uses, normal. Some labs say 12 or 14. Most importantly, you need to look for a change if they're increasing then. And you have someone who needs to be followed more closely. And again, all this needs to be repeated. So in terms of risk, this is, this glance typology article as it's lovingly referred to in the entity group, I think is the most important piece of research that's been done, like ever, on colostasis. So what they did was they studied all of the pregnancies in part of Sweden, and 1.5% of them were diagnosed with ICP. And just to take a little aside here, it's an interesting statistic that they found 1.5% when they specifically went looking and screened everyone with that specifically in mind. The studies that I see coming out of different countries that are very, very, very small numbers, I wonder if they are incorrect. I worry a lot after being a sufferer myself and spending years on, you know, there's a Yahoo group and there's a Facebook group and now there's new online forums and stuff. So many women come in and they can't even get their care providers to take them seriously. They're kept awake at night by scratching. They can't sleep. They can't relax. They're in serious agony and their care providers are saying, yes, yes. Hitching is normal in pregnancy. It'll go away dear. I'm not sure why that is, but there's a lack of education on the part of care providers or a lack of listening to the women in general. But I'm thinking this specific care we see with 1.5% is probably a world kind of average. But again, I don't have the strength to say that. That's my feeling after being around. So what they found in this prospective cohort study was that the probability of fetal complications increased by 1% to 2% per additional mycelinol of serum bile acids. So these are very important. They also found that fetal complications did not arise at all until bile acid levels were above 40 mycelinol. So this is why it's so important to do the right testing. So what they did is they defined the difference between a mild form of full-estasis of pregnancy and a severe form, with 40 being the line. So anything above 40, they suggest here that if your patient has bylaces below 40 micromoles per litre that their data don't indicate that this group would benefit from induction of labor before term. Basically, this day is a mild form with no increased risk, or very few. So they found 693 full-esthetic women. To me it's not like a giant sample size, but in terms of full-estasis is what we have to work with. There's not any other study with bigger numbers. This is as good as it gets. I actually brought this study to almost like care providers. I littered them around my city. Please read this. It's very important. Fetal evaluation tools. So this is kind of a depressing slide too. We don't really have fetal evaluation tools that are proven to be useful for full-estasis ultrasound by physical profiles, but it's not a reliable measure of fetal well-being with ICT. They don't help at all, which is why the Guant's Hectology article is so interesting to me, because serum bylacid is the most effective tool we have. Once you get the number, if your client stays below 40, the risk stays incredibly small, and as soon as we get above that magic number, things increase. For midwives that might mean changing care providers as well, depending on your laws and various other things. So there are medical treatment options for ICT. There's one medication, and I had a beautiful chemical structure here on my other set of slides that you're missing that you can google it. Earth of the Oxycholic Acid. It has a bunch of different names. It's abbreviated down to UDCA. It has a bunch of brand names. ActiGaul. It's the LDIL. Most women with ICT could just call it Eartho. So it stimulates some biliary secretion and can bring down the bylacid level into, I mean, hopefully into a regular number, a lower number. So it will also work to, as it decreases the bylacid levels, it will also decrease the symptoms. So a lot of women find a decreasing symptom as well as can stay in the low risk category of ICT. So the other medical treatment options are induction of labor. As we saw a couple of slides ago, the IUSD rates skyrocket sometime around 37 to 39 weeks. And so in higher risk situations or places where proper testing is not available, induction of labor is definitely recommended. And I would make an argument that it's also indicated. This is why the few places where I think induction of labor is really, really, really indicated. Vitamin K is also a medical treatment option for women. The post heartic women will have, will often have lowered vitamin K levels due to problems with the re-uptake in the colon. And therefore the baby as well can have low vitamin K levels. So vitamin K can be indicated both innately and is absolutely indicated postpartum for the newborn. If that's something you often leave as an option for your client, this is something that has a real, real indication postpartum for the newborn. Alternative and complementary treatment options. So the, there are, I always have with herbs because I'm a clinical herbalist myself. Melcosysl seed and dandelion root are two very safe in general herbs that can be used as coasases. They're just gentle yet still strong liver. Dandelion is more of a drainer than melcosysl. And people do have a lot of success with them. Acupuncture, I always recommend acupuncture for pretty much anything depending on the person. People get a lot of relief from acupuncture, both for symptoms of ICT and for the related liver problems. So some of these supplements are kind of interesting. I don't know how useful but definitely interesting. Sam, if you remember that from way back in the day, actually enjoyed some time in the sun for colostatic pregnancies. There is a little bit of research that went on with that as well as for guargamel and activated charcoal. Just enough research with small amount of sample sizes that one person came along and said, oh yeah, this works for sure. And then another person came along in no way. They may be worth trying anyway depending on your client's motivation or desire to do things naturally. Bair bile, I put this here just because it's an interesting point, point more than anything. Bair bile is used in traditional Chinese medicine, contains aerosol biocicolic acid. And so it's been used for liver disorders since they started harvesting bile from dairy whenever that was. I see a question about Croftrombin Tun and vitamin K, and I can get back to that in a second. Dietary changes, a lot of women find a decrease in symptoms and decreasing symptoms and problems related to colostasis with serious dietary changes. There are some women who find their disease process pretty much disappears if they go too low to no fat diets. I think you have to be pretty motivated to have no fat in your diet. It's very, very, very difficult. I've seen some people discuss it on the message board. If it works, it works, and if it decreases your risk and you're willing to do it, I think it's definitely worth trying. It's really difficult, but worth trying. Increased fiber, for the same reason as lowering your fat because fiber helps clean up the fat in the system. Apple fiber vinegar, lemon and lime juices. Again, these are all foods that help to move the liver and can be used in liver disorders in general, especially as they're food sources and so not contraindicated in pregnancy. I myself had a lot of amazing success with fresh lime juice during the lime season there. We have over here where I could get a bag for a dollar. Of course, once the price went back up, it got a little more tricky as I was having a bag a day of lime. I did not until over to get my symptoms to disappear completely, which I think was very interesting in this. Luckily, I had a craving for lime juice and I wasn't just forcing it down my goal. It might be difficult if you're not having a craving for lime juice, however, to consume that many on a daily basis. It also doesn't do so great for the heartburn, you guys. A very important woman, you get a way risk for your benefits as usual. Comfort measures. I was discussing this slide. I had a really funny picture with this one, actually. I was discussing this slide with somebody just the other day and we realized how sad it was. Mental-related creams, they suggest 2% mental or losin or powder. If you follow my links that I'll see later on, you'll see everyone else in the UK swears by a mental-related cream. There's also powder, of course, the gold-bond powders we have here in North America. I think they're called gold-bond medicated powders. They're typically used by your grandparents, at least if you're my age. A cold water immersion is the picture I had of a woman with her legs in a bucket of ice water. Now, if you picture how pleasant that must be, you have to realize in what state of discomfort you need to be in to find this to be a comfort measure for your symptoms. When you get to the point where you're itchy enough that you're scratching yourself into your bleed or pouring ice cubes into a bucket and finding it relieving for your symptoms, you're in a bad state. That's your comfort measure, but this is what women's ICT deal with on a daily basis, often enough. Active function can also work to relieve some of the symptoms. There are some fairly easy points that you can access yourself with active pressure that helps to relieve itching. I suggest it be helpful for the patient that she talks to her own active functions about that. Like I said, I spent a lot of time following the board and listening to people on the Yahoo groups and stuff. I found an excellent, excellent way to learn about a disease process because you get to hear the human side of it. Women saying the keywords. These are some of the gems that I learned from being there for so long. We are often ignored. When I call the police, I find them everywhere. Now, in my travels around the internet, but also on the list, people just come on constantly saying, nobody is taking me seriously. No one is taking me seriously. I can't sleep. I can't sleep scratching. I can't eat. I'm sick. And they're telling me it's normal. And this is where the education needs to change. Any itching in pregnancy needs to be further looked into. Any itching in pregnancy, especially one without a rash. Too many care providers are not aware of the necessary testing to diagnose ICT. Even in my area, I was in a wealthy country. I was in Canada. We don't actually have the necessary labs to test for the vaccinated bile acids. My care providers didn't know it either. Of course, I had to enlighten them and put studies under their noses. And there's just a lot of people who have, for some reason, missed that part of their education, whereas they know about ICT. Pareddys is often worse where there is prior damage to the skin. So in ICT, pregnancy, spars, tattoos, stretch marks. I find tattoos actually to be one of the key places where women start scratching first. Maybe the eighth, I don't know. I'm not going to, I guess I shouldn't dream up a reason why that would be other than the fact that there was prior damage to that particular area. Antihistamines are often cited as a thing that can be given as a care provider, as a safe medication to give to women with ICT to help control the symptoms. And they don't work. That's what the ladies say. They don't work. You can look at them, but no one's liking them. Some women, finally, help with sleeping, but not with scratching. Cyclical itching around ovulation and menstruation can plague ICT sufferers for years postpartum, which can also be worse by hormonal birth control. People in the know know that you don't give hormonal birth control of any source alone with a history of ICT. Someone can get away with using it and not having their symptoms come back, but most cannot. So midwifery-related issues, on a world scale, things are so different from one country to another. And midwifery laws and midwifery climates and midwifery training are so different from one country to another that it's hard to address what actually to do. But if there are some questions you can consider, can your client still be considered for midwifery care or do you need to co-manage? Can you even co-manage if you live in a country where you're but is even possible to co-manage a client, or maybe she just needs to be cared for in a high-risk clinic? Skopal practice for midwest changes dramatically from country to country or training to training. So it depends also on your particular scope of practice. Hormbirth, you have to consider laws in your area for your own scope of practice. You have to consider informed consent where your client thinks it's okay. Is induction indicated or necessary? And if so, are you capable of inducing at home? What's your PTT? I really want to drive that home. I really want to drive that one home. If you're going to consider home birth, what's your PTT? Are you ready to deal with hemorrhage even if your PTT is fine? What is your RDS protocol? That's a big risk, especially if you're doing a borderline term as I call it induction. Because with colostasis, if an induction is indicated, it's often indicated early or at the edge of term. So I know the World Health Organization recently changed the definition of term to 38 weeks from 37. So, depending on your definition, it could be preterm induction that perhaps has not been dealt with at home. And do you have access to vitamin K? No, they're in the middle of the adult. So the newborn or will your client have to go in to go and find some afterwards? Yeah, those are the things to think about. This is another spot where I want to go back to the glance at the ecology article where they talk about the difference between a severe case and a mild case. To me, that's the line. If your client is under 40 micromol per liter, then her risks are not increased. And if they're above, do you be dealing with her anyway? It becomes a question. Let's take home message that I want to leave you guys with is you need to pay attention. Close attention to all the ITC moms. And we can go back to the specifics where no, what's the word I'm looking for, where women weren't treated expectantly rather than actively managed, where the specific was 10% to 15% and the experience is IUSD, 10% to 15% of women with colostasis. So if we think about the ones that were neglected for whatever reason to be diagnosed, the number to be higher. So generalized itching without rash. And then generalized itching with excreation marks. And you need to look to see what's the difference between a rash and an excreation mark. And that's the thing. I'd like to have pictures about that, but it's difficult. You have to ask questions. Yes, I have to ask a lot of questions. A rash may come on from itching as well, so you need to be asking which came first. Did you start scratching and then the rash appeared or are you scratching because you have a rash? She's scratching because she has a rash, then you might need a dermatologist. If you have a rash because you've been scratching, then you might need a hepatologist. The serum bile acid test, I think this point on my slide is dreads at home. Please remember to do the serum bile acid test, whether function tests are supportive but not diagnostic. And again, if you're considering your close-up of clients for home birth, do a TTP. Resources for sufferers, I think these are all actually clickable. So there's a Facebook group, there's a Yahoo group. ICPTair.org is a fantastic website. It has resources for professionals. It has resources for the media and resources for sufferers as well. It's a great website to go and prove. And I hear someone's mic coming on to tell me something earlier. Oh, Andy. And then my last slide is just the article. Sorry, I'm excited. So I think that's it for now. Does anybody have any questions? Yeah, thanks Sarah. So people want to post their questions up. I think there was a question earlier that you were going to raise just about the differences between... somebody wasn't quite sure on the link between the vitamin K and... The vitamin K issue with the colostasis is... So if the liver's not functioning properly, there can be steateria. So there's an increase in our staff in the colon, which is where the bacteria thrive that then die off and produce the vitamin K that we need to survive on. Does that make sense? It's kind of long. Kind of long and rambly. So if the bacteria are being washed out because of steateria, then they are not producing the vitamin K we need. So diet can maybe help fill some of that void, but not necessarily all of it depending on the severity of the symptoms. And of course if the mother is clinically low on vitamin K, the newborn will be as well. Does that make sense? Yeah, one of the questions I was wondering was about... You know, you're mentioning about the 40 minimal of bile acid and if it was greater than 40, you were classed as having severe colostasis. Would the woman feel very different? Would it be experienced in her physical symptoms if it was greater than 40? Or is that just a medical definition? Yeah, I'm not sure about that either. I'm not sure if I haven't come across any good research on that topic. I have definitely noticed the difference between how some women experience their symptoms and itching. So it may or may not correlate to symptoms, the severity of the symptoms. Okay, man, I see someone saying... Yeah, there's a question becoming more prevalent. I don't know if it's becoming more prevalent. I really hope it's being recognized more. Because when you see the studies from the 50s, they're clearly missing a lot of people. I think... I don't think it's increasing. I mean, it could be increasing, silly, I don't know. I do hope it's getting more and more recognition. My care providers are still slow. This is part of the reason I really wanted to do this presentation today, to keep people in the know. I see a question about vitamin K. How do you give vitamin K to the mum? I guess it depends on what model you use. I've definitely heard of mums being given or your regular synthetic vitamin K1 injections. It can also be given as a supplement from the health food store. What else do we have? I know treatment should be individualized. Yeah, I didn't get into the treatment for sake of the time constraints, so if you're going to be using a medication yourself, you should be able to use the medication. You can't just learn it from Sarah Hunter on the International Day of the Midlife Conference. It's got to be something you know a little bit about. The same with herbs. I definitely prefer people to refer their clients to somebody who is knowledgeable and trained in herbs before playing with sausages to look for a real response from them. Is there a decrease in vitamin K? How does this lead to increase in profile then? Is there a decrease in vitamin K to help this problem? Yeah, well, they're directly linked. Vitamin K and profile have been done as far as my understanding goes. Okay, so any other questions that people have? Well, here's one from Megan, too. If you can only get totals, I only managed to get totals by sending my stuff off to another province here. I would use 40 as the cut-off as well. Yeah, definitely. There's not really a fractionated level for severe versus mild form, of course. Okay, so oh, now we've got a question or comment there. Yeah, and many supplementary deal, many pregnancy supplements do contain vitamin K. If it's something you want to go towards where a co-status client is probably not enough, but, again, it depends on symptoms and individual issues, and postpartum has to be the question, actually, that I didn't get into. Most women find that their symptoms are relieved fairly quickly postpartum within a week or two. Some women still have signs and symptoms up to a few weeks later, and then, other than that, it just comes back down to, again, hormonal increases of ovulation or menstruation, or being put on hormonal birth control where the signs and symptoms can come back. So it usually resolves quite quickly. At least the worst of it resolves almost immediately, like within 48 hours, and then decreases as the day we need to go on. Okay, we've got just a couple more minutes before we need to hand over the preparations for the next talk, so I think this is just a couple more comments there to look at. So, yes, follow-up LFTs and polybylox as well are recommended, until after six weeks, sure, fine, that sounds legit, but until they go back into the normal range as well. So LFTs may or may not change during a co-status pregnancy. If they do change, they need to be followed until they go back into a normal range. However long that might take. The question about subsequent ICP pregnancies, yes, if you've had one, absolutely. The statistics, again, are all over the mouth for this, from 50% to 90%, but I think if you've had one ICP pregnancy, you're likely to have another unless it was caused by the increased risk of having multiples or something specific to cause. And Sarah, standing up, whether she wonders if there's a link between poor diets at the start of pregnancy and ICP. I think co-status, if all over the thought is, I think it takes more than poor diet at the start of pregnancy, I think it's got to be a lot of poor diet if it's caused by diet at all, if it's related to diet at all in that individual, it's got to be more than just at the beginning of pregnancy where the issue comes from. Okay, well, I think we might need to close this presentation now and the next presenters can get ready to find so much Sarah for the enlightening presentation. There's so much information in 40 minutes. So for more questions, I know people are still typing, go to theicpcare.org link. They're a fantastic balance for everything for you. Yes, honestly, thank you Sarah. You can feel everybody there finding news for a brilliant presentation. And thanks also to people for their comments. But hopefully you've had time now to write down those links or use those links that Sarah's got up there and have a look at her references. So I'm just going to turn off record now.