Speaker 1: All right, so in today's podcast, we're going to be
Speaker 1: going over a couple high old complications related to pregnancy.
Speaker 1: This is going to be the first of a few
Speaker 1: podcasts I plan on making on pregnancy related complications. Thank
Speaker 1: you everybody for the support, the really nice comments, the
Speaker 1: five star reviews on Apple Podcasts and Spotify. I truly
Speaker 1: do appreciate it. Thank you so much. And let's go
Speaker 1: ahead and get started. So let's start with placental abruption
Speaker 1: aka abruptio plucente. What is this, Well, it's a partial
Speaker 1: or complete separation of the placenta at or after twenty
Speaker 1: weeks of gestation. So we have this premature separation of
Speaker 1: the placenta from the uterus. We'll talk about why this
Speaker 1: happens in a moment, but first let's talk about timing.
Speaker 1: So why is timing so important? Why is it generally
Speaker 1: only considered a placental abruption if it occurs after twenty weeks. Well,
Speaker 1: if this happens prior to twenty weeks, in that case,
Speaker 1: it's usually considered to be part of a spontaneous abortion
Speaker 1: rather than an abruption, except for some rare cases, and
Speaker 1: then it also has to be prior to fetal expulsion,
Speaker 1: and this part is pretty obvious. After the fetus is delivered,
Speaker 1: the placenta naturally separates from the world the uterus, and
Speaker 1: so this is no longer an abnormal finding. So again
Speaker 1: timing it's after twenty weeks and prior to delivery of
Speaker 1: the fetus. All right, So we have this placental abruption,
Speaker 1: this separation of the placenta. Why is this happening, Well,
Speaker 1: it's due to a rupture of maternal vessels in something
Speaker 1: called the decidua basalus. So this is the main area
Speaker 1: to focus on for patho thrumb and also plays a
Speaker 1: role with the clinical consequences seen contractions, tissue brick down,
Speaker 1: et cetera. But rupture of the maternal vessels in the
Speaker 1: decidua basalus is what you need to know so quick
Speaker 1: anatomy review. The placenta is where the nutrient and gas
Speaker 1: exchange occurs between the mother and the fetus. It has
Speaker 1: two sides, the baby side called the coreon and the
Speaker 1: mother's side the decidua basalice, which is attached to the
Speaker 1: uterine wall. The deciduo basalus contains the maternal blood vessels,
Speaker 1: arteries and veins that supply oxygen rich blood to the fetus.
Speaker 1: In a placental abruption, the vessels in the deciduoa basalus
Speaker 1: mom's side become damaged or weakened, which causes them to rupture,
Speaker 1: which obviously leads to significant bleeding causing hematoma. And all
Speaker 1: of this just pushes the uterine wall in placenta apart
Speaker 1: and the separation it can be partial or complete, depending
Speaker 1: on the severity of the bleed. So basically to recap
Speaker 1: in a placental abruption, vessels in the decidu of basalus rupture.
Speaker 1: These ruptured vessels bleed and accumulate, which eventually causes the
Speaker 1: placenta to separate and peel away. So then the next
Speaker 1: question becomes why did these vessels rupture in the first place,
Speaker 1: And that takes us to our risk factors. So think,
Speaker 1: what are some things that damage and weaken blood vessels
Speaker 1: that disrupt vascular integrity. Let's start with an easy one,
Speaker 1: and that is smoking. So this is one of the
Speaker 1: few modifiable risk factors. It's also associated with a fourfold
Speaker 1: increased risk and it's thought to be related to its
Speaker 1: phasoconstrictive effects which cause placental hypoperfusion necrosis et cetera. Another
Speaker 1: one is cocaine again vasoconstriction, eschemia, et cetera. Up to
Speaker 1: ten percent of pregnant women using cocaine to the third
Speaker 1: trimester will develop an abruption hypertension. This one's really important,
Speaker 1: five fold increased risk compared to normal intensive Obviously, anytime
Speaker 1: the blood pressure is increased, you can have arterial wall damage.
Speaker 1: And then the next one is trauma, so blunt trauma,
Speaker 1: a motor vehicle accident, fall, et cetera. Even though this
Speaker 1: isn't the most common risk factor, it's definitely popular on
Speaker 1: exam questions and I have this one in school. So
Speaker 1: in trauma like a motor vehicle accident, for instance, you
Speaker 1: have this rapid acceleration deceleration of the uterus where the
Speaker 1: uterine wall stretches with the sudden movement. As the uterus
Speaker 1: is pretty flexible, but the placenta it's not so stretchy,
Speaker 1: so it stays in place. So you have this shearing
Speaker 1: force that just rips the two apart. And then we
Speaker 1: have our last risk factor, which is previous abruption. Like
Speaker 1: so many things in medicine, if you had it before,
Speaker 1: good chance you'll hap it again. And in the case
Speaker 1: of a placental abruption, very good chance. So there are
Speaker 1: some other risk factors, but those are the five to
Speaker 1: focus on, smoking, cocaine, hypertension, trauma, and previous abruption. All right,
Speaker 1: let's talk about something super high yield next, and that
Speaker 1: is your clinical manifestations. So for clinical manifestations, there's really
Speaker 1: two things that you need to know, pain and bleeding.
Speaker 1: Neither as one hundred percent in real life, but in
Speaker 1: preparation for an exam, you need to assume you'll be
Speaker 1: given the most common clinical presentation, which is abrupt onset
Speaker 1: of vaginal bleeding and mild to moderate abdominal pain. So
Speaker 1: let's talk about that vaginal bleeding. This is usually going
Speaker 1: to be abrupted onset, and this is a key component,
Speaker 1: but it's not very specific because there's obviously other causes
Speaker 1: of third trimester bleeding, like with placenta previa, which will
Speaker 1: go over next, and there is something called a concealed
Speaker 1: abruption where most of the blood is actually trapped behind
Speaker 1: the placenta, and in these cases, even in a very
Speaker 1: severe abruption, there may be little to no vaginal bleeding.
Speaker 1: So that's clinical knowledge, but for an exam, always be
Speaker 1: thinking classic presentation, which is abrupt onset of vaginal bleeding,
Speaker 1: as this will be how the vast majority of patients
Speaker 1: present around eighty percent of individuals with a placental abruption. Next,
Speaker 1: abdominal pain, so pain. This is associated with the uterine contractions,
Speaker 1: which are often high frequency in low amplitude, So the
Speaker 1: abdominal pain. It's important because on an exam, in some cases,
Speaker 1: the only thing to differentiate an abruption from placenta previa
Speaker 1: is the mention of some type of abdominal pain. So
Speaker 1: classic presentation mild to moderate abdominal pain is going to
Speaker 1: be typical. Back pain is also a possibility when the
Speaker 1: placenta is on the posterior wall of the uterus. In
Speaker 1: some cases the abdominal pain can be very severe, so
Speaker 1: abdominal pain very important to remember. So clinical manifestations. Nothing's
Speaker 1: one hundred percent in medicine, but for the exam, associate
Speaker 1: placental abruption with painful vaginal bleeding at or after twenty
Speaker 1: weeks gestation. Next is our physical exam, so really just
Speaker 1: one thing to focus on, and this is really important
Speaker 1: because it's another key to help you on your exam question,
Speaker 1: and that is the uterus it's going to be tender
Speaker 1: and rigid. On exam. You also may hear it being
Speaker 1: described as hypertonic, which just means high muscle tone, which
Speaker 1: is from those frequent contractions. So really important to remember rigid,
Speaker 1: tender or hypertonic uterus. Okay, diagnosis next, So in acute
Speaker 1: placental abruption, it's mainly a clinical diagnosis and you should
Speaker 1: suspect this in any pregnant patient that has abrupt onset
Speaker 1: of vaginal blas, abdominal pain contractions, especially in the presence
Speaker 1: of uterine tenderness and increase uterintone. As we talked about before,
Speaker 1: there are some other things that help support the diagnosis
Speaker 1: feudal heart rate, abnormalities, disseminated intravascular coagulation which can be
Speaker 1: associated with abruption. So remember again this is mainly a
Speaker 1: clinical diagnosis and you should suspect it in any pregnant
Speaker 1: patient with sudden onset vaginal bleeding, abdominal pain, contractions, tender
Speaker 1: and rigid uterus. With that being said, you should also
Speaker 1: know ultrasound can be helpful and what you should know
Speaker 1: for your ultrasound finding is something that's known as a
Speaker 1: retro placental hematoma. So a clot behind the placenta. If
Speaker 1: this is present, this strongly supports the diagnosis and on
Speaker 1: an exam question, if you see this mentioned, slam dunk,
Speaker 1: it's a placental abruption. In real life it can be
Speaker 1: absent and a good deal of patience, So it's great
Speaker 1: if it's present, but not so helpful when it's not.
Speaker 1: Ultrasound is also helpful to rule out your differentials such
Speaker 1: as placenta previa, which will go over next. So again,
Speaker 1: diagnosis mainly clinical, but the ultrasound what you're looking for.
Speaker 1: The classic finding is going to be a retro placental hematoma,
Speaker 1: all right, So treatment it depends on a lot of factors,
Speaker 1: including hemodynamic stability of the mother, the status of the fetus,
Speaker 1: and I don't think the questions you'll get will be
Speaker 1: about treatment, but just so you have an idea. Part
Speaker 1: of the treatment is focused on hemodynamic support for the mother,
Speaker 1: so things like blood transfusion, IV fluids, et cetera. Of
Speaker 1: course continuous fetal heart rate monitoring, and then depending on
Speaker 1: a number of factors, often emergent delivery is indicated, whether
Speaker 1: by vaginal or cesarean birth. Okay, so quick recap placental abruption.
Speaker 1: Placenta is peeling away from the uterus prematurely. This is
Speaker 1: at or after twenty weeks of gestation and prior to birth.
Speaker 1: Those maternal vessels, whether diseased from hypertension, smoking, or damaged
Speaker 1: from car accident fall, have ruptured and are filling that
Speaker 1: separated space with blood. Most often will see bleeding on
Speaker 1: physical exam. In some cases the bleeding can be hidden.
Speaker 1: One thing I want you to remember is this patient
Speaker 1: will likely be in pain, very likely contractions, et cetera.
Speaker 1: Uterus is going to be tender and rigid. Diagnosis is
Speaker 1: made clinically ultrasound. If it shows a retro placental hematoma,
Speaker 1: slam dunk, But it doesn't always For things you need
Speaker 1: to remember that always come up in the description on
Speaker 1: an exam question. That's pain, bleeding, the rigid uterus, and contractions.
Speaker 1: This is how I remembered it and hopefully it will
Speaker 1: help you too. Instead of placental abruption, I used to
Speaker 1: remember it as placental crab eruption. Think of a crab
Speaker 1: with its little claws literally snipping the placenta away from
Speaker 1: the uterine wall and crab and placental crab eruption stands
Speaker 1: for four super important things you need to remember that
Speaker 1: will be on an exam question. So C and crab
Speaker 1: is for contractions, R is for rigid, as in a
Speaker 1: rigid or hypertonic uterus, A is for abdominal pain, which
Speaker 1: is so important, and then B is for bleeding. So again,
Speaker 1: placental crab eruption, crab contractions, rigid, abdominal pain, bleeding. All right,
Speaker 1: let's talk about the next condition which will be very
Speaker 1: similar in many ways to placental abruption, and that is
Speaker 1: going to be placenta previa. And this is the presence
Speaker 1: of placental tissue that extends over or near the internal
Speaker 1: cervical os. So really straightforward. In a normal pregnancy, the
Speaker 1: placenta is usually right around the top of the uterus.
Speaker 1: In placenta previa, the placenta is at the bottom of
Speaker 1: the uterus, sometimes covering the entire cervical oss. This can
Speaker 1: cause a number of problems which will go over but
Speaker 1: again placenta previa. The placenta is in the wrong spot,
Speaker 1: plugging up the internal cervical oss and varying degrees. Now
Speaker 1: why this happens, we're not really sure, which is good news.
Speaker 1: From an exam standpoint. As one less thing to remember.
Speaker 1: But one hypothesis is that the upper uterine cavity where
Speaker 1: the placenta normally in plants, is not well vascularized, whether
Speaker 1: this is due to previous surgery, multi parity, or other issues.
Speaker 1: So I do have a quick knuomonic placenta abruption which
Speaker 1: we just went over. The placenta was moving away from
Speaker 1: the uterus. Remember it is kind of being ripped apart
Speaker 1: and placenta previa. The placenta is plugging up the uterus.
Speaker 1: So placenta abruption placenta away. Placenta previa placenta plug essentially,
Speaker 1: so placenta abruption has an a. Remember the placenta is
Speaker 1: moving away from the uterus. Placenta previa has a p
Speaker 1: so remember the placenta is plugging up the uterus. Just
Speaker 1: another way to help you remember the differences between the two.
Speaker 1: All right, So with placenta previa, what are some risk
Speaker 1: factories you should know? There's three main ones to focus on.
Speaker 1: Starting with a previous placenta previa. Again, like so many
Speaker 1: things in medicine, if you had it before, higher risk
Speaker 1: of having it again. Previous cesarean birth and then finally,
Speaker 1: multiple gestation, so carrying more than one baby at a time, twins,
Speaker 1: et cetera. One study found placenta previa was forty percent
Speaker 1: higher among twin berths than among singleton berths. There's other
Speaker 1: risk factors, increasing maternal age, smoking, cocaine use, male fetus,
Speaker 1: but focus on the three we went over above, if
Speaker 1: you're even going to bother them memorizing risk factors at all,
Speaker 1: because to be honest, they're not the highest deeled thing
Speaker 1: to know. With that being said, though, let's talk about
Speaker 1: something that is very high yield, and that's the clinical manifestations.
Speaker 1: So let's start with the fact that this may be
Speaker 1: an asymptomatic finding on routine ultrasound at approximately eighteen to
Speaker 1: twenty weeks of gestation. So the majority of placenta previus
Speaker 1: will be an asymptomatic finding on mid trimester ultrasound examination,
Speaker 1: and luckily about ninety percent identified on ultrasound at eighteen
Speaker 1: to twenty weeks will resolve before delivery, So many women
Speaker 1: may be asymptomatic. But this isn't what you should remember
Speaker 1: for the exam. On the exam, they're not going to
Speaker 1: give you an asymptomatic patient what they're going to give
Speaker 1: you is a patient with painless vaginal bleeding. Painless I'll
Speaker 1: repeat it again, painless vaginal bleeding. In the second half
Speaker 1: of pregnancy, the most common symptom of placenta previa is
Speaker 1: painless vaginal bleeding, which occurs in up to ninety percent
Speaker 1: of cases. Compared this to placental abruption, which again, remember
Speaker 1: more often than not had painful bleeding. So placenta previa
Speaker 1: painless bleeding. Now in real life, ten to twenty percent
Speaker 1: of patients with placenta previa may have some pain from
Speaker 1: uterine contractions, et cetera. But we're preparing for an exam,
Speaker 1: and for an exam, remember the most common which is
Speaker 1: painless vaginal bleeding. So how do you remember that? While
Speaker 1: instead of placenta previa, remember it as placenta stevia. Placenta
Speaker 1: previa is now placenta stevia. Stevia as we know, is
Speaker 1: that sugar free or a sugarless sweetener, and placenta previa
Speaker 1: is the pain free or painless vaginal bleeding. It works
Speaker 1: for me. I know it's a little weird, but hopefully
Speaker 1: it helps you too. Placenta stevia sugar free sweetener pain
Speaker 1: free vaginal bleeding. Okay, diagnosis, Let's first talk about what
Speaker 1: you do not want to do, and this will often
Speaker 1: be tested on. So you don't want to perform a
Speaker 1: digital vaginal exam anytime there is any vaginal bleeding in
Speaker 1: the second or third trimester. A digital examination is absolutely
Speaker 1: contraindicated until you perform ultrasound and rule out a placenta previa.
Speaker 1: If you perform a digital vaginal exam on a patient
Speaker 1: with placenta previa, remember the placenta. It's in the wrong spot,
Speaker 1: positioned low in the uterus, covering or near the cervix,
Speaker 1: and a digital exam can reach this area and dislodge
Speaker 1: the placental's attachment site, causing severe bleeding. So remember that
Speaker 1: because it definitely could be a question. Okay, So now
Speaker 1: that we know what we should not do, what should
Speaker 1: we do to help make the diagnosis, Well, that's using ultrasound.
Speaker 1: So this is how you diagnose placenta previa. Ultrasound is
Speaker 1: what you need to know. So you'll usually start with
Speaker 1: trans abdominal ultrasound as a screening test, and then the
Speaker 1: gold standard is with transvaginal ultrasound, which provides better detail
Speaker 1: and better defines the placental position. Now we just said
Speaker 1: never do a digital vaginal exam on a patient with
Speaker 1: a suspected placenta previa, Why the heck can we do
Speaker 1: a transvaginal ultrasound? While with a transvaginal ultrasound you're able
Speaker 1: to visualize the anatomy, so you're not going in blind,
Speaker 1: and the optimal position of the vaginal probe is actually
Speaker 1: far enough away from the cervix to make this a
Speaker 1: safe test. So when you do the ultrasound, what are
Speaker 1: you looking for to confirm the diagnosis? So that's going
Speaker 1: to be placental tissue visualized over the internal cervical oss.
Speaker 1: So again diagnosis, do not perform a digital vaginal exam,
Speaker 1: do perform an ultrasound. What about treatment next? Just like
Speaker 1: with placental abruption, I don't think many or any questions
Speaker 1: will be asked about management, but just so you have
Speaker 1: a general idea. In asymptomatic patients where placenta previa is
Speaker 1: seen on routine ultrasound at eighteen to twenty two weeks,
Speaker 1: close monitoring is an option. If you have a mother
Speaker 1: with an actively bleeding placenta previa, this is a potential
Speaker 1: obstetric emergency, so monitoring maternal hemodynamic status, blood transfusions, monitoring
Speaker 1: fetal heart rate. Once the bleeding has resolved in some patient's,
Speaker 1: outpatient management is reasonable. You want to recommend to avoid
Speaker 1: excessive physical activity, avoid sexual intercourse. Some women will receive
Speaker 1: antenatal corticosteroid therapy and then when delivery is recommended in
Speaker 1: some patient's, vaginal delivery can be an option, but quite
Speaker 1: often a Cissaian birth is recommended. Okay, So, placenta previa.
Speaker 1: This is the abnormal presence of placental tissue that extends
Speaker 1: over or near the internal cervical oss. While this may
Speaker 1: be an asymptomatic finding on routine exam, the classic symptom
Speaker 1: of placenta previa that you will not forget is painless
Speaker 1: vaginal bleeding. Up to ninety percent of persistent cases will
Speaker 1: have painless painless painless fagional bleeding. Remember placenta stevia sugar
Speaker 1: free pain free diagnosis. Do not perform a digital vaginal exam,
Speaker 1: Do perform an ultrasound treatment, manage the bleeding, observe and
Speaker 1: deliver when appropriate. That's placenta previa. Now let's do a
Speaker 1: quick recap of what I feel are the highest yield
Speaker 1: things to know for both placental abruption and placenta previa. Okay, So,
Speaker 1: Placenta abruption is a premature separation of the placenta from
Speaker 1: the uterus. Placenta previa is abnormal placental tissue over or
Speaker 1: near the internal cervical os So placenta abruption placenta moving
Speaker 1: away from the uterus. Placenta previa is plugging up the uterus.
Speaker 1: Remember placental abruption has an A, so placenta is moving
Speaker 1: away from the uterus, and placenta previa has a p
Speaker 1: so the placenta is plugging up the uterus. Next presentation
Speaker 1: placental abruption painful bleeding cramping along with rigid hypertonic uterus
Speaker 1: on physical exam, remember your placental crab eruption and then
Speaker 1: placenta previa remember painless faginal bleeding. Remember placenta stevia sugar
Speaker 1: free pain free. Remember placenta previa. You do not perform
Speaker 1: a digital vaginal exam as this can cost of your hemorrhage.
Speaker 1: And finally, with placental abruption, a retroplacental hematoma is the
Speaker 1: classic ultrasound finding. So those are the most important things
Speaker 1: to remember about these two conditions. Let's do some questions.
Speaker 1: Next question one, A thirty two year old G three
Speaker 1: P twoter woman presents to the emergency department at twenty
Speaker 1: eight weeks gestation with painless vaginal bleeding that started an
Speaker 1: hour ago. She denies any contractions, abdominal pain, or trauma.
Speaker 1: Her pregnancy has been uncomplicated until now. On examination, she
Speaker 1: is hemo dynamically stable and the fetal heart rate is
Speaker 1: one hundred and forty five beats per minute. Which of
Speaker 1: the following should be avoided in the workup of this patient?
Speaker 1: A trans abdominal ultrasound, B, transvaginal ultrasound, C digital vaginal
Speaker 1: examination or d fetal heart rate monitoring? Again, which of
Speaker 1: the following should be avoided in the workup of this
Speaker 1: patient A trans abdominal ultrasound, B, transvaginal ultrasound, C, digital
Speaker 1: vagili examination or DE fetal heart rate monitoring. All right,
Speaker 1: So I'm sure you know the answer to that one,
Speaker 1: and that is going to be CE digital vaginal examination.
Speaker 1: All right. So we have a pregnant patient with vaginal
Speaker 1: bleeding after twenty weeks tessation. G three P two minting
Speaker 1: three pregnancies and two berths at term. The vignette clearly
Speaker 1: states there is no pain or contractions, so while we
Speaker 1: can't definitively say that this is a placenta previa without imaging,
Speaker 1: it should definitely be high on the list of differentials.
Speaker 1: Most important thing is to remember that anytime a patient
Speaker 1: has vaginal bleeding late in pregnancy, you do not perform
Speaker 1: a digital vaginal examination until you rule out a placenta previa,
Speaker 1: as this can lead to severe hemorrhage. So the other
Speaker 1: answer is ultrasound. For Answers A and B, this is
Speaker 1: first line imaging to assess placental position that includes transvaginal ultrasound,
Speaker 1: which can be safely performed even with placenta previa. And
Speaker 1: then finally, fetal heart rate monitoring always appropriate with active
Speaker 1: vaginal bleeding and a pregnant patient, So again answers CEE,
Speaker 1: digital vaginal examination is the only choice that is absolutely
Speaker 1: contraindicated until previa is ruled out. Question two. A thirty
Speaker 1: five year old G four P three female currently thirty
Speaker 1: six weeks pregnant, presents the emergency department after being involved
Speaker 1: in a motor vehicle accident she's complaining of severe abdominal
Speaker 1: pain and vaginal bleeding. She admits to using cigarettes and
Speaker 1: cocaine during her pregnancy. Abdominal exam reveals a rigid uterus
Speaker 1: with palpable uterine contractions and blood is observed in the
Speaker 1: vaginal vault. If an ultrasound were performed, which of the
Speaker 1: following findings would be most consistent with the likely diagnosis?
Speaker 1: A placenta covering the internal OS and extending posteriorly B
Speaker 1: low lying placenta one centimeter from the internal oss. C
Speaker 1: retro placental hematoma, D normal placental position with no abnormalities. Again,
Speaker 1: which of the following would be most consistent with the
Speaker 1: likely diagnosis if ultrasound were obtained. A placenta covering the
Speaker 1: internal OS and extending posteriorly B low lying placenta one
Speaker 1: centimeters from the internal oss see retroplacental hematoma or D
Speaker 1: normal placental position with no abnormalities. Okay, that is going
Speaker 1: to be ce retroplacental hematoma. So first, what is the
Speaker 1: likely diagnosis in this patient? Well, first, does this patient
Speaker 1: have She does? She has crab, which again we know
Speaker 1: is contractions. She has a rigid uterus. She has abdominal
Speaker 1: pain and she has bleeding, so a suspicion for a
Speaker 1: placental abruption should be high. The vignette also mentions she
Speaker 1: used in a motor vehicle accident, which we know is
Speaker 1: a risk factor for placental abruption, and then finally it
Speaker 1: mentions cocaine and cigarette use. Highly likely this patient has
Speaker 1: a placental abruption, and as we discussed earlier, while this
Speaker 1: may not be found in all patients, a retroplacental hematoma
Speaker 1: or clot is a classic ultrasound finding and strongly supports
Speaker 1: the diagnosis question three for the patient. Reference in the
Speaker 1: previous question, what underlying pathophysiological mecha mechanism is most likely
Speaker 1: responsible for their condition? So in the patient we just
Speaker 1: mentioned what underlying pathophysiological mechanism is most likely responsible for
Speaker 1: their condition? Okay, and remember that is going to be
Speaker 1: a rupture of maternal vessels in the decidua based sallus.
Speaker 1: So remember in a placental abruption, vessels in the decidua
Speaker 1: bas salice rupture. These ruptured vessels bleed and accumulate, which
Speaker 1: eventually causes the placenta to separate and peel away. Okay,
Speaker 1: so I hope that was helpful. Thank you so much
Speaker 1: for listening. If it's helping you, please leave a review
Speaker 1: in the podcast comments and if you really like it,
Speaker 1: a five star review would absolutely be helpful. And thank
Speaker 1: you so much again