WEBVTT - Ep 169 Pregnancy: Act 2 0:00:00.200 --> 0:00:02.560 We want to start with a disclaimer that throughout this 0:00:02.680 --> 0:00:07.480 series we feature explanations and stories that include some heavy material, 0:00:07.680 --> 0:00:13.920 including early pregnancy, loss, stillbirth, and other traumatic experiences of pregnancy, childbirth, 0:00:13.920 --> 0:00:15.160 and the postpartum period. 0:00:17.160 --> 0:00:19.880 I'm Siena. I'm twenty eight years old and twenty eight 0:00:19.920 --> 0:00:23.440 weeks pregnant with my first child. It seems like a cliche, 0:00:23.480 --> 0:00:26.840 but my most daunting pregnancy symptom has been mourning sickness. 0:00:27.400 --> 0:00:29.520 I was aware that it was a misnomer and that 0:00:29.560 --> 0:00:32.280 it would not be restricted to the morning, but my 0:00:32.320 --> 0:00:36.360 biggest surprise was how frequent, long, and intense morning sickness is. 0:00:37.240 --> 0:00:39.599 I didn't expect to lose weight during the first time 0:00:39.680 --> 0:00:42.800 master or be woken up at one am because of 0:00:42.840 --> 0:00:46.559 the sudden urge to vomit. I'm not a stranger to vomiting. 0:00:47.000 --> 0:00:51.440 I've thrown up before with the flu, food poisoning, intense migraines, 0:00:51.520 --> 0:00:54.960 anxiety episodes, and of course after a night of having 0:00:55.000 --> 0:00:57.520 a little bit too much fun, as they say, But 0:00:57.720 --> 0:01:02.200 morning sickness is different. It feels similar to motion sickness, 0:01:02.800 --> 0:01:05.280 like you're on a boat all the time when there's 0:01:05.280 --> 0:01:09.160 nothing in your stomach. The urge to throw up is 0:01:09.200 --> 0:01:12.559 so intense, and you end up throwing up this thick, 0:01:13.319 --> 0:01:18.199 bright yellow fluid that looks like, honestly like lemon gatorade. 0:01:18.360 --> 0:01:20.880 I had my eyewatch give me sound warnings from my 0:01:20.920 --> 0:01:24.280 own vomiting, saying just ten minutes at this level can 0:01:24.319 --> 0:01:28.160 cause temporary hearing loss, and in my experience, the heaving 0:01:28.160 --> 0:01:30.399 has been so intense that even if I just went 0:01:30.440 --> 0:01:34.720 to the bathroom, I still end up peeing myself. It's 0:01:34.880 --> 0:01:38.839 just so aggressive. I actually have to wear diapers now 0:01:39.640 --> 0:01:41.880 just in the off chance that I happen to throw up, 0:01:43.360 --> 0:01:45.800 and that's just something I've accepted as part of my 0:01:45.840 --> 0:01:49.640 life now. With my pregnancy journey, it has been a challenge, 0:01:49.800 --> 0:01:52.680 especially with working full time and having to commute two 0:01:52.680 --> 0:01:55.040 and a half hours every day. You never know when 0:01:55.080 --> 0:01:57.160 morning sickness is going to strike, so I even have 0:01:57.200 --> 0:02:02.000 little bags in my car. My morning sickness started at 0:02:02.040 --> 0:02:06.760 week five and was pretty much all day every day 0:02:07.760 --> 0:02:10.760 until week twenty two. I got a little bit of 0:02:10.840 --> 0:02:14.320 a break, and then it started up again around week 0:02:14.360 --> 0:02:15.000 twenty six. 0:02:15.440 --> 0:02:17.440 Although it's no longer all day. 0:02:17.440 --> 0:02:21.320 It is truly just in the morning usually, and I've 0:02:21.320 --> 0:02:25.520 tried all the remedies that they tell you, ginger B six, 0:02:26.560 --> 0:02:30.760 unise pressure point bands, the list goes on. Zil friend 0:02:30.800 --> 0:02:33.120 has worked the best for me, but it's still very 0:02:33.240 --> 0:02:35.840 hit or miss on whether or will work on any 0:02:35.880 --> 0:02:36.440 given day. 0:02:38.800 --> 0:02:41.680 When I went in from my first ultrasound at seven weeks, 0:02:41.919 --> 0:02:44.760 the doctor was able to see a gestational sack and 0:02:44.800 --> 0:02:48.480 a yolk sack, but no fetal pull. My doctor tried 0:02:48.520 --> 0:02:50.639 to assure me that it was possible I wasn't as 0:02:50.639 --> 0:02:52.920 far along as I'd thought, but I had been tracking 0:02:52.919 --> 0:02:55.400 my ovulation and I knew this wasn't a good sign, 0:02:56.160 --> 0:02:59.679 since this was a deeply wanted pregnancy. My doctor suggested 0:02:59.720 --> 0:03:03.640 we win week and do another ultrasound at eight weeks. 0:03:03.919 --> 0:03:07.520 The ultrasound showed some growth, a fetal pull, and a heartbeat. 0:03:08.200 --> 0:03:11.680 At first, I felt so relieved, certain that progress from 0:03:11.680 --> 0:03:14.639 the week before meant that maybe things would actually be okay. 0:03:15.320 --> 0:03:18.320 But then my doctor explained that the embryo was measuring 0:03:18.400 --> 0:03:21.280 less than six weeks and the heartbeat was only eighty four. 0:03:22.200 --> 0:03:24.639 When I got home, I turned to Google and found 0:03:24.680 --> 0:03:27.560 a study that said first trimester heart rates under ninety 0:03:27.600 --> 0:03:31.920 had a quote dismal prognosis The following week, when I 0:03:32.000 --> 0:03:34.280 was nine weeks into my pregnancy, I went in for 0:03:34.360 --> 0:03:38.200 my final ultrasound, which showed an embryo measuring only six 0:03:38.280 --> 0:03:41.920 weeks one day and no heart beat. My doctor was 0:03:41.960 --> 0:03:45.280 able to schedule me for a DNC the next day. 0:03:45.640 --> 0:03:49.520 My whole pregnancy, I had no indication that anything was wrong. 0:03:50.280 --> 0:03:53.120 I had strong dark lines on my home pregnancy test, 0:03:53.200 --> 0:03:56.680 and early blood tests showed my hCG doubling at an 0:03:56.720 --> 0:04:00.440 appropriate rate. I felt lucky that I was experiencing only 0:04:00.480 --> 0:04:04.000 mild nausea, but I did have all the usual pregnancy symptoms, 0:04:04.600 --> 0:04:08.000 and I had no bleeding or spotting at all, no cramping, 0:04:08.240 --> 0:04:11.280 absolutely nothing that led me to think my pregnancy wasn't 0:04:11.320 --> 0:04:15.200 progressing exactly as it should. I knew miscarriage was common, 0:04:15.400 --> 0:04:18.560 especially for women in their late thirties like me, but 0:04:18.640 --> 0:04:20.720 I always assumed that there would be some kind of 0:04:20.760 --> 0:04:25.320 outward sign. Going through a missed miscarriage led to feelings 0:04:25.360 --> 0:04:29.560 of profound betrayal. My pregnancy wasn't viable and my body 0:04:29.680 --> 0:04:32.719 had no idea. I feel as though I am no 0:04:32.760 --> 0:04:36.000 longer able to trust the signals that my body is sending. 0:05:00.400 --> 0:05:24.680 New Thank you all so much for sharing your story 0:05:24.680 --> 0:05:27.960 with us, and really a huge thank you to everyone 0:05:27.960 --> 0:05:31.320 who has written in with their experiences. We read each 0:05:31.360 --> 0:05:35.320 and every single one of the hundreds of first hand 0:05:35.320 --> 0:05:39.040 accounts that people submitted, and we're so grateful and truly 0:05:39.080 --> 0:05:41.479 honored that you felt like you could share those with us, 0:05:41.920 --> 0:05:44.000 and we tried to include as many of your stories 0:05:44.040 --> 0:05:47.239 as possible and you'll hear more first hand accounts throughout 0:05:47.240 --> 0:05:49.719 the rest of this episode and the other episodes in 0:05:49.760 --> 0:05:50.280 this series. 0:05:50.480 --> 0:05:54.000 Yeah, thank you again. It really was a huge privilege 0:05:54.040 --> 0:05:56.719 to be able to read all of your stories listen 0:05:56.760 --> 0:05:58.400 to all of the stories that you guys sent in. 0:05:58.760 --> 0:06:01.760 I genuinely like cried through, oh my most of whether 0:06:01.800 --> 0:06:04.839 it was happy or sad tears. So really, thank you 0:06:04.880 --> 0:06:06.800 again so much from the bottom of our hearts for 0:06:06.839 --> 0:06:07.960 sharing all of your stories with. 0:06:07.960 --> 0:06:08.640 Us, truly. 0:06:08.800 --> 0:06:12.839 Yeah. Hi, I'm erin Welsh and I'm erin Allman Updy. 0:06:12.720 --> 0:06:14.760 And this is this podcast will kill You. 0:06:14.920 --> 0:06:19.160 Today is episode two of our four part series, four 0:06:19.240 --> 0:06:22.680 parts on pregnancy. Yep, yeah, yet again coming to you 0:06:22.720 --> 0:06:24.599 from the exactly right studios. 0:06:24.839 --> 0:06:26.800 I know, I feel like I'm getting more used to 0:06:26.880 --> 0:06:27.160 it now. 0:06:27.240 --> 0:06:29.039 Yeah, it's good. It's going to be like this is 0:06:29.080 --> 0:06:29.840 this is the new normal. 0:06:29.920 --> 0:06:35.359 This is the new normal. But before we get into 0:06:35.560 --> 0:06:38.520 this episode, we want to share a few words about 0:06:38.640 --> 0:06:41.120 what these four episodes will cover. And if you listen 0:06:41.160 --> 0:06:43.440 to our first episode, this will sound familiar to you, 0:06:43.560 --> 0:06:45.360 but in case this is your first time tuning in, 0:06:45.440 --> 0:06:48.360 welco just want to go everything over again. Yes, welcome, 0:06:49.320 --> 0:06:51.520 but we also want to get into the language that 0:06:51.560 --> 0:06:54.680 we'll be using and our goals with creating this series. 0:06:55.080 --> 0:06:58.000 So we decided early on to dedicate four episodes to 0:06:58.200 --> 0:07:00.560 cover pregnancy, one for E to trimester. 0:07:00.680 --> 0:07:03.680 Not enough, we realized early on, but alas. 0:07:03.440 --> 0:07:06.760 Very very much not enough. And yeah, and so we 0:07:06.760 --> 0:07:09.200 we did realize this, and you know, we're not going 0:07:09.240 --> 0:07:12.000 to be able to cover everything, and throughout the series 0:07:12.040 --> 0:07:15.080 we started to jot down like different ideas for future episodes, 0:07:15.120 --> 0:07:17.360 and so do keep in mind that, you know, if 0:07:17.400 --> 0:07:18.960 you're listening in and you're like, oh, I want to 0:07:19.000 --> 0:07:21.240 know more about that, Hey, send us your idea. Yeah, 0:07:21.280 --> 0:07:23.440 you know, maybe we will cover it in the future episod' 0:07:23.520 --> 0:07:25.080 sure we will, I'm sure that we will. 0:07:25.400 --> 0:07:29.080 So knowing that this entire series will likely not answer 0:07:29.120 --> 0:07:32.520 all of your questions about pregnancy or cover every experience 0:07:32.560 --> 0:07:35.600 that a person can have during pregnancy. Pregnancy is an 0:07:35.600 --> 0:07:39.400 incredibly individual experience, as highlighted by all of our first 0:07:39.440 --> 0:07:40.240 hand accounts. 0:07:40.680 --> 0:07:41.640 But what we aim to. 0:07:41.560 --> 0:07:43.520 Do with this whole series is take you through the 0:07:43.560 --> 0:07:46.600 broad changes that we see in the human body and 0:07:46.680 --> 0:07:50.640 that you might experience during pregnancy, childbirth, and the postpartum period, 0:07:51.160 --> 0:07:54.960 and then also explore the historical and today especially the 0:07:55.000 --> 0:08:00.119 evolutionary aspects of pregnancy and childbirth. So each episode very 0:08:00.200 --> 0:08:04.120 roughly corresponds to each trimester. So last week we covered 0:08:04.160 --> 0:08:06.840 the first trimester, how you even know whether or not 0:08:06.880 --> 0:08:11.720 you're pregnant, and what was happening in very early development yep. 0:08:12.360 --> 0:08:16.440 Then today and our second episode, we're going to talk 0:08:16.480 --> 0:08:20.600 about the amazing organ that is the placenta and some 0:08:20.720 --> 0:08:25.040 of the physiological changes which are really I'm so excited 0:08:25.040 --> 0:08:27.440 to learn more about what is happening. Okay, I can't 0:08:27.440 --> 0:08:29.960 tell you how I have two more episodes to like 0:08:29.960 --> 0:08:33.200 briefly go through, but we're gonna talk today about the 0:08:33.240 --> 0:08:36.319 placenta and these physiological changes that someone will experience as 0:08:36.320 --> 0:08:39.079 they go through pregnancy, including some of the complications that 0:08:39.160 --> 0:08:39.640 might arise. 0:08:40.360 --> 0:08:42.679 And then next week in our third episode, we'll talk 0:08:42.720 --> 0:08:45.840 about childbirth itself, will cover labor, all of the different 0:08:45.840 --> 0:08:49.760 modes of delivery, and then the history of cesarean sections Yep, 0:08:50.800 --> 0:08:51.439 it's gonna be good. 0:08:51.440 --> 0:08:54.080 It's gonna be good. And then finally, our fourth episode, 0:08:54.120 --> 0:08:58.680 which happens to be our season finale, will be about 0:08:58.679 --> 0:09:02.839 this concept of the fourth trimester, exploring the changes that 0:09:02.960 --> 0:09:05.440 happen after pregnancy, and we're also going to be talking 0:09:05.480 --> 0:09:10.439 big picture history about overall medicalization of pregnancy and childbirth 0:09:10.880 --> 0:09:13.920 and how the transition from home to hospital happened and 0:09:13.960 --> 0:09:15.440 some of the consequences of that. 0:09:16.559 --> 0:09:19.199 We intend for all of these episodes to be inclusive 0:09:19.280 --> 0:09:22.959 of all families, and we recognize that not everyone who 0:09:23.000 --> 0:09:26.840 experiences pregnancy identifies as a woman, so we try wherever 0:09:26.880 --> 0:09:30.080 we can to use general neutral language such as pregnant person, 0:09:30.559 --> 0:09:33.160 while at the same time, we recognize that a lot 0:09:33.200 --> 0:09:35.000 of what we're going to discuss when it comes to 0:09:35.040 --> 0:09:39.520 medical bias during pregnancy and childbirth, both historically and today, 0:09:39.720 --> 0:09:42.920 really is the result of gender discrimination as well as racism, 0:09:43.280 --> 0:09:45.640 and so in those contexts we will also be using 0:09:45.679 --> 0:09:48.960 the term women and women, and throughout these episodes will 0:09:48.960 --> 0:09:51.679 be using terms like mother or maternal and paternal as 0:09:51.679 --> 0:09:53.440 these are terms that are very often used in the 0:09:53.480 --> 0:09:54.800 scientific and medical literature. 0:09:56.120 --> 0:09:58.960 And we also want to acknowledge that there is no 0:09:59.080 --> 0:10:02.400 such thing as a normal pregnancy. Yeah right, there is 0:10:02.440 --> 0:10:06.040 no textbook pregnancy. There's plenty of textbooks about pregnancy, yes, 0:10:06.400 --> 0:10:10.319 but when it comes to pregnancy, there's no textbook example. Yeah, 0:10:10.600 --> 0:10:13.600 but we do want to also provide a baseline of 0:10:13.720 --> 0:10:17.560 the expected physiologic and anatomic changes that occurred during pregnancy, 0:10:17.559 --> 0:10:20.080 because that can help us to understand where these complications 0:10:20.120 --> 0:10:23.760 are coming from and what we actually mean by complication exactly. 0:10:24.040 --> 0:10:25.280 Yeah. 0:10:25.320 --> 0:10:31.599 And so now today we enter the second trimester. We 0:10:31.960 --> 0:10:34.520 shall but first first quarantine any time. 0:10:34.600 --> 0:10:36.040 And we are drinking again. 0:10:36.640 --> 0:10:40.720 Great expectations, great expectations. Yeah, I do have great expectations 0:10:40.760 --> 0:10:43.200 for this episode. I have great expectations for this whole 0:10:43.240 --> 0:10:48.320 series too. Yeah, remind us, Aaron, what is in great expectations? 0:10:48.559 --> 0:10:52.480 Of course, it is blackberries and muddled with mint, some 0:10:53.040 --> 0:10:55.800 ginger ale and lemon. It's a plus. 0:10:56.080 --> 0:10:59.679 Plusy Berita for a pregnancy series for obvious reasons. It's 0:10:59.720 --> 0:11:02.520 great And if you haven't already, please do check out 0:11:03.040 --> 0:11:06.640 YouTube where you can find the exactly right network channel 0:11:07.000 --> 0:11:11.439 that now includes our content, including a very special quarantine 0:11:11.559 --> 0:11:15.120 recipe by Georgia Hartstark made just for this series. 0:11:16.360 --> 0:11:19.560 We're thrilled and we'll also be posting the recipes for 0:11:19.840 --> 0:11:23.559 this quarantining plus suber rita set on our social media 0:11:24.040 --> 0:11:26.319 and as well as our website. This podcast will kill 0:11:26.360 --> 0:11:27.080 you dot com? 0:11:27.120 --> 0:11:28.000 Have you been there yet? 0:11:28.320 --> 0:11:29.960 I get to shut it again to you? 0:11:31.960 --> 0:11:33.840 On our website, This podcast will kill you dot Com, 0:11:33.880 --> 0:11:36.320 you can find so many incredible things. For example, you 0:11:36.320 --> 0:11:38.600 can find transcripts from each and every one of our episodes. 0:11:38.600 --> 0:11:41.320 You can find a good Reads list from uh where 0:11:41.440 --> 0:11:43.360 Aaron Welsh like story books mostly. 0:11:44.440 --> 0:11:45.960 There's also a bookshop dot org affiliate. 0:11:45.960 --> 0:11:47.360 Again, I was going to say that this time, I 0:11:47.360 --> 0:11:50.320 forgot it last time. We've also got merch, some pretty 0:11:50.679 --> 0:11:53.240 incredible merch that we're wrapping today. If you're seeing this 0:11:53.320 --> 0:11:57.040 on video. What else do we have? We have sources 0:11:57.080 --> 0:11:58.960 from every single one of our episodes. We have links 0:11:59.000 --> 0:12:01.120 to Bloodmobile who provide it's the music for all of 0:12:01.120 --> 0:12:04.200 our episodes. We've got a contact us form, a first 0:12:04.200 --> 0:12:07.240 hand account form. Have you been to our website yet? 0:12:08.200 --> 0:12:10.280 No one is gonna want to go. They're like, I've 0:12:10.280 --> 0:12:12.240 seen it all. I've heard you talk about it all. 0:12:12.360 --> 0:12:12.800 What else? 0:12:12.880 --> 0:12:13.680 What else do I need? 0:12:13.840 --> 0:12:14.520 Nothing new? 0:12:14.760 --> 0:12:15.480 Nothing new? 0:12:15.559 --> 0:12:18.040 Okay, shall we think? We shall? 0:12:18.040 --> 0:12:20.520 I don't have any other business for today. Same so 0:12:21.040 --> 0:12:25.240 me Aaron all about the placenta. 0:12:25.440 --> 0:12:27.800 I really can't wait. Good, Let's take a break out 0:12:28.160 --> 0:12:29.400 and then and then I'll get started. 0:12:29.400 --> 0:12:46.600 Okay. 0:12:46.800 --> 0:12:46.959 Hi. 0:12:47.120 --> 0:12:49.439 My name is Tracy and I was thirty years old 0:12:49.480 --> 0:12:51.920 and went off the birth control pill. I had been 0:12:51.920 --> 0:12:54.720 on it since I was sixteen. Hoping for the best, 0:12:54.840 --> 0:12:57.640 my husband and I went for it. Three months into 0:12:57.679 --> 0:12:59.959 being off the pill, I was late having my period. 0:13:00.120 --> 0:13:03.200 It was a Friday night and I would normally be 0:13:03.280 --> 0:13:05.880 having a nice gen and tonic to greet the weekend, 0:13:06.480 --> 0:13:08.679 so I went to the store and bought a pregnancy 0:13:08.760 --> 0:13:12.080 test and immediately took it. It was negative. Okay, I 0:13:12.080 --> 0:13:13.880 guess I will be having a J ANDT and went 0:13:13.920 --> 0:13:16.920 into the kitchen to mix up my favorite cocktail. Five 0:13:17.040 --> 0:13:20.280 days later, on April first, I had a regular checkup 0:13:20.320 --> 0:13:22.880 at my o BA. She and I talked about what 0:13:22.960 --> 0:13:25.640 my plan was and that I was officially off the pill. 0:13:26.360 --> 0:13:29.160 I did the normal things at the appointment, you're in sample, etc. 0:13:30.000 --> 0:13:31.720 She was gone for a bit and when she came 0:13:31.720 --> 0:13:33.720 back into the room, she said, well, this is no 0:13:33.800 --> 0:13:38.559 April Fool's joke, but you're pregnant. WHOA Okay. I went 0:13:38.559 --> 0:13:40.360 home to tell my husband and thought I'd have a 0:13:40.360 --> 0:13:43.640 little fun with the fact that it was April Fool's Day. So, 0:13:43.679 --> 0:13:46.720 aside from being totally shocked, we were excited and a 0:13:46.720 --> 0:13:49.800 bit terrified. The next week, I went into the doctor's 0:13:49.800 --> 0:13:53.560 office to have my hCG levels measured. My doctor said 0:13:53.600 --> 0:13:55.800 they weren't great, but perhaps that is why I got 0:13:55.840 --> 0:13:59.080 a negative reading when I had taken the test. I 0:13:59.080 --> 0:14:00.920 would need to come back into the office a few 0:14:01.000 --> 0:14:03.719 days later to see if they had increased. But they 0:14:03.720 --> 0:14:07.199 had not increased. They should be doubling. At this point 0:14:07.360 --> 0:14:10.040 I figured this pregnancy might not make it. But the 0:14:10.040 --> 0:14:12.520 good news was as I had become pregnant and I 0:14:12.559 --> 0:14:16.400 could try again. A few days later, I went back in. Nope, 0:14:16.559 --> 0:14:19.160 not have any luck with the numbers. I went back 0:14:19.200 --> 0:14:22.360 several times over a couple of weeks, and it just 0:14:22.440 --> 0:14:25.160 didn't seem like this is going to happen. Then a 0:14:25.160 --> 0:14:28.120 couple of weeks into the process, I went in for 0:14:28.240 --> 0:14:30.720 yet another test, and my doctor came into the exam 0:14:30.800 --> 0:14:33.680 room and said, your numbers are all great. Everything had 0:14:33.720 --> 0:14:36.960 rebounded and I was exactly where I should be, So 0:14:37.000 --> 0:14:39.600 I thought I could get a little excited now from 0:14:39.640 --> 0:14:42.800 then on out, Aside from feeling very dizzy and sick 0:14:42.920 --> 0:14:46.440 for four months, she came bounding out a week early, 0:14:46.960 --> 0:14:49.840 a healthy baby girl, and now she is about to 0:14:49.880 --> 0:14:52.920 start her third year of medical school. You never really 0:14:52.960 --> 0:14:55.480 know how things are going to play out. And yes, 0:14:55.640 --> 0:14:59.520 she is the one who got me hooked on tp WK. 0:15:00.000 --> 0:15:05.840 Why Hi. My name is Sarah and I live in Oxydghire, England, 0:15:05.880 --> 0:15:09.200 with my husband Mike and our younger son Ethan. Like 0:15:09.280 --> 0:15:12.160 many people, I didn't actually know my blood group until 0:15:12.160 --> 0:15:16.200 I became pregnant. Thankfully, being Reese's negative made very little 0:15:16.200 --> 0:15:19.120 difference to either of my first two pregnancies. I had 0:15:19.120 --> 0:15:21.800 the routine anti D injections and both boys were born 0:15:21.840 --> 0:15:25.520 full term and healthy. Sadly, my third pregnancy ended in 0:15:25.600 --> 0:15:28.760 early miscarriage. No reason was found and I was reassured 0:15:28.760 --> 0:15:32.480 that it wasn't connected to Reese's disease. However, when I 0:15:32.520 --> 0:15:35.080 became pregnant with Ethan the following year, signs of a 0:15:35.200 --> 0:15:38.320 Reese's reaction appeared very early. A blood test showed the 0:15:38.360 --> 0:15:40.760 presence of antibodies that were found to be resistant to 0:15:40.800 --> 0:15:44.880 anti D. Thankfully, the antibody levels remained low and regular 0:15:44.920 --> 0:15:48.160 skins reassured us that he was growing as expected. Each 0:15:48.200 --> 0:15:51.880 week that passed felt like a victory. Unfortunately, at about 0:15:51.920 --> 0:15:56.160 five months, the antibody levels rose sharply. Regular checkups continued 0:15:56.200 --> 0:15:58.760 as we monitored him for any sign of distress. The 0:15:58.800 --> 0:16:01.640 plan was supposedpone any intervention for as long as we could. 0:16:02.240 --> 0:16:04.440 We made it to seven months before the scans showed 0:16:04.480 --> 0:16:07.480 that he was developing fetal anemia. He needed a blood 0:16:07.480 --> 0:16:10.120 transfusion to limit the effects of the anemia and to 0:16:10.120 --> 0:16:14.920 give him more time before delivery became necessary. Despite signing 0:16:14.960 --> 0:16:17.280 all of the waivers who really weren't prepared for the 0:16:17.280 --> 0:16:20.200 transfusion to fail and for an emergency CEA section to 0:16:20.240 --> 0:16:23.320 be performed to save his life. I vividly remember the 0:16:23.360 --> 0:16:26.080 shock of seeing him for the first time, so small 0:16:26.120 --> 0:16:29.240 in his incubator, covered in wires, with a machine breathing 0:16:29.280 --> 0:16:32.760 for him. It just didn't feel real. I was dischonged 0:16:32.760 --> 0:16:35.280 a few days after Ethan was born, and going home 0:16:35.320 --> 0:16:37.920 without him was one of the hardest moments in my life. 0:16:38.120 --> 0:16:40.800 My husband's paternity leave was soon over, and I then 0:16:40.880 --> 0:16:44.040 faced continuing to recover from surgery while caring for our 0:16:44.080 --> 0:16:46.600 older boys and trying to visit the hospital as often 0:16:46.640 --> 0:16:50.600 as possible. Slowly, Ethan became stronger and he worked his 0:16:50.680 --> 0:16:54.000 way through the nurseries in a nicu and scaboo. Finally, 0:16:54.080 --> 0:16:56.240 after eight long weeks, we got to bring him home 0:16:56.520 --> 0:16:58.720 just a few days before his due date and without 0:16:58.760 --> 0:17:02.440 the need for any additional oxygen support. Our four pound 0:17:02.440 --> 0:17:05.560 Premium is now a happy, very tall, thirteen year old 0:17:05.800 --> 0:17:08.719 with a brilliant sense of humor. His difficult start in 0:17:08.760 --> 0:17:10.840 life has had no effect on his health, and most 0:17:10.880 --> 0:17:13.600 people can't believe that he was premature. We can never 0:17:13.640 --> 0:17:15.920 do enough to thank the NHS and everyone at the 0:17:16.000 --> 0:17:18.800 John Radcliffe Hospital in Oxford. Our lives are ritual with 0:17:18.840 --> 0:17:45.240 Ethan in them. 0:17:46.000 --> 0:17:50.040 Around the world and over centuries, the placenta has held 0:17:50.200 --> 0:17:54.399 and continues to hold deep meaning. Some cultures revere it, 0:17:54.720 --> 0:17:58.400 honoring it with a special burial. Mummified placentas have been 0:17:58.440 --> 0:18:00.960 found in ancient Egyptian two ms. You know I would 0:18:01.000 --> 0:18:06.760 get back to ancient Egypt again and others consume it 0:18:06.800 --> 0:18:10.000 and recognition of its power. It's been used in beauty 0:18:10.040 --> 0:18:13.359 products preserved in a jar to ensure good health. It 0:18:13.400 --> 0:18:17.400 is varyingly seen as an older sibling, a twin part 0:18:17.400 --> 0:18:21.520 of the baby itself, a friend, the finest jacket. This 0:18:21.720 --> 0:18:26.400 reverence is not unwarranted. The placenta, at its core, represents 0:18:26.520 --> 0:18:30.880 the fundamental vital connection between a mother and developing fetus, 0:18:31.440 --> 0:18:36.399 a physical, metabolic, and immunologic bond. It's the first organ 0:18:36.440 --> 0:18:38.840 you make and the first you say goodbye to. 0:18:40.600 --> 0:18:42.480 That feels so profound. 0:18:44.560 --> 0:18:45.199 Because it is. 0:18:45.600 --> 0:18:46.680 Am I going to cry about it? 0:18:47.200 --> 0:18:50.400 I just teared up a little bit myself. I've read 0:18:50.400 --> 0:18:51.640 this over this a million times. 0:18:51.720 --> 0:18:54.760 Yeah, but wow, aronkay. 0:18:54.119 --> 0:18:58.840 It's the only organ ever connected to another individual. It 0:18:58.920 --> 0:19:03.040 filters waste, it transfers vital nutrients, and acts as an 0:19:03.080 --> 0:19:07.800 important immunological barrier between mother and fetus. It's remarkable. 0:19:07.880 --> 0:19:11.560 I also, I have shared before how much I love 0:19:11.560 --> 0:19:14.320 the uterus. Yeah, and I still feel that way. Like 0:19:14.359 --> 0:19:17.240 I feel so. I have my earrings on today. I 0:19:17.320 --> 0:19:19.360 love thank you their gift from you. 0:19:20.960 --> 0:19:22.840 Congrats to myself for the good gift. 0:19:23.840 --> 0:19:28.120 I especially doing this research, and I haven't even learned 0:19:28.119 --> 0:19:32.160 what you're going to teach me yet. But I love 0:19:32.240 --> 0:19:35.159 the placenta, I know so much. 0:19:36.280 --> 0:19:39.840 Yeah, you know, and I think it had always been 0:19:39.920 --> 0:19:43.920 just a secondary character what in your life story or 0:19:44.280 --> 0:19:47.520 in my life story, in the story that I imagine, you know. 0:19:48.119 --> 0:19:50.440 And I don't even know if I had a good 0:19:50.440 --> 0:19:53.440 idea of what a placenta looks like. Yeah, so Aaron, 0:19:53.800 --> 0:19:54.440 would you mind? 0:19:54.480 --> 0:19:55.960 Do you want to see I would like to see 0:19:56.359 --> 0:20:00.359 I have today with us here today bottle of a 0:20:00.359 --> 0:20:05.720 plas not a placenta. Thank you to UCSC Family Medicine 0:20:05.720 --> 0:20:06.840 Department for letting me borrow this. 0:20:08.240 --> 0:20:08.760 Shout out. 0:20:08.960 --> 0:20:10.960 Yeah, I mean that's that's basically it. 0:20:10.960 --> 0:20:14.080 It is round, it's discoyed. It's discoyed. 0:20:14.280 --> 0:20:17.080 It has vessels on one side that is connected to 0:20:17.119 --> 0:20:19.359 the baby by a numbilical cord, and then on the 0:20:19.400 --> 0:20:21.840 other side where it was connected to the uterus. It 0:20:21.960 --> 0:20:24.360 usually is more rough and bumpy. That's why this one 0:20:24.400 --> 0:20:24.760 is like that. 0:20:24.960 --> 0:20:28.520 Yeah, I think it's it's bigger than than I think. 0:20:28.560 --> 0:20:30.199 A lot of people think it's better that bigger than 0:20:30.240 --> 0:20:30.560 I thought. 0:20:30.640 --> 0:20:32.400 Yeah it would be, and some of them are hefty. 0:20:32.520 --> 0:20:35.400 Oh yeah, I was looking at pictures and I was just. 0:20:35.400 --> 0:20:37.119 I don't know if I should leave this blown away 0:20:37.280 --> 0:20:40.399 or that's up to you. Keep it here there for 0:20:40.480 --> 0:20:41.200 the vibes. 0:20:41.560 --> 0:20:45.680 But yeah it is good. Yeah we can. We can 0:20:45.720 --> 0:20:49.199 honor the placenta here. Yeah, but yeah it is. It 0:20:49.280 --> 0:20:53.000 is a remarkable organ it really is. And I really want, 0:20:53.560 --> 0:20:55.760 if nothing else, just for us to think more about 0:20:55.760 --> 0:20:59.040 the placenta, like going forward. Anyone who's listening, okay, because 0:20:59.080 --> 0:21:03.439 the placenta deserves this recognition. At the same time, the 0:21:03.440 --> 0:21:06.239 placenta is also at the root of some of the 0:21:06.240 --> 0:21:11.160 most common disorders of pregnancy, such as preclamsia. It can 0:21:11.240 --> 0:21:14.879 invade into the uterine wall too deeply, not deeply enough, 0:21:15.240 --> 0:21:18.480 or in a problematic spot. It can separate too early 0:21:18.920 --> 0:21:22.160 or not separate when it should, and the placenta acting 0:21:22.320 --> 0:21:25.560 in these unexpected ways can lead to potentially harmful or 0:21:25.600 --> 0:21:29.760 even deadly consequences for both fetus and pregnant person. As 0:21:29.800 --> 0:21:32.560 I'm always saying on this podcast, life is full of 0:21:32.600 --> 0:21:36.800 trade offs, and the placenta is no exception. The intimacy 0:21:36.920 --> 0:21:41.120 formed by this connection is necessary for fetal growth and development, 0:21:41.920 --> 0:21:44.879 but it can also leave both mother and fetus vulnerable 0:21:44.920 --> 0:21:49.000 when things go wrong. Despite this potentially high cost, the 0:21:49.000 --> 0:21:52.320 placenta is a widespread feature of mammals, and it has 0:21:52.359 --> 0:21:56.080 evolved in many other classes of animals. The how and 0:21:56.280 --> 0:21:59.080 why of that evolutionary story is what I'm going to 0:21:59.080 --> 0:22:03.879 talk about today. So exciting from the human placenta's ancient origins, 0:22:03.880 --> 0:22:06.600 to the diversity we see in the placentas of present 0:22:06.680 --> 0:22:10.560 day mammals, from the role viruses may have played in 0:22:10.600 --> 0:22:13.000 its development, to some of the trade offs that we 0:22:13.200 --> 0:22:16.159 humans face when it comes to our invasive placentas, and 0:22:16.200 --> 0:22:18.600 also what I mean by invasive. I'll get into it. 0:22:19.160 --> 0:22:21.200 My overall goal is to get us to think about 0:22:21.280 --> 0:22:24.600 why the placenta as opposed to other reproductive strategies like 0:22:24.600 --> 0:22:28.000 egg laying, and why the human placenta as opposed to 0:22:28.119 --> 0:22:31.239 other mammalian placentas, like why why these things? How did 0:22:31.240 --> 0:22:33.679 we get here? Before I dig in, I want to 0:22:33.680 --> 0:22:36.840 mention a couple of things upfront. The first is that 0:22:36.840 --> 0:22:39.040 I'll be talking about the placenta in terms of what 0:22:39.280 --> 0:22:42.200 it is expected to do throughout a pregnancy, which does 0:22:42.240 --> 0:22:45.959 not capture the incredible variation that can occur between individuals, 0:22:46.119 --> 0:22:50.960 or even within one individual. Pregnancy. Yeah, nor will I 0:22:51.000 --> 0:22:53.960 be exploring the multitude of things that can happen when 0:22:53.960 --> 0:22:56.920 the placenta acts Outside of that. We could do an 0:22:57.119 --> 0:23:01.960 entire episode on each placental disorder. We really really could. 0:23:02.960 --> 0:23:04.879 The other thing is that this is not a comprehensive 0:23:04.880 --> 0:23:07.600 review of the placenta in all of its dimensions, like 0:23:07.640 --> 0:23:10.960 the cultural importance, the history of its study, its physiology, 0:23:11.119 --> 0:23:13.440 and so on. It's just a quick tour through one 0:23:13.480 --> 0:23:17.000 of the coolest organs. But fortunately there are many sources 0:23:17.000 --> 0:23:19.160 where you can get that more detailed info, and we'll 0:23:19.160 --> 0:23:24.359 be posting those on our website. Okay, okay, you know 0:23:24.400 --> 0:23:26.000 that I love to start deep. 0:23:26.960 --> 0:23:27.959 How deep are we going to go? 0:23:28.359 --> 0:23:32.520 It's pretty deep. Before the dinosaurs life on Earth began 0:23:32.680 --> 0:23:33.200 in the water. 0:23:34.800 --> 0:23:38.200 I love it when you do this, I really doh 0:23:38.240 --> 0:23:38.720 my gosh. 0:23:39.000 --> 0:23:42.720 Ok And there it remained for hundreds of millions of years. 0:23:43.160 --> 0:23:44.000 We're going pretty deep. 0:23:44.040 --> 0:23:44.480 I love it. 0:23:44.560 --> 0:23:47.240 Around three hundred and fifty to four hundred million years ago, 0:23:47.400 --> 0:23:50.680 a group of four legged animals made their way onto land. 0:23:51.200 --> 0:23:55.520 This group is the ancestor of all vertebrates except for fish, 0:23:55.880 --> 0:23:59.280 so it includes humans right not fish. These first the 0:23:59.320 --> 0:24:02.760 land dwelling animals couldn't quite shake their aquatic roots, and 0:24:02.800 --> 0:24:06.560 so they continued to keep laying their unfertilized eggs in water, 0:24:06.880 --> 0:24:09.800 where a male would later come by and fertilize them. 0:24:10.320 --> 0:24:13.000 This water aspect of these eggs, it's not a preference, 0:24:13.119 --> 0:24:15.880 it was a necessity. Without it, the eggs would dry out. 0:24:16.200 --> 0:24:20.480 But this reliance on water was limiting, so some of 0:24:20.480 --> 0:24:23.880 these animals evolved another strategy, eggs covered with a more 0:24:23.920 --> 0:24:27.560 protective coating, which meant that they could last outside of water, 0:24:27.760 --> 0:24:31.480 which then enabled these animals to further explore land and 0:24:31.680 --> 0:24:35.320 go out deeper and deeper into land. But this coating 0:24:35.880 --> 0:24:39.520 made the eggs less permeable, which meant that fertilization had 0:24:39.520 --> 0:24:43.080 to happen internally, acquired a whole new set of things 0:24:44.280 --> 0:24:48.400 before the egg and the yulk had fully formed. Okay, yep, yeah, 0:24:48.400 --> 0:24:51.639 And then that was in contrast to externally, like the 0:24:51.640 --> 0:24:52.920 way that frogs will lay. 0:24:52.720 --> 0:24:54.399 Eggs in or like a lot of fish, a lot 0:24:54.440 --> 0:24:55.680 of fish, right exactly. 0:24:56.680 --> 0:25:00.760 And so then after fertilization internally and after the yolk 0:25:00.800 --> 0:25:03.120 and egg had formed, the female would then lay her 0:25:03.160 --> 0:25:06.600 eggs and wait for them to hatch like a crocodile, right, right. 0:25:07.560 --> 0:25:09.359 Not the first egg laying animal that I think of, 0:25:09.400 --> 0:25:11.600 by the way, but I love that that for example. 0:25:11.200 --> 0:25:12.520 What is the first one? A bird? 0:25:13.200 --> 0:25:13.400 Yeah? 0:25:13.480 --> 0:25:17.320 But like, yeah, I mean it's true, I think of crocodiles. 0:25:17.400 --> 0:25:20.240 I love that were turtles. 0:25:20.359 --> 0:25:22.960 I don't often think about crocodile reproduction. I think that's 0:25:22.960 --> 0:25:23.439 what it is. 0:25:24.440 --> 0:25:24.480 You. 0:25:24.680 --> 0:25:26.760 Oh, but you think often about bird reproduction. 0:25:26.880 --> 0:25:30.720 Well, I eat eggs, so, oh egg like that's mine. 0:25:30.760 --> 0:25:32.240 Yeah, I guess I don't eat crocodile eggs. 0:25:32.240 --> 0:25:32.760 But I just. 0:25:34.800 --> 0:25:36.520 Also, that's so funny because when you said bird, I 0:25:36.560 --> 0:25:40.160 pictured like robins, not chickens, which is the most Oh 0:25:40.200 --> 0:25:41.439 my god, I love it. 0:25:41.480 --> 0:25:45.400 Okay, so crocodiles, crocodiles la eggs and so. 0:25:45.920 --> 0:25:50.840 But the time window between internal fertilization and egg laying, 0:25:50.960 --> 0:25:53.719 so like when those eggs were fertilized and formed and 0:25:53.720 --> 0:25:58.120 then when they were actually like deposited, right, was variable. 0:25:58.520 --> 0:26:00.679 If you kept your eggs inside longer, it meant that 0:26:00.720 --> 0:26:04.000 you could more closely control the temperature and humidity that 0:26:04.080 --> 0:26:06.720 these eggs were exposed to, which could increase the chances 0:26:06.760 --> 0:26:10.680 that your offspring survived. Okay, Eggs can be quite vulnerable 0:26:10.720 --> 0:26:15.439 to environmental threats, predators, weather extremes, fungal pathogens, and so 0:26:15.680 --> 0:26:18.879 some animals took this one step further, keeping the eggs 0:26:18.880 --> 0:26:22.840 inside until they were ready to hatch. Okay, one major 0:26:22.960 --> 0:26:26.920 transition remained though, How did the embryo get its nutrients? 0:26:26.920 --> 0:26:30.080 How did that embryo inside the eggs? So egg layers 0:26:30.359 --> 0:26:34.520 provided nutrients through the yolk encased in that less permeable barrier. 0:26:35.520 --> 0:26:38.640 But the thing is you were limited. So like when 0:26:38.640 --> 0:26:41.119 that egg was formed, that yolk it was usually going 0:26:41.200 --> 0:26:43.119 to deplete until that's all you have. It's all you have. 0:26:43.280 --> 0:26:45.639 The embryo has to be able to survive and develop 0:26:45.760 --> 0:26:47.320 enough with just whatever is in that yolk. 0:26:47.440 --> 0:26:50.320 Yeah, it's like meal prepping essentially. 0:26:56.040 --> 0:26:56.760 Yeah, it's exactly. 0:26:56.840 --> 0:26:58.240 That's exactly like prepping. 0:27:00.080 --> 0:27:00.560 I love it. 0:27:00.640 --> 0:27:04.880 Okay, Okay, there you go. See. But then what if 0:27:04.880 --> 0:27:06.600 you didn't want a meal prep and you're like this 0:27:06.720 --> 0:27:08.800 is not enough food. I'm yeah. Later in the week 0:27:08.840 --> 0:27:12.040 and you're like I'm starving. Yeah yeah, So what if 0:27:12.080 --> 0:27:17.000 instead you could provide nutrients to the embryo directly and continuously. 0:27:16.280 --> 0:27:18.600 Continuous throughout pregnant. You could make your meals on the 0:27:18.600 --> 0:27:19.600 go right, Yeah. 0:27:19.480 --> 0:27:21.560 You could always have like a resource. Oh well, just 0:27:21.680 --> 0:27:22.880 there's a little snack drawer. 0:27:22.960 --> 0:27:23.480 Snack drawer. 0:27:23.640 --> 0:27:27.879 Yeah, I don't know, these metaphors might not work. I 0:27:28.000 --> 0:27:29.720 really like we can. We can reel it back in. 0:27:31.000 --> 0:27:34.240 And so a subset of these egg laying animals evolved 0:27:34.320 --> 0:27:38.000 the ability to pass nutrients directly to the developing embryo, 0:27:38.359 --> 0:27:41.520 not via a yolk, but through an organ that connected 0:27:41.720 --> 0:27:45.399 mother to embryo, an organ that we know as the placenta. 0:27:46.480 --> 0:27:49.879 So we went from laying unfertilized eggs and water, to 0:27:49.960 --> 0:27:53.639 laying fertilized eggs on land, to retaining those fertilized eggs 0:27:53.640 --> 0:27:56.399 for longer periods of time, to then getting rid of 0:27:56.440 --> 0:27:59.560 this eggshell that didn't let nutrients in or out to 0:27:59.720 --> 0:28:04.119 directly connect with the fetus and remain in contact for 0:28:04.200 --> 0:28:05.200 the duration of pregnancy. 0:28:05.280 --> 0:28:09.639 Okay, that's how we got boom boom boom to the placenta, straightforward, honestly, right. 0:28:09.520 --> 0:28:12.960 Okay, it's an oversimplification, of course, it's like covering hundreds 0:28:13.000 --> 0:28:16.760 of billions of years. And I also don't want to 0:28:16.920 --> 0:28:19.359 with this, you know, with this explanation give off the 0:28:20.480 --> 0:28:23.600 impression that the placenta or live birth is like the 0:28:23.680 --> 0:28:26.240 end all, be all reproductive strategy, or that it's one 0:28:26.320 --> 0:28:29.600 unique to mammals. Like I said earlier, it evolved independently 0:28:29.640 --> 0:28:32.399 in many classes of animals. And the fact that we 0:28:32.480 --> 0:28:38.440 see so many different reproductive strategies today, like laying unfertilized eggs, 0:28:38.680 --> 0:28:41.760 laying fertilized eggs, retaining eggs until they're ready to hatch, 0:28:41.800 --> 0:28:44.760 life birth, and so on, the variation is endless. Yeah, 0:28:44.960 --> 0:28:46.840 what was the one that I like texted you about 0:28:46.880 --> 0:28:48.440 gastric brooding frogs? 0:28:48.680 --> 0:28:51.040 Yeah, and then I came back with the sea horses. 0:28:51.280 --> 0:28:53.600 Yes, yeah, I know. There are so many different ways, 0:28:53.640 --> 0:28:56.800 so many reproductive strategy It's incredible. And this shows us 0:28:56.800 --> 0:28:59.040 that there are pros and cons for each and that 0:28:59.080 --> 0:29:01.680 what works for one species might not work for another. 0:29:02.320 --> 0:29:05.600 So sure, laying eggs might make them more susceptible to 0:29:05.720 --> 0:29:08.720 external threats, but it frees you up out running or 0:29:08.760 --> 0:29:12.160 out flying a predator is more challenging when you're carrying 0:29:12.280 --> 0:29:15.560 around a load of offspring in your uterus literally. On 0:29:15.640 --> 0:29:18.560 the other hand, investment in offspring is generally higher than 0:29:18.600 --> 0:29:22.480 placental mammals, which can translate into higher survival for those offspring. 0:29:23.040 --> 0:29:26.880 I mean, we could spend hours discussing and you know, 0:29:27.120 --> 0:29:30.240 arguing the trade offs of different reproductive strategies, but we're 0:29:30.240 --> 0:29:31.200 not going to do it today. 0:29:31.280 --> 0:29:31.400 No. 0:29:32.080 --> 0:29:35.840 So I mentioned that the placenta evolved independently multiple times 0:29:35.880 --> 0:29:39.080 across the animal kingdom. Yeah, what in mammals though it 0:29:39.120 --> 0:29:39.840 happened just once? 0:29:39.880 --> 0:29:40.040 Ok. 0:29:40.160 --> 0:29:41.120 I gotta talk about the mammals. 0:29:41.160 --> 0:29:43.600 Okay, Now I really want to know about the other ones. Interesting. 0:29:43.560 --> 0:29:46.520 You know, I can send you some sources. Can go 0:29:46.560 --> 0:29:48.360 to our website, this podcast with you dot com, go 0:29:48.400 --> 0:29:52.480 to the sources tet. But this means that the incredible 0:29:52.480 --> 0:29:55.320 placental diversity that we see in mammals today comes from 0:29:55.560 --> 0:29:59.640 just one origin. Wow, around two hundred and fifty million 0:29:59.680 --> 0:30:01.880 years go. We still have to go far back. A 0:30:02.040 --> 0:30:05.360 group of animals called the thrapsids split off from the rest. 0:30:05.720 --> 0:30:08.680 And these were reptile like creatures, and they differed from 0:30:08.720 --> 0:30:12.920 the rest in three key ways. First, they could generate 0:30:12.960 --> 0:30:17.200 their own body heat and maintain temperature crucial. Second, they 0:30:17.240 --> 0:30:20.880 had body hair, which helped provide insulation for heat maintenance. 0:30:21.280 --> 0:30:25.120 And third they developed the ability to produce milk. Oh. 0:30:26.240 --> 0:30:29.120 Interesting, I know, I didn't know it went that far 0:30:29.200 --> 0:30:29.920 back either. 0:30:30.280 --> 0:30:31.000 Yeah, Okay. 0:30:31.520 --> 0:30:33.560 Over the next one hundred million years or so, this 0:30:33.640 --> 0:30:36.680 group continued to diversify, splitting off into the three main 0:30:36.720 --> 0:30:40.560 groups that today make up modern mammals. We've got the monitories, 0:30:40.880 --> 0:30:43.560 the egg laying mammals like the platypus and the Echidna 0:30:43.680 --> 0:30:46.080 love them. We've got the marsupials, the one who use 0:30:46.120 --> 0:30:50.000 a pouch and birth teeny tiny young like the Tasmanian devil, kangaroo, Koala, 0:30:50.000 --> 0:30:53.320 etct some of my faves. And then the Eutherians or 0:30:53.320 --> 0:30:58.120 the placental mammals, which includes all other mammals today, including humans. 0:30:58.960 --> 0:31:01.240 I have to throw in this way actually because it 0:31:01.400 --> 0:31:03.440 just it bothered me as I read this, and it's 0:31:03.480 --> 0:31:05.800 probably old news to people who know more about the placenta. 0:31:05.880 --> 0:31:09.520 But marsupials also possess structures resembling a placenta. They just 0:31:09.560 --> 0:31:12.320 play a slightly different role and are very different than 0:31:12.360 --> 0:31:16.360 our placentas. And so one key difference between marsupials and 0:31:16.400 --> 0:31:19.880 Eutherians is when nutrient transfer takes place. So in marsupials 0:31:19.880 --> 0:31:23.560 it mostly takes place during lactation, while in Eutherians most 0:31:23.640 --> 0:31:26.040 nutrient transfer happens during gestation. 0:31:26.560 --> 0:31:29.080 Got it right, I think I understand. 0:31:29.240 --> 0:31:31.680 Yeah, so they have something that's like a placenta, but 0:31:31.760 --> 0:31:33.040 its main role is not. 0:31:33.080 --> 0:31:36.000 Provided, not threading the nutrients. Yeah, yeah, makes sense. But 0:31:36.080 --> 0:31:39.480 it's like, but we still call the Eutherian mammals the placentals, okay, 0:31:39.520 --> 0:31:43.000 And I'm just like, well, actually, yeah, I know it's 0:31:43.040 --> 0:31:45.560 my I can't resist. But what I wanted to say 0:31:45.560 --> 0:31:49.360 about lactation was that in monotremes they don't have nipples. 0:31:49.400 --> 0:31:51.960 They have like little pores. Yes, I knew that, and 0:31:52.000 --> 0:31:55.680 they like the little the little babies lap up. I know, 0:31:56.120 --> 0:31:58.160 it's so so amazing. 0:31:58.320 --> 0:32:01.840 I know I want to ask more about I won't though. 0:32:02.040 --> 0:32:03.400 You get to ask me, and I'll just say I 0:32:03.400 --> 0:32:03.720 don't know. 0:32:04.280 --> 0:32:05.840 Well, I don't know how to form my question. 0:32:06.000 --> 0:32:08.520 Okay, problem because it's like going back to like those 0:32:08.800 --> 0:32:12.680 early early early apps, the thrapcids, like you know, dimetrodon 0:32:13.000 --> 0:32:15.920 Yeah was that a thrapsid or was that something? See 0:32:17.560 --> 0:32:19.520 it's only because I'm thinking of like our all of 0:32:19.520 --> 0:32:21.120 the dinosaur toys that we have at home, and I 0:32:21.160 --> 0:32:22.479 always go, well, this one's not right. 0:32:22.480 --> 0:32:25.880 Which ones are therapids? In which ones or something like that. 0:32:26.000 --> 0:32:26.160 Yeah. 0:32:26.360 --> 0:32:27.520 See, and this is where. 0:32:27.320 --> 0:32:30.800 My anyways, Yeah, I might did evo bio off topic, 0:32:31.280 --> 0:32:31.880 off topic. 0:32:33.080 --> 0:32:35.200 Well, well we'll bring it back to the placenta. 0:32:35.280 --> 0:32:35.800 That's please. 0:32:35.840 --> 0:32:41.920 Okay. So, so these earliest Eutherian placenta having mammals probably 0:32:42.000 --> 0:32:43.800 emerged around one hundred and ten to one hundred and 0:32:43.800 --> 0:32:46.840 twenty five million years ago. Okay, Yeah, and from there 0:32:47.320 --> 0:32:50.760 nature did its thing. Evolution did its thing. The asteroid 0:32:50.800 --> 0:32:53.640 that caused a massed extinction event sixty six million years 0:32:53.680 --> 0:32:56.080 ago did its thing. Cleared the way for the age 0:32:56.120 --> 0:32:59.360 of mammals. Check out our blast of Mycosest episode for more, 0:32:59.440 --> 0:33:03.480 so much more, and the placenta diversified. When it comes 0:33:03.520 --> 0:33:07.400 to Eutherian placentas, there's a whole lot of variation from 0:33:07.560 --> 0:33:10.800 size to shape to invasiveness. You know, we held up 0:33:10.840 --> 0:33:14.640 the human placenta, which is like a discoid shape. They 0:33:14.680 --> 0:33:19.240 come in all different shapes. It's amazing. One book I 0:33:19.280 --> 0:33:22.360 read suggested that it is probably the most variable of 0:33:22.400 --> 0:33:24.000 all mammalian organs. 0:33:24.120 --> 0:33:25.800 Really yeah, that's interesting. 0:33:25.920 --> 0:33:28.280 I mean I wonder if every organ researcher says the 0:33:28.280 --> 0:33:29.160 same thing about their. 0:33:29.120 --> 0:33:31.240 Organ, like my organ is actually the cold. 0:33:31.040 --> 0:33:34.360 Blood is the most divert. 0:33:33.640 --> 0:33:35.120 Sure it's not that one. 0:33:36.480 --> 0:33:39.040 We'll do an episode on okay, but for today, I'm 0:33:39.040 --> 0:33:42.280 only going to get into one dimension of this variation 0:33:42.360 --> 0:33:45.520 in mammalian placentas, and that is in the invasiveness right 0:33:45.600 --> 0:33:48.320 of the placenta. So you can look at invasiveness in 0:33:48.400 --> 0:33:51.000 two ways. One is in the number of cell layers 0:33:51.040 --> 0:33:54.160 separating fetal and maternal bloodstreams, and the second is in 0:33:54.320 --> 0:34:00.120 how physically deeply fetal tissue invades and restructures maternal tissue. 0:34:00.200 --> 0:34:02.000 So one is like how many layers are in between, 0:34:02.040 --> 0:34:02.720 and the other is. 0:34:02.680 --> 0:34:04.560 Like, how how deep do those villa I go? 0:34:04.800 --> 0:34:09.360 Exactly? Yeah. Researchers generally group the invasiveness of the placenta 0:34:09.400 --> 0:34:13.400 into three categories. Sometimes there's a fourth one added depending 0:34:13.560 --> 0:34:16.719 on the number of cellular layers. So on the less 0:34:16.760 --> 0:34:22.520 invasive side of things, we've got like pigs, sheep, dolphin, hippo. 0:34:22.840 --> 0:34:27.440 In the medium invasive, we've got dogs, sloths, elephants, ardvarks, raccoons. 0:34:27.719 --> 0:34:29.920 And on the maximally invasive, Yeah. 0:34:29.800 --> 0:34:31.320 That was like a really wide range. 0:34:31.520 --> 0:34:34.640 Well that's okay, yeah, yeah, okay, in a second, kap. 0:34:35.440 --> 0:34:38.880 On the maximally invasive, as in the placental tissue is 0:34:38.920 --> 0:34:41.880 often referred to as being bathed in maternal blood. Right, 0:34:42.200 --> 0:34:46.840 We've got humans and other great apes, mice, rabbits, guinea pigs, 0:34:47.080 --> 0:34:49.880 nine banded armadillos, hyenas, and others. 0:34:50.280 --> 0:34:54.359 Okay, that's also more than I realized. Yeah, that are 0:34:54.520 --> 0:34:56.320 like that considered that invasive. 0:34:56.440 --> 0:34:59.239 Yeah, on the invasive side of yeah, like in terms 0:34:59.239 --> 0:35:02.680 of the cell layers. Yeah, And so unless I specify otherwise, 0:35:02.840 --> 0:35:05.680 when I'm talking about invasiveness, I'm usually referring to this 0:35:05.800 --> 0:35:09.280 classification based on cell layers between fetal and maternal blood. 0:35:10.239 --> 0:35:14.960 Why is there such variation? Is there a benefit to 0:35:15.040 --> 0:35:16.840 one type of placenta over another? 0:35:17.880 --> 0:35:22.480 I mean, yes, well, yes, or trade offs? Yeah, yeah, I. 0:35:22.400 --> 0:35:24.360 Mean, and it's it's a great we don't fully know 0:35:24.560 --> 0:35:29.719 the answer class classic, and it doesn't seem to be 0:35:29.800 --> 0:35:33.400 driven solely by like how related like different animal groups 0:35:33.800 --> 0:35:35.839 and like, oh well all of the you know, there 0:35:35.840 --> 0:35:38.680 are some broad trends, but for the most part, it 0:35:38.680 --> 0:35:41.239 doesn't really seem that way. 0:35:41.360 --> 0:35:45.200 So it's like a bunch of examples of convergent evolution essentially. 0:35:45.000 --> 0:35:48.200 Friend of like what is driving in different species? We 0:35:48.200 --> 0:35:49.040 don't fully understand. 0:35:49.080 --> 0:35:51.520 I think the drivers for interesting for that. 0:35:51.760 --> 0:35:55.200 Yeah, but one thing that we do know is that 0:35:55.560 --> 0:36:00.680 our invasive placenta, like the human invasive placenta, is the 0:36:00.880 --> 0:36:04.440 type that probably evolved first, and then it evolved to 0:36:04.440 --> 0:36:05.400 become less invasive. 0:36:05.680 --> 0:36:06.480 Interesting. 0:36:06.760 --> 0:36:11.200 Interesting. Indeed, Okay, it's possible that, like so we're talking 0:36:11.200 --> 0:36:14.200 about trade offs, it's possible that certain molecules like iron 0:36:14.440 --> 0:36:16.920 have a slightly more difficult time getting to the fetus 0:36:16.920 --> 0:36:20.960 in mammals with less invasive placentas. But that's not entirely clear. 0:36:21.360 --> 0:36:24.600 And another hypothesis is that the more invasive the placenta, 0:36:24.800 --> 0:36:28.040 the better the signaling in all directions like mom to fetus, 0:36:28.080 --> 0:36:31.239 fetus to mom, placenta to mom, et cetera. I also 0:36:31.280 --> 0:36:35.960 read that placental transfer of certain antibodies IgG if you're curious, 0:36:35.960 --> 0:36:38.360 which is the most abundant in our blood, has only 0:36:38.440 --> 0:36:44.000 been observed in invasive placentas, possibly demonstrating active transport of 0:36:44.040 --> 0:36:46.759 this antibody to the fetus, which could have then like 0:36:47.040 --> 0:36:48.279 protective roles. 0:36:48.040 --> 0:36:50.520 Right, because then your fetus is basically your baby's being 0:36:50.560 --> 0:36:54.919 born with all of the antibodies that mom has had. Yeah, 0:36:54.920 --> 0:36:57.520 so like protection from all protections at least passively, at 0:36:57.600 --> 0:36:58.880 least for those first few months. 0:36:58.719 --> 0:37:02.520 Right, which question mark? Okay is not fully clear? 0:37:02.600 --> 0:37:03.080 Yeah, okay? 0:37:04.000 --> 0:37:07.439 Why still, why do we have this invasive placenta? One 0:37:07.520 --> 0:37:11.320 popular but now largely discarded hypothesis is that our invasive 0:37:11.360 --> 0:37:14.800 placentas were necessary to get enough nutrients to the developing 0:37:14.960 --> 0:37:19.560 human fetal brain. For one, our big brains came after 0:37:20.040 --> 0:37:21.080 this invasive. 0:37:20.760 --> 0:37:23.520 Clearly, if this was the first type first time, well 0:37:23.560 --> 0:37:25.200 it wasn't always known that that was the case. 0:37:25.320 --> 0:37:26.320 Right, that makes sense. 0:37:26.360 --> 0:37:31.040 But two, not all animals with invasive placentas have big brains, 0:37:31.360 --> 0:37:34.799 and not all animals with big brains have invasive placentas, 0:37:34.840 --> 0:37:38.840 like dolphins, which have among the least invasive type of placenta. 0:37:39.400 --> 0:37:42.640 And four, there is no evidence that transfer of nutrients 0:37:42.680 --> 0:37:45.760 is somehow greater or more efficient and more invasive placentas 0:37:45.760 --> 0:37:46.959 compared to less invasive books. 0:37:47.239 --> 0:37:48.000 Okay, all right. 0:37:49.239 --> 0:37:52.319 The idea that invasive placentas were necessary for our big 0:37:52.360 --> 0:37:55.759 brains was based on this arrogant assumption that whatever placenta 0:37:55.760 --> 0:37:58.279 we humans have must be the most advanced and the 0:37:58.360 --> 0:38:01.839 least primitive. It's the best, it's the best. But since 0:38:01.880 --> 0:38:03.920 that's not the case, we may have to consider instead 0:38:04.000 --> 0:38:08.000 two related questions, what are the potential downsides to an 0:38:08.000 --> 0:38:11.320 invasive placenta and how have those of us with invasive 0:38:11.360 --> 0:38:15.960 placentas adapted to deal with those downsides. So let's start 0:38:15.960 --> 0:38:19.440 with one of the major potential drawbacks, the fact that 0:38:19.719 --> 0:38:24.759 during pregnancy there is an alien thing growing inside you. Yes, yes, 0:38:24.840 --> 0:38:27.319 it's fifty percent you, but only fifty percent, but only 0:38:27.360 --> 0:38:30.040 fifty percent. That other fifty percent is not you, not 0:38:30.080 --> 0:38:33.520 you over the past five hundred million years, which is 0:38:33.520 --> 0:38:36.200 when the first natural killer cells are thought to have evolved. 0:38:36.239 --> 0:38:38.920 Oh my god, wow, Okay, I know, wow. 0:38:38.840 --> 0:38:39.120 I know. 0:38:39.680 --> 0:38:42.640 That shows how fundamental this idea is. 0:38:42.719 --> 0:38:45.799 And like just immunology of needing to be able to 0:38:46.680 --> 0:38:48.080 find non self. 0:38:48.440 --> 0:38:51.279 That is the whole point of the immune system is 0:38:51.320 --> 0:38:55.319 distinguishing self and non self. Like that is pretty much 0:38:55.360 --> 0:38:58.480 the point of any I mean, and it's that's an oversimplification, sure, 0:38:59.080 --> 0:39:04.200 but pretty much at its core, y versus self. Yeah, 0:39:04.239 --> 0:39:06.959 And so sometimes our immune system works a little better 0:39:07.000 --> 0:39:08.840 than we want it to, like when we reject a 0:39:08.840 --> 0:39:12.680 transplanted organ. Sometimes it's a little overzealous and it blurs 0:39:12.680 --> 0:39:14.840 the line between self and non self. Is in the 0:39:14.840 --> 0:39:18.520 case of autoimmune diseases, and sometimes it might need a 0:39:18.520 --> 0:39:23.239 little help, but overall, this ability is so crucial to 0:39:23.280 --> 0:39:27.480 our survival that it's a universal feature in all multicellular 0:39:27.520 --> 0:39:30.239 life on this planet and has been for quite some time. 0:39:30.880 --> 0:39:35.360 And so pregnancy then should offer a pretty huge immunological challenge. Right, 0:39:35.800 --> 0:39:37.880 there's this non self thing inside that has. 0:39:37.760 --> 0:39:40.319 To stay there for however many months, depending on what 0:39:40.360 --> 0:39:42.839 species you are, right, two hundred and sixty six days 0:39:42.880 --> 0:39:45.000 at least, there are yeah, yeah. 0:39:45.040 --> 0:39:49.239 Yep, yeah yeah, And so from an immunological standpoint, our 0:39:49.280 --> 0:39:53.200 bodies should flag the newly implanted blasticist and mount a 0:39:53.239 --> 0:39:56.839 defense against it. Sometimes this is what happens. And one 0:39:56.840 --> 0:39:59.879 potential downside of our invasive placentas is that the deep 0:40:00.080 --> 0:40:02.799 for the invasion, the higher the risk for triggering an 0:40:02.840 --> 0:40:06.480 immune response from the mother. Right, Many species that have 0:40:06.560 --> 0:40:10.600 similarly invasive placentas like ours tend to have much shorter gestations, 0:40:11.360 --> 0:40:15.480 in part potentially to minimize this risk, but we seem 0:40:15.600 --> 0:40:16.880 to manage overall. 0:40:16.960 --> 0:40:20.439 Right, This is though, why we see things like recist disease, right, 0:40:20.719 --> 0:40:23.319 where you have at least some fetal cells that are 0:40:23.400 --> 0:40:28.000 able to cross over this barrier and come onto the 0:40:28.040 --> 0:40:30.479 other side of our cells, and then we do see 0:40:30.520 --> 0:40:34.880 those and mount a defense against them in a future pregnancy. 0:40:34.480 --> 0:40:36.879 Potentially with and with potentially really. 0:40:36.800 --> 0:40:39.480 Really disastrous consequences. Exactly exactly, yeah. 0:40:39.400 --> 0:40:40.480 Yeah, yeah. 0:40:40.520 --> 0:40:43.440 And so there is like this immune relationship that is 0:40:43.600 --> 0:40:44.920 really complex. 0:40:45.000 --> 0:40:47.760 It's a very tight rope that we are walking. 0:40:47.920 --> 0:40:53.480 Yep, yeah, yeah. So what like how like why what 0:40:53.640 --> 0:40:56.000 allows for tolerance over rejection? 0:40:56.239 --> 0:40:56.719 Yeah? 0:40:56.840 --> 0:40:59.080 One thing that helps is that a fetus is not 0:40:59.320 --> 0:41:02.680 the same as an organ transplant. A transplanted organ is 0:41:02.719 --> 0:41:06.440 connected to the recipient's blood supply, whereas during pregnancy, the 0:41:06.480 --> 0:41:10.719 fetal and maternal blood are kept separate, right, and they 0:41:10.719 --> 0:41:13.880 are kept separate by the outer layer of the placenta. 0:41:13.920 --> 0:41:16.719 And this outer layer consists of a bunch of cells 0:41:17.040 --> 0:41:19.960 that are fused together to make a tissue. So it's 0:41:19.960 --> 0:41:23.160 not like individual cells anymore. The membranes have been fused 0:41:23.160 --> 0:41:26.680 together to create like one giant cell with like multinucleated cell. 0:41:26.719 --> 0:41:29.520 That's why they call it a sensicio trophoblasts. If you 0:41:29.560 --> 0:41:33.399 remember our RSV episode, that stands for respiratories and social virus. 0:41:33.440 --> 0:41:38.480 I'm going nerdy, I'm so sorry, but sensisium. Yeah, multinucleated cell. 0:41:38.600 --> 0:41:41.399 Multinucleated cells, so it's just like one cell, but it's 0:41:41.440 --> 0:41:43.000 a long, giant cell. 0:41:43.080 --> 0:41:46.040 It goes the whole entire outside of that lastosis. 0:41:46.200 --> 0:41:50.560 Yep. And this tissue is pretty impenetrable because these cells 0:41:50.560 --> 0:41:54.120 are fused together. There are no more membranes between the cells, 0:41:54.840 --> 0:41:57.480 which means there aren't any gaps to let in let's say, 0:41:57.480 --> 0:42:00.680 for example, mom's antibodies, which might flag the fetus as 0:42:00.760 --> 0:42:03.080 non self. So it just creates this like there are 0:42:03.120 --> 0:42:05.800 no gaps, right, you can't you can't even get no 0:42:05.960 --> 0:42:06.560 foot in the door. 0:42:06.760 --> 0:42:10.319 No maternal stuff can get in to the placenta at 0:42:10.360 --> 0:42:10.680 that point. 0:42:10.800 --> 0:42:11.000 Yeah. 0:42:11.120 --> 0:42:13.719 Yeah, And this is a pretty crucial tissue and its 0:42:13.800 --> 0:42:17.000 role is not limited to barrier right. It's also a 0:42:17.120 --> 0:42:21.200 hugely important regulator in the expression of hormones like upregulate 0:42:21.280 --> 0:42:25.960 that hormone, down regulate that hormone, proteins and other molecules 0:42:26.000 --> 0:42:29.239 that are used in communication between placenta and mom. And 0:42:29.440 --> 0:42:32.759 we owe it all to an ancient virus stop it 0:42:33.160 --> 0:42:34.680 oh yeah what? 0:42:35.080 --> 0:42:35.520 Oh yeah. 0:42:36.280 --> 0:42:39.800 At some point one of our ancestors was infected with 0:42:39.920 --> 0:42:44.920 a retrovirus which inserted its genetic material into one of 0:42:44.960 --> 0:42:46.440 their sperm or egg cells. 0:42:46.520 --> 0:42:47.320 Okay, okay. 0:42:48.040 --> 0:42:51.880 When those cells replicated, like when they formed an embryo 0:42:52.040 --> 0:42:55.640 and someone so did, the viral DNA carried it with it, okay, 0:42:56.080 --> 0:42:59.160 which was then also passed down to subsequent generations because 0:42:59.160 --> 0:43:00.520 it would have been an all all of the germ 0:43:00.560 --> 0:43:04.040 cells down the line. Over time, we lost bits of 0:43:04.160 --> 0:43:08.440 that viral DNA, but some crucial parts remained, genes that 0:43:08.600 --> 0:43:10.799 maybe we were like, huh, this seems like it could 0:43:10.880 --> 0:43:15.160 be worth keeping around. We call these viral remnants in 0:43:15.280 --> 0:43:19.480 general endogenous retroviruses, and our genome is chock full of them. 0:43:19.680 --> 0:43:21.520 I think I've talked about this before on the podcast 0:43:21.760 --> 0:43:25.239 being really excited. About five to eight percent of the 0:43:25.400 --> 0:43:29.400 human genome is a viral origin. Five to eight percent. 0:43:29.520 --> 0:43:33.800 That's a huge proportions. Not us virus, I mean, it 0:43:33.920 --> 0:43:39.200 is us the genes since it in one and since 0:43:39.239 --> 0:43:42.240 it in two, which help us to fuse these cells 0:43:42.320 --> 0:43:46.759 together to make that like one layer, and also help 0:43:46.880 --> 0:43:51.040 us escape detection from mom. They come from a couple 0:43:51.120 --> 0:43:56.160 of these ancient viruses. That's what allows for that that 0:43:56.440 --> 0:43:59.160 formation of tissue, that barrier. 0:43:59.360 --> 0:43:59.560 Yeah. 0:43:59.640 --> 0:44:03.040 Really, really, these genes these viral genes. Essentially, these genes 0:44:03.040 --> 0:44:04.000 that are viral in origin. 0:44:04.200 --> 0:44:06.960 Yeah, wow it and one since it in two. Without 0:44:07.040 --> 0:44:09.680 these ancient viral infections, we would not be able to 0:44:09.840 --> 0:44:12.759 form the super important tissue. We wouldn't be here. 0:44:13.080 --> 0:44:13.360 Wow. 0:44:13.680 --> 0:44:20.160 Yeah. And what's amazing about these indogenous retroviruses, these since 0:44:20.200 --> 0:44:25.080 sittant genes, is that they appear across eutherean mammals, but 0:44:25.360 --> 0:44:29.680 not from just one infection event. Mammals have been infected 0:44:29.920 --> 0:44:33.080 over and over again with different viruses that have found 0:44:33.160 --> 0:44:35.960 their way into our genomes and have been co opted 0:44:36.040 --> 0:44:37.640 into helping us build this tissue layer. 0:44:38.280 --> 0:44:38.560 Wow. 0:44:39.200 --> 0:44:39.439 Wow. 0:44:41.520 --> 0:44:44.359 I know I'm being mind blown right now. 0:44:44.600 --> 0:44:48.880 I say I'm read being mind blown, and I've. 0:44:48.719 --> 0:44:51.600 Wrote that, I wrote this, and it's still blowing my mind. 0:44:52.920 --> 0:44:56.440 But the immunological relationship between mother and fetus isn't just 0:44:56.600 --> 0:45:01.040 one of avoiding detection or building barriers, right. The activation 0:45:01.200 --> 0:45:04.479 of the maternal immune system is actually a necessary part 0:45:04.760 --> 0:45:08.360 of pregnancy, and instead of that activation leading to a 0:45:08.480 --> 0:45:12.520 destructive response, it leads to a regulatory or protective one, 0:45:13.040 --> 0:45:16.840 one in which acceptance of the embryo is initiated. The 0:45:16.960 --> 0:45:22.440 portrayal of pregnancy as immunosuppressive isn't accurate. In fact, the 0:45:22.520 --> 0:45:25.520 mother is very aware. The mother's immune system is very 0:45:25.560 --> 0:45:28.839 aware of this new non self thing growing. And it's 0:45:28.960 --> 0:45:33.360 more that the maternal immunological self is modified a change 0:45:33.400 --> 0:45:36.440 in immune tolerance. As a side note, this shift in 0:45:36.640 --> 0:45:39.320 self might help to explain why some people with autoimmune 0:45:39.360 --> 0:45:44.000 diseases experienced symptoms lessening pregnancy. Yeah, but there may be 0:45:44.040 --> 0:45:48.040 a cost to this tolerance. Recent research has investigated whether 0:45:48.160 --> 0:45:52.040 our invasive placenta us, which require more immune tolerance than 0:45:52.120 --> 0:45:55.400 less invasive ones, may have made us more vulnerable to 0:45:55.560 --> 0:45:57.040 cancer as a species. 0:45:57.560 --> 0:45:59.840 Really really, I did not know this connection. 0:46:00.120 --> 0:46:02.440 Yeah, okay, it's been like I think, in the past 0:46:02.600 --> 0:46:04.799 ten ish years or so, there's been a lot more 0:46:04.920 --> 0:46:08.040 interest in this aspect of the immunological side of placentas 0:46:08.200 --> 0:46:09.239 interest and placentation. 0:46:09.360 --> 0:46:09.920 Yeah okay. 0:46:10.360 --> 0:46:14.080 In fact, many researchers have noted the similarities between cancer 0:46:14.320 --> 0:46:18.239 and placentation. The formation of the placenta very interesting. There 0:46:18.320 --> 0:46:25.320 is immune evasion, proliferation, invasion into other tissue and blood 0:46:25.400 --> 0:46:26.279 vessel remodeling. 0:46:26.480 --> 0:46:26.760 Wow. 0:46:27.600 --> 0:46:32.719 Yeah, I know, and it's like self, but not because 0:46:32.719 --> 0:46:34.720 it's abnormal cell division. 0:46:35.200 --> 0:46:35.399 Ooh. 0:46:36.320 --> 0:46:41.040 Interesting yep, And studies that have compared cancer rates across 0:46:41.120 --> 0:46:43.880 mammals have found that cancer tends to be higher in 0:46:44.040 --> 0:46:48.200 species that have more invasive placentas, like humans, compared to 0:46:48.320 --> 0:46:51.719 ones that don't, like cows. And I'm sure like that 0:46:51.920 --> 0:46:54.920 other things play a role, you know, lifespan, body, seze. 0:46:55.120 --> 0:46:59.000 It's never one thing. Yeah, yeah, but the pattern isn't 0:46:59.040 --> 0:47:01.440 cut and dry. Where is it clear how cancer and 0:47:01.520 --> 0:47:06.560 invasive placentation might be related mechanistically. It's a fascinating area 0:47:06.960 --> 0:47:10.000 for future study though, especially what it might be able 0:47:10.040 --> 0:47:14.000 to tell us about our individual responses to invasive placentation. Yeah, 0:47:14.640 --> 0:47:19.480 because wow, there is a range of responses. So, like 0:47:19.600 --> 0:47:21.680 we talked about, the placenta is more than just a 0:47:21.760 --> 0:47:25.239 gateway for communication between mother and fetus. It's also the 0:47:25.320 --> 0:47:30.240 place where we see maternal, fetal and paternal needs expressed. 0:47:30.840 --> 0:47:35.600 From the fetus's perspective, more is better, more resources, more nutrients, 0:47:35.719 --> 0:47:37.520 more everything to help you grow. 0:47:37.560 --> 0:47:40.319 Sometimes and we'll get there, not always. 0:47:40.160 --> 0:47:43.440 Not always. But also from mom's point of view, you 0:47:43.880 --> 0:47:46.920 also want fetus to grow, but you can't give away 0:47:47.120 --> 0:47:49.720 all of your resources since that would impact your ability 0:47:49.800 --> 0:47:52.680 to care for the fetus later in pregnancy after birth, 0:47:53.160 --> 0:47:56.880 in future pregnancies, and also for existing offspring. And so 0:47:57.080 --> 0:48:01.320 these needs might be in immediate conflict, but there seems 0:48:01.400 --> 0:48:05.640 to me to be an ultimate shared goal for the two, right, 0:48:05.719 --> 0:48:08.719 a healthy newborn while also not draining mom to the 0:48:08.760 --> 0:48:11.040 point where postpartum care is impossible. 0:48:11.080 --> 0:48:12.760 Right, A little balance, a little balance. 0:48:12.880 --> 0:48:14.759 It's like, I think a lot of people refer to 0:48:14.800 --> 0:48:17.279 it as maternal fetal conflict, which is a whole separate thing, 0:48:17.360 --> 0:48:19.160 and there are a lot of dimensions to that, and 0:48:19.600 --> 0:48:22.920 there's like also the social sociology and political side and 0:48:23.120 --> 0:48:26.440 legal side of that. But I have been thinking of 0:48:26.520 --> 0:48:29.080 it as like a maternal fetal conversation. 0:48:29.400 --> 0:48:29.560 Right. 0:48:29.880 --> 0:48:33.280 Yeah, it's a balance, a balance, it's a dance, a balance, 0:48:34.040 --> 0:48:37.800 and that balance is not always struck. Sometimes, for instance, 0:48:37.880 --> 0:48:41.279 the placenta invades too deeply into the uterine wall, past 0:48:41.320 --> 0:48:44.520 the dissidua, which can cause hemorrhage or perforation of the uterus. 0:48:45.239 --> 0:48:48.279 Or sometimes it doesn't invade deeply enough, and maybe this 0:48:48.440 --> 0:48:53.160 is because our immune system prevents it. This incomplete invasion 0:48:53.280 --> 0:48:55.400 is thought to be at the root of pre eclampsia. 0:48:56.560 --> 0:49:00.839 We don't know the precise mechanism or if preeclamsia has 0:49:00.880 --> 0:49:04.759 one root cause or multiple, is it a syndrome or 0:49:04.920 --> 0:49:06.399 is it well one? Yeah. 0:49:06.600 --> 0:49:08.840 Well, also I'll talk more about like the different types 0:49:08.840 --> 0:49:11.759 of preeclampsia, whether it's early term, whether it's term, whether 0:49:11.800 --> 0:49:13.200 it's postpartum preeclamsia. 0:49:13.560 --> 0:49:15.480 Are they different, are they the same. 0:49:16.200 --> 0:49:18.319 It's the same pathway that's getting us to these things, 0:49:18.560 --> 0:49:23.200 or multiple pathways? Yeah, yeah. But one idea for preeclamsia 0:49:23.320 --> 0:49:25.920 is that the placenta doesn't invade deeply enough, which can 0:49:26.040 --> 0:49:29.920 limit the blood supply to the placenta and fetus. Initially, 0:49:30.200 --> 0:49:32.560 in earlier in pregnancy, that's not a problem since the 0:49:32.600 --> 0:49:36.520 fetus actually needs a low oxygen environment to develop. But 0:49:36.719 --> 0:49:41.080 as pregnancy progresses, oxygen demands increase, and if that initial 0:49:41.160 --> 0:49:45.680 invasion wasn't deep enough, if those arteries weren't remodeled enough, 0:49:46.200 --> 0:49:48.560 that can mean that the fetus is getting low or 0:49:48.760 --> 0:49:53.160 intermittently low oxygen. And so then mom senses this or 0:49:53.280 --> 0:49:56.120 through the placenta is told this, and then her blood 0:49:56.120 --> 0:49:59.919 pressure will spike to compensate, But that doesn't always solve 0:50:00.080 --> 0:50:02.160 the problem, and so then things can kind of get 0:50:02.280 --> 0:50:06.040 increasingly out of balance, and then there can be a 0:50:06.160 --> 0:50:10.080 lot of danger, right that happens. Yeah, Aaron, I know 0:50:10.160 --> 0:50:12.000 that You'll get into more of the details later on. 0:50:12.960 --> 0:50:16.080 But one of the things that I find fascinating about 0:50:16.120 --> 0:50:19.960 preeclampsia relates back to this idea that invasive placentas might 0:50:20.040 --> 0:50:24.120 be related to higher rates of cancer. If pre eclampsia 0:50:24.239 --> 0:50:28.360 has an immunological component, and if mother's immune system is 0:50:28.480 --> 0:50:32.360 preventing deep invasion of the placenta, might cancer rates be 0:50:32.520 --> 0:50:36.000 lower in people who have had pre eclampsia. Huh, I 0:50:36.080 --> 0:50:38.640 don't like so first of all that now I'm like, not, 0:50:39.400 --> 0:50:40.080 we're wondering. 0:50:40.280 --> 0:50:41.080 You are wondering. 0:50:41.200 --> 0:50:44.720 Yeah, I'm not saying like, and here's there's been reviews 0:50:44.760 --> 0:50:48.080 about this and meta analyzes. I did look up a 0:50:48.160 --> 0:50:51.920 few large studies and a meta analysis that did suggest 0:50:52.160 --> 0:50:55.160 that people who have had preeclamsia are overall less likely 0:50:55.280 --> 0:50:59.440 to develop breast cancer. Interesting, but there's like, there's so 0:50:59.600 --> 0:51:01.839 much more to that story or so many factors. How 0:51:01.960 --> 0:51:05.480 protective might pre acclamcia be. What's the mechanism of protection 0:51:05.640 --> 0:51:07.759 if there is one? Is this a causal connection or 0:51:07.880 --> 0:51:11.160 just you know, a correlation. And the same can be 0:51:11.200 --> 0:51:14.239 said for the placenta. Like, there's so so much more 0:51:14.520 --> 0:51:17.440 to the story. This was really just a brief or 0:51:17.640 --> 0:51:19.000 at least as brief as. 0:51:18.960 --> 0:51:21.520 I could make it could keep going and keep listening 0:51:21.600 --> 0:51:21.799 to you. 0:51:23.320 --> 0:51:26.480 Just a brief tour through the evolutionary history of one 0:51:26.520 --> 0:51:30.440 of the most fascinating mammalian organs out there. And I 0:51:30.600 --> 0:51:32.839 hope that even if you don't remember any one thing 0:51:33.160 --> 0:51:35.879 from this story, you at least find yourself thinking more 0:51:36.040 --> 0:51:37.759 about the placenta. 0:51:37.320 --> 0:51:39.839 The placenta that we all used to have, we all use. 0:51:39.920 --> 0:51:41.440 I think that's the thing that's interesting that no one 0:51:41.480 --> 0:51:44.319 ever thinks about, Like, yeah, we all because I think 0:51:44.360 --> 0:51:46.319 a lot about the uterus and how we all came 0:51:46.400 --> 0:51:49.080 from a uterus, whether you have one or not, right, 0:51:49.280 --> 0:51:50.080 you came from. 0:51:50.000 --> 0:51:52.000 One, which is so interesting. 0:51:52.840 --> 0:51:55.239 But then like we all, I never thought about the 0:51:55.280 --> 0:51:57.840 fact that, like, we all had at a. 0:51:57.840 --> 0:51:59.759 Placenta and we all no longer do. 0:52:00.160 --> 0:52:03.239 Yeah, unless unless you kept yours. 0:52:03.600 --> 0:52:06.880 Yeah, but then that's not yours. That was your fetuses. 0:52:06.960 --> 0:52:08.080 That was your baby's placenta. 0:52:08.440 --> 0:52:11.080 But if you, if someone, if you, if you kind 0:52:11.120 --> 0:52:11.880 of kept your. 0:52:11.719 --> 0:52:14.480 Oh that's interesting thought about that. Yeah, Okay, so some 0:52:14.560 --> 0:52:16.000 people have their I. 0:52:16.040 --> 0:52:18.239 Mean yeah, it's no longer attached to us. Yeah, it's 0:52:18.280 --> 0:52:20.680 no longer it doesn't serve using. 0:52:20.239 --> 0:52:23.520 The function that after birth, it stops serving its function. 0:52:23.640 --> 0:52:26.160 I mean, it's just so interesting and it's huge. 0:52:26.480 --> 0:52:28.960 Yeah, it's like that takes a lot of resources. 0:52:29.000 --> 0:52:29.480 Oh my gosh. 0:52:29.560 --> 0:52:32.200 Yes, yeah, it's hefty. It's a hefty organ and you 0:52:32.280 --> 0:52:35.360 can tell when they're not hefty. Oh interesting, Yeah, like 0:52:35.440 --> 0:52:38.120 I I mean, you see a whole variety of placentas 0:52:38.120 --> 0:52:40.200 when you've been delivering babies. I haven't done a lot 0:52:40.280 --> 0:52:42.480 of but seen a lot of fairy number and there 0:52:42.640 --> 0:52:44.080 they range for sure. 0:52:43.960 --> 0:52:46.560 Which is amazing and interesting. 0:52:46.800 --> 0:52:47.360 I know, I know. 0:52:47.920 --> 0:52:49.759 Okay, we I mean we could we could keep talking 0:52:49.920 --> 0:52:53.120 about yeah. Yeah, but yeah no, that's I mean that 0:52:53.239 --> 0:52:55.799 and that basically is the placenta story. You know, let's 0:52:55.800 --> 0:52:59.120 think about viruses, Let's think about what the placenta allows 0:52:59.200 --> 0:53:01.120 us to do from what a journey we mede a 0:53:01.200 --> 0:53:04.399 logical standpoint, it's incredible. Yeah, so yeah, let's keep going 0:53:04.440 --> 0:53:06.560 with the journey. Aaron, tell me what's going on with 0:53:06.960 --> 0:53:08.160 your body and pregnancy? 0:53:08.239 --> 0:53:12.239 Okay, I literally can't wait to take We'll take a 0:53:12.360 --> 0:53:14.040 quick break and then we'll get into it. 0:53:28.640 --> 0:53:33.000 During both of my pregnancies, I experienced intrahabatic colostasis of pregnancy. 0:53:33.880 --> 0:53:36.720 This is a rare complication where your liver cannot process 0:53:36.760 --> 0:53:39.960 aile salts and acids, so those begin to accumulate in 0:53:40.080 --> 0:53:43.600 your blood. This causes itchy, which is mainly focused on 0:53:43.680 --> 0:53:45.640 the palms of your hands and soles of your feet. 0:53:46.320 --> 0:53:49.800 It was the worst age I have ever experienced. It 0:53:49.960 --> 0:53:52.480 was not a dangerous complication for me as a pregnant person, 0:53:52.880 --> 0:53:56.839 but it was extremely dangerous for the fetus. Mortality rate 0:53:56.880 --> 0:53:59.880 in utero is very high. That is why I have 0:54:00.120 --> 0:54:02.800 to be monitored very closely up until thirty seven weeks 0:54:02.840 --> 0:54:07.400 when I was used both times. During both of my pregnancies, 0:54:07.440 --> 0:54:09.479 I had to go to the hospital every few days 0:54:09.560 --> 0:54:12.960 to have a CTG taken. They did numerous ultrasounds and 0:54:13.080 --> 0:54:16.799 I was even hospitalized the first time around. They also 0:54:16.920 --> 0:54:20.320 prescribed urso, the oxygalic acid, which helped a lot with 0:54:20.480 --> 0:54:25.200 lowering bile salts and acids. Itchiness also went away after that. 0:54:26.600 --> 0:54:29.320 The last ten weeks of my pregnancies were very stressful, 0:54:29.480 --> 0:54:31.680 and looking back, I am amazed that I would call 0:54:31.800 --> 0:54:34.960 I managed to stay. Both of my kids were born 0:54:35.080 --> 0:54:39.880 healthy at thirty seven weeks after induction. Chances of getting 0:54:39.920 --> 0:54:44.600 intracapathic colostasis of pregnancy with every subsequent pregnancy are higher 0:54:44.719 --> 0:54:47.160 if you have had it before. Two was enough for 0:54:47.239 --> 0:54:50.880 me that feeling of unbearable itchiness will always stay with me. 0:54:53.120 --> 0:54:56.120 My name is Sarah, she heard thirty six year old 0:54:56.160 --> 0:54:59.880 female mother to an awesome daughter. I had a positive 0:55:00.080 --> 0:55:03.880 home pregnancy tests on Christmas Day twenty twenty two. I 0:55:04.040 --> 0:55:06.480 was thirty four years old at the time. We were 0:55:06.600 --> 0:55:10.200 very lucky to conceive on our very first try. We 0:55:10.360 --> 0:55:13.880 had our confirmation ultrasound in eight weeks, and as I 0:55:13.960 --> 0:55:16.920 progressed towards the second dry master, I felt my mental 0:55:16.960 --> 0:55:20.480 health spiraling. In addition to all of the other common 0:55:20.600 --> 0:55:24.880 pregnancy side effects like morning sickness and fatigue, my anxiety 0:55:24.960 --> 0:55:28.480 started to worsen to the point of panic attacks. My 0:55:28.640 --> 0:55:31.400 body was changing in a million ways, and I had 0:55:31.440 --> 0:55:34.359 no control over any of it, let alone any peace 0:55:34.400 --> 0:55:37.160 of mind to assure me the baby was okay, or 0:55:37.239 --> 0:55:41.040 how to judge what was normal. I started to feel 0:55:41.120 --> 0:55:43.719 like maybe my medical background was not an advantage in 0:55:43.800 --> 0:55:47.239 this situation, because I knew too much when I brought 0:55:47.280 --> 0:55:50.160 my fears up to my OB. I felt dismissed. Each 0:55:50.320 --> 0:55:53.840 visit was short about five minutes. They checked the fetal 0:55:53.880 --> 0:55:56.800 heartbeat and sent me on my way. Even though this 0:55:56.960 --> 0:56:00.560 was my first pregnancy, I took it upon myself to 0:56:00.680 --> 0:56:05.680 research pregnancy mental health and found mostly postpartum articles. I 0:56:05.800 --> 0:56:08.880 eventually talked to my PCP, who started me on lexipro 0:56:09.080 --> 0:56:12.280 and busbar. I was referred to a mental health provider, 0:56:12.680 --> 0:56:15.800 and over the remaining six months of my pregnancy, I 0:56:15.920 --> 0:56:21.320 had weekly video calls with an LCSW. She helped me 0:56:21.800 --> 0:56:25.920 develop coping strategies for my anxiety and guided me in 0:56:26.000 --> 0:56:30.760 conversations with my OB and my husband. I made affirmation journals, 0:56:31.160 --> 0:56:34.400 mantras to recite, and fell asleep listening to guided hypno 0:56:34.440 --> 0:56:39.280 birthing podcasts, all of which eventually helped me to overcome 0:56:39.760 --> 0:56:44.279 my anxieties about giving birth. I had to learn how 0:56:44.360 --> 0:56:46.680 to be the patient, not to provide her, and to 0:56:46.800 --> 0:56:49.560 have faith in my husband, family, and healthcare team to 0:56:49.640 --> 0:56:52.520 take care of me. By all accounts, I had a 0:56:52.680 --> 0:56:57.600 very normal pregnancy and easy birth. At the pediatrician visits 0:56:57.640 --> 0:57:00.439 with my daughter, I filled out mood questionnaires at every 0:57:00.600 --> 0:57:04.680 visit to screen for postpartum depression, which thankfully I didn't develop, 0:57:05.239 --> 0:57:08.440 but it did make me wonder why aren't these types 0:57:08.440 --> 0:57:11.040 of questionnaires available throughout the entire pregnancy. 0:57:37.520 --> 0:57:40.880 So I left off the biology last week kind of 0:57:40.960 --> 0:57:43.720 at the start of the second trimester. But in that 0:57:43.800 --> 0:57:47.280 episode I mostly was talking about the embryo and the 0:57:47.400 --> 0:57:51.320 invasion and the thing and etc. But in this episode, 0:57:51.800 --> 0:57:55.040 I'm going to focus on the pregnancy and the pregnant 0:57:55.120 --> 0:57:58.920 person and not the fetus. Okay, because as incredible and 0:57:59.040 --> 0:58:02.240 awesome as the process of fetal development is, like, it 0:58:02.400 --> 0:58:05.520 only happens inside of a uterus, and so like the 0:58:05.680 --> 0:58:08.480 changes that are required in our bodies in order for 0:58:08.560 --> 0:58:12.520 a pregnancy to actually continue to term, Like, that's where. 0:58:12.400 --> 0:58:15.160 I'm that's where the money is for me, right now. Okay, 0:58:15.320 --> 0:58:17.440 someday we'll do fiddel development because it's really cool too. 0:58:17.640 --> 0:58:17.840 Yeah. 0:58:18.440 --> 0:58:21.840 Okay, So we're going to actually take steps backwards to 0:58:22.000 --> 0:58:27.200 the beginning of the pregnancy, okay, kind of, We're going 0:58:27.280 --> 0:58:30.720 to go back to fertilization, Okay. Yeah, So that we 0:58:30.880 --> 0:58:35.360 will recall from last week, is about two weeks after 0:58:35.520 --> 0:58:38.640 your last menstrual cycle, right, is when you ovulate and 0:58:38.680 --> 0:58:42.080 then you get fertilized, okay, and then about six days 0:58:42.160 --> 0:58:45.960 after that is when we have implantation that starts. So 0:58:46.000 --> 0:58:46.960 we're about day. 0:58:46.880 --> 0:58:48.680 Twenty one ish of our menstrual cycle. 0:58:48.760 --> 0:58:49.040 Okay. 0:58:49.560 --> 0:58:52.640 By about this time, and then like the next week after, 0:58:53.280 --> 0:58:56.080 when you may have missed a period and may have 0:58:56.200 --> 0:59:02.240 had that positive pregnancy test, all ready your own physiology 0:59:02.400 --> 0:59:07.320 has changed dramatically because of the way that embryo has 0:59:07.400 --> 0:59:10.120 embedded itself into the wall of your uterus, Like you 0:59:10.280 --> 0:59:14.320 just walked us through and started secreting hormones that are 0:59:14.400 --> 0:59:16.680 going to cause our body to change in ways that 0:59:16.760 --> 0:59:21.520 it really only changes in the context of pregnancy. I 0:59:21.680 --> 0:59:24.440 get really excited, And what I'm going to do for 0:59:24.520 --> 0:59:27.280 this episode is go through these changes, not week by 0:59:27.360 --> 0:59:29.960 week like you might see on all of the websites, 0:59:30.080 --> 0:59:31.840 like your body is doing this this week. 0:59:32.320 --> 0:59:32.360 No. 0:59:32.480 --> 0:59:35.120 No, We're going to go body system by body system 0:59:35.640 --> 0:59:37.920 and explain why we see maybe some of the like 0:59:38.080 --> 0:59:42.680 weird or uncomfortable symptoms that you might experience, and why 0:59:42.800 --> 0:59:45.640 we are susceptible to some of the complications that then 0:59:45.760 --> 0:59:49.360 arise because of these changes in our physiology. Okay, I'm 0:59:49.440 --> 0:59:52.240 going a rapid fire through it, but stop me at anytime. Okay, 0:59:53.240 --> 0:59:55.680 We're going to start with our cardiovascular system because it's 0:59:55.680 --> 0:59:57.400 one of the most important and one of my favorites. 0:59:57.960 --> 1:00:00.080 One of the first changes that we see is in 1:00:00.240 --> 1:00:03.480 our blood vessels. So because of the increased levels of 1:00:03.640 --> 1:00:07.760 progesterone and other hormones like estrogen and prostaglandins, we see 1:00:07.920 --> 1:00:11.360 a dilation or a widening of our blood vessels. And 1:00:11.480 --> 1:00:14.640 what this does is decrease the resistance to flow of 1:00:14.760 --> 1:00:19.560 fluid because of physics. Yeah, and so right away you 1:00:19.640 --> 1:00:23.160 can start to see weird symptoms because this vasodilation can 1:00:23.280 --> 1:00:27.240 cause edema or swelling as these blood vessels, as they 1:00:27.280 --> 1:00:29.920 get wider, become a little bit more leaky. So then 1:00:29.920 --> 1:00:32.440 you get fluid that can go out through the blood 1:00:32.480 --> 1:00:34.280 vessels and into places like our ankles. 1:00:34.360 --> 1:00:36.959 And this is like a body anywhere, your whole body. 1:00:37.120 --> 1:00:39.200 It could have yeah, not like extreme, but a little bit. 1:00:40.080 --> 1:00:42.400 I mean, like the blood vessel widening, yes, everywhere. 1:00:42.120 --> 1:00:44.080 Everywhere in your whole body, which also means you might 1:00:44.120 --> 1:00:47.000 get things like nasal congestion or nose bleeds. 1:00:48.160 --> 1:00:49.000 Oh my god. 1:00:49.320 --> 1:00:52.600 Now, this vasodilation will also cause a decrease in your 1:00:52.640 --> 1:00:55.880 blood pressure, usually early in pregnancy, which is very interesting 1:00:55.960 --> 1:00:59.560 to then contrast with what we'll see in preeclampsia, which 1:00:59.600 --> 1:01:02.520 is when we have higher blood pressures. Now, on top 1:01:02.640 --> 1:01:05.720 of this change of the width of our blood vessels, 1:01:05.840 --> 1:01:09.120 we also have an increase in our blood volume by 1:01:09.200 --> 1:01:13.000 how much you might ask, I would by forty to 1:01:13.360 --> 1:01:17.760 fifty percent. What uh huh, okay, tell me more about 1:01:17.800 --> 1:01:19.960 what that means. It means that if you have I 1:01:20.200 --> 1:01:22.440 actually meant to look up, like what your normal blood 1:01:22.480 --> 1:01:25.560 volume is. However many leaders I don't remember, but it 1:01:25.720 --> 1:01:27.160 is now fifty percent higher. 1:01:27.120 --> 1:01:28.280 Within a number of weeks. 1:01:29.000 --> 1:01:29.320 Okay. 1:01:30.320 --> 1:01:30.440 Uh. 1:01:31.000 --> 1:01:33.640 And it's you literally just make. 1:01:33.680 --> 1:01:36.520 More blood volume. It means your plasma Okay, we're gonna 1:01:36.560 --> 1:01:38.600 get a more into it. Yeah, because it's your plasma 1:01:38.760 --> 1:01:40.560 volume that's primarily increasing. 1:01:40.760 --> 1:01:41.000 Okay. 1:01:41.120 --> 1:01:43.080 And this means a few things. Number one, it means 1:01:43.160 --> 1:01:45.320 your heart has to be able to keep up with 1:01:45.440 --> 1:01:48.640 this increased amount of flow, and so to do that, 1:01:48.880 --> 1:01:52.920 we actually see structural changes to your heart to allow 1:01:53.000 --> 1:01:55.080 for an increase in cardiac output. 1:01:55.320 --> 1:01:57.160 What kind of structural changes we see? 1:01:57.320 --> 1:02:01.680 Thickening of the like wall of the left ventricle. 1:02:02.680 --> 1:02:05.360 Do you bring over the heart? Oh my god? 1:02:06.840 --> 1:02:08.840 If you have a diagram of a heart. Your left 1:02:08.960 --> 1:02:12.160 ventricle is over here, right, and that's the aorda is 1:02:12.200 --> 1:02:14.440 going to come out here, and this is what this 1:02:14.600 --> 1:02:16.160 is where your blood goes to the rest of your 1:02:16.200 --> 1:02:18.480 body from. So yeah, the left ventricle of your heart 1:02:18.520 --> 1:02:20.200 is going to get a little bit thicker, Your overall 1:02:20.240 --> 1:02:22.400 heart is going to get a little bit bigger. And then, 1:02:22.480 --> 1:02:24.560 as we'll talk about later, because of the changes in 1:02:24.680 --> 1:02:27.880 your diaphragm and the size of your thoracic cavity, it 1:02:27.920 --> 1:02:29.080 also gets shifted. 1:02:28.880 --> 1:02:29.720 Up into the left. 1:02:29.960 --> 1:02:32.760 Interesting, I know now. 1:02:33.000 --> 1:02:34.360 Also I think you. 1:02:34.480 --> 1:02:35.400 Give that back to you. 1:02:37.720 --> 1:02:37.880 Now. 1:02:38.040 --> 1:02:42.120 Also, we will see a compensatory increase as well in 1:02:42.240 --> 1:02:46.000 our heart rate because your overall cardiac output is a 1:02:46.080 --> 1:02:49.000 function of both the volume and also the rate. So 1:02:49.120 --> 1:02:51.560 we see an increase in heart rate, which I remember 1:02:51.600 --> 1:02:53.040 seeing on my smart watch where. 1:02:52.840 --> 1:02:55.400 It was like you have a new normal. Oh interesting, 1:02:55.560 --> 1:02:56.320 and you're like, when I. 1:02:56.360 --> 1:02:59.080 Was pregnant, how soon does that happen? 1:02:59.440 --> 1:03:01.560 So that is that a lot of these changes are 1:03:01.680 --> 1:03:04.600 kind of gradual where they start really early, but then 1:03:04.720 --> 1:03:08.080 it just like continues to change all the way till 1:03:08.120 --> 1:03:11.760 the third trimester until term. Okay, for the most part. Okay, 1:03:11.840 --> 1:03:13.600 and it's sort of an up. It's just sort of 1:03:13.880 --> 1:03:16.640 this it's a linear well not yet not linear, I mean, 1:03:16.720 --> 1:03:18.880 but yes, it's a kind of contained directional, you know, 1:03:19.160 --> 1:03:21.400 for the most part. Okay, Yeah, there's probably nuance there 1:03:21.440 --> 1:03:25.440 that I'm skipping now. I said, your blood volume increases 1:03:25.480 --> 1:03:31.360 my fifty percent. However, your red blood cell volume, and 1:03:31.600 --> 1:03:34.000 remember red blood cells are the ones that actually carry 1:03:34.040 --> 1:03:36.800 oxygen to our tissues, so they're like kind of pretty important. 1:03:37.440 --> 1:03:41.080 They also increase, but only by about twenty to thirty percent. 1:03:42.680 --> 1:03:46.000 What does this then, difference in rate increase? How does 1:03:46.040 --> 1:03:47.240 that manifest in other parts? 1:03:47.280 --> 1:03:47.320 Like? 1:03:47.400 --> 1:03:47.720 What is that? 1:03:47.800 --> 1:03:48.960 What are the implications of that? 1:03:50.120 --> 1:03:50.800 Okay, let me tell you. 1:03:51.120 --> 1:03:53.000 Why aren't your red blood cells also increasing? 1:03:53.160 --> 1:03:55.800 They are increasing, just not to the same not to 1:03:55.880 --> 1:03:58.440 the same degree. So what does this? What does it mean? 1:03:58.520 --> 1:04:01.600 What are the implications? Means that you have during pregnancy 1:04:01.760 --> 1:04:06.480 a physiologic anemia and your blood is it has less viscosity, 1:04:06.840 --> 1:04:09.640 so it can less right because you have less part 1:04:09.680 --> 1:04:12.360 of Yeah, it can flow a little bit more easily. 1:04:13.320 --> 1:04:15.320 It also though, means that of course you can carry 1:04:15.320 --> 1:04:18.040 a little bit less oxygen relatively speaking, like on the 1:04:18.160 --> 1:04:21.160 whole you're carrying more because everything is increased, but you 1:04:21.320 --> 1:04:25.160 have this physiologic anemia. You also then have this fetus 1:04:25.280 --> 1:04:27.800 that is going to be relying on the oxygen that 1:04:27.960 --> 1:04:31.640 you are giving to them. So that means that you 1:04:31.800 --> 1:04:36.960 have to become very efficient with your oxygen transport, which 1:04:37.040 --> 1:04:38.600 is the thing I could go really too deep on, 1:04:38.680 --> 1:04:41.600 but I won't. But what we then see during pregnancy 1:04:41.760 --> 1:04:44.440 is an increase in this production of this compound on 1:04:44.560 --> 1:04:48.040 our red blood cells called two three DPG. It basically 1:04:48.160 --> 1:04:51.439 means that when you are pregnant, your body is better 1:04:51.560 --> 1:04:54.800 at giving away that oxygen, So your red blood cells 1:04:54.840 --> 1:04:57.760 are more efficient at offloading oxygen so that the fetus 1:04:57.800 --> 1:05:01.640 can get access to that oxygen. Okay, it's just like easier, 1:05:01.880 --> 1:05:05.440 it's easier to drop off exactly, Okay, exactly. Yeah, it's 1:05:05.520 --> 1:05:10.480 so interesting. There's also like fetal hemoglobin, things that are hemoglobin. 1:05:10.680 --> 1:05:14.200 I know, I know, it's cool, Okay, So but it 1:05:14.320 --> 1:05:17.000 also means you set another implication. Another implication is that 1:05:17.120 --> 1:05:19.440 in order for our bodies to keep up with this demand, 1:05:19.800 --> 1:05:23.920 iron requirements are significantly higher in pregnancy compared to outside 1:05:23.920 --> 1:05:26.640 of pregnancy. And that's for two reasons, one to support 1:05:26.680 --> 1:05:28.520 the growth of the fetus who needs iron to grow, 1:05:28.800 --> 1:05:31.480 but also to keep up with this increased red blood 1:05:31.480 --> 1:05:36.000 cell production, and so iron deficiency anemia can develop on 1:05:36.160 --> 1:05:40.400 top of this physiologic anemia. And so during pregnancy people 1:05:40.480 --> 1:05:43.520 are at pretty high risk of like anemia in general 1:05:43.680 --> 1:05:46.520 because you already have this physiologic anemia and now you 1:05:46.640 --> 1:05:49.520 have this increased iron requirement. So if you're not getting 1:05:49.600 --> 1:05:51.920 enough iron in your diet, then you're not able to 1:05:52.000 --> 1:05:53.200 make enough red blood cells. 1:05:53.360 --> 1:05:55.520 Okay, makes sense, and so right. 1:05:55.640 --> 1:05:58.360 And so then what if anemia di or if this 1:05:58.440 --> 1:06:02.000 one two punch happens, then what are some of the downstream. 1:06:01.760 --> 1:06:04.560 I mean, it can affect It can be really problematic 1:06:04.680 --> 1:06:07.720 when we get then into delivery because in delivery you 1:06:07.880 --> 1:06:10.760 are going to lose some degree of blood most likely, 1:06:10.880 --> 1:06:13.040 and so that can put people at higher risk of 1:06:13.080 --> 1:06:15.840 complications from hemorrhage or just from blood loss in general. 1:06:15.960 --> 1:06:18.720 Okay, yeah, okay, that's. 1:06:18.640 --> 1:06:20.640 Mein I mean, it can cause problems for the fetuses 1:06:20.640 --> 1:06:22.560 all too if you were like severely deficient. 1:06:22.360 --> 1:06:24.560 And so physiologic like are there I'm sure there's a 1:06:24.720 --> 1:06:28.320 range of physiologic anemia, like outside of iron deficient in 1:06:28.360 --> 1:06:30.040 the area, and so is there a point at which, 1:06:30.200 --> 1:06:34.080 just like physiologic anemia, is where it needs problematic. 1:06:33.680 --> 1:06:34.920 Yeah, exactly, I don't think so. 1:06:35.240 --> 1:06:38.280 Okay, yeah, because it's it is what is expected during pregnancy, 1:06:38.440 --> 1:06:41.400 right right, you expect that to happen. Okay, So if 1:06:41.440 --> 1:06:44.120 we move on from our blood vessels in our cardiovascular system, 1:06:44.360 --> 1:06:46.880 we'll move to another vessel that's being affected kind of 1:06:47.080 --> 1:06:48.640 is not really vessel, it's your kidneys. 1:06:49.280 --> 1:06:51.440 They're connected by tubes. Okay, it's like a vessel. 1:06:52.360 --> 1:06:54.680 You have all this extra blood, right, your kidneys are 1:06:54.680 --> 1:06:57.000 responsible for filtering all of your blood. That's what they do, 1:06:57.400 --> 1:06:59.400 and so your kidneys have to work a heck of 1:06:59.440 --> 1:07:02.840 a lot harder. And during pregnancy, your kidney's enlarge and 1:07:03.120 --> 1:07:06.360 increase their filtration rate by fifty percent, which is so 1:07:06.560 --> 1:07:09.080 impressive and means that you're making a crap ton of 1:07:09.200 --> 1:07:11.760 urine and you have to pee all the time, even 1:07:11.840 --> 1:07:15.000 before there is a fetus literally crushing your bladder. 1:07:15.120 --> 1:07:18.280 That's that's something I had never I know, thought about it. 1:07:18.360 --> 1:07:20.480 And that's why even early in pregnancy people be like, 1:07:20.480 --> 1:07:22.280 I'm peeing all the time, and it's not because of 1:07:22.320 --> 1:07:24.400 the fetus because that thing is like a couple cells big. 1:07:24.520 --> 1:07:27.280 It's because you're making so much more blood, and so 1:07:27.400 --> 1:07:29.480 your kidneys are filtering all that blood, and so you're 1:07:29.480 --> 1:07:32.000 peeing all the time, Okay, and then eventually, of course, 1:07:32.080 --> 1:07:33.959 this fetus is going to grow large enough to crush 1:07:34.000 --> 1:07:36.040 your bladder. And when they do, you also can get 1:07:36.080 --> 1:07:38.600 compression of some of the tubes that lead from your 1:07:38.680 --> 1:07:41.760 kidneys to your bladder. And then that along with the 1:07:41.840 --> 1:07:44.480 fact that progesterone, which I talked about already, that causes 1:07:44.520 --> 1:07:49.320 that vasodilation, progesterone also causes like a slow down of everything. 1:07:49.440 --> 1:07:52.400 Everything's just like moving more slowly, and so your bladder 1:07:52.560 --> 1:07:55.160 has a little bit more stasis. It's not like squeezing 1:07:55.240 --> 1:07:56.000 out as much. 1:07:56.200 --> 1:07:56.520 Uh huh. 1:07:56.680 --> 1:07:59.080 So you can be more prone to UTIs or urine 1:07:59.080 --> 1:08:02.760 aritract infections during pregnancy. Interesting because you, yeah, even though 1:08:02.800 --> 1:08:04.720 you're making so much p and ping all the time, 1:08:05.080 --> 1:08:07.160 it also just can kind of sit there a little 1:08:07.160 --> 1:08:10.520 bit longer. And and then because of all of these 1:08:10.560 --> 1:08:12.720 things that are happening with like compression and blah blah blah, 1:08:12.920 --> 1:08:15.040 you have a higher risk of those UTIs getting up 1:08:15.120 --> 1:08:17.080 into your kidneys and causing a kidney infection. 1:08:18.320 --> 1:08:21.719 Okay, does that is that risk consistent throughout pregnancy? 1:08:22.320 --> 1:08:24.360 I don't have an answer to that question. Okay, it's 1:08:24.400 --> 1:08:24.960 a good question. 1:08:26.400 --> 1:08:28.080 And it's not like it's major, like that's not like, 1:08:28.360 --> 1:08:29.920 oh my god. It's just like you're a little bit 1:08:30.000 --> 1:08:32.080 higher some of the things that some of the things 1:08:32.120 --> 1:08:32.599 that can happen. 1:08:33.720 --> 1:08:34.360 So that was a lot. 1:08:34.479 --> 1:08:37.320 Someone take a big breath, just kidding. You can't take 1:08:37.320 --> 1:08:38.719 a deep breath during pregnancy. 1:08:40.040 --> 1:08:40.960 Did you have that written now? 1:08:41.080 --> 1:08:41.320 I did. 1:08:41.800 --> 1:08:42.840 It was a joke, I wrote. 1:08:44.320 --> 1:08:45.800 I love when your jokes are written out. 1:08:45.880 --> 1:08:46.160 Thank you. 1:08:46.960 --> 1:08:47.760 Still felt natural. 1:08:48.000 --> 1:08:48.240 Thank you. 1:08:48.560 --> 1:08:50.679 It was my segue into the respiratory system. 1:08:50.760 --> 1:08:52.080 It's a good seg thank you. 1:08:52.560 --> 1:08:55.120 So the changes that happen in your respiratory system, they 1:08:55.160 --> 1:08:57.519 actually start really early in pregnancy. I think we think 1:08:57.520 --> 1:09:00.280 about the changes later in pregnancy when you have a 1:09:00.439 --> 1:09:04.080 large volume that's compressing things, and we'll get there. But 1:09:04.640 --> 1:09:09.200 the hormonal changes actually cause an increase in ventilation called 1:09:09.320 --> 1:09:12.760 hyperventilation of pregnancy, and that starts really early. So your 1:09:12.800 --> 1:09:15.480 respiratory rate actually increases hormonally. 1:09:15.840 --> 1:09:22.960 Okay, hormonally what hormone progesterone mostly progesterone. How does that work? 1:09:25.560 --> 1:09:27.439 We're not going to go deep into mechanism here, Aaron, 1:09:27.439 --> 1:09:29.519 because I got too many other bodies make talk about it. 1:09:30.920 --> 1:09:32.800 I don't know why not have any answer to that 1:09:32.920 --> 1:09:34.719 in what I wrote so far, but I got plenty 1:09:34.760 --> 1:09:36.200 of papers that you can read about. 1:09:36.200 --> 1:09:36.880 Because it does it. 1:09:37.280 --> 1:09:39.559 Yeah, I'm just yeah, amazing, It's so cool. 1:09:40.040 --> 1:09:42.160 And then, as I have alluded too many times now, 1:09:42.680 --> 1:09:46.720 as pregnancy progresses and this uterus increases in size significantly, 1:09:47.280 --> 1:09:50.680 it displaces every single other organ in your abdomen. It 1:09:51.360 --> 1:09:54.840 moves from being a pelvic organ to an abdominal organ, 1:09:55.439 --> 1:09:58.640 and in doing so, it elevates your diaphragm, which is 1:09:58.680 --> 1:10:01.720 that muscle between your chest and your belly, and your 1:10:01.760 --> 1:10:04.680 diaphragm is what allows for your lungs to expand. It 1:10:04.760 --> 1:10:06.639 has to move down for you to take a deep 1:10:06.720 --> 1:10:12.400 breath in. During pregnancy, this gets shoved about four centimeters upward, 1:10:13.120 --> 1:10:17.160 so your lungs cannot expand as fully as they could previously. 1:10:17.760 --> 1:10:20.519 That's what also causes that displacement of the heart, which 1:10:20.560 --> 1:10:22.200 gets pushed up and a little bit to the left. 1:10:23.000 --> 1:10:26.520 And now some of this is compensated for this displacement 1:10:26.760 --> 1:10:29.479 is compensated for by the same hormones like progesterone and 1:10:29.560 --> 1:10:33.559 also other ones like relaxing in things that cause ligamentous laxity. 1:10:33.800 --> 1:10:39.160 There's a hormone called relaxing, relax and just relaxing. I 1:10:39.280 --> 1:10:40.800 want to know who named that. 1:10:41.640 --> 1:10:42.280 I have no idea. 1:10:42.400 --> 1:10:44.360 That's a main question. Relaxin. 1:10:44.640 --> 1:10:47.120 Yeah, so it's what allows all of your ligaments to 1:10:47.439 --> 1:10:49.680 expand and relax so that you can like. 1:10:49.840 --> 1:10:51.280 Fit a baby through your pelvist. 1:10:51.439 --> 1:10:53.800 And then also so that the bottom part of your 1:10:53.880 --> 1:10:57.559 rib cage can flail out and actually expand in diameter 1:10:57.760 --> 1:11:01.440 this way, like front to back, about five to seven centimeters. 1:11:01.880 --> 1:11:02.840 You get change here. 1:11:03.000 --> 1:11:05.120 Wow, just the bottom part of your ribs all thanks 1:11:05.160 --> 1:11:08.439 to relaxing, well, relax in, progesterone, all of these hormones. 1:11:08.840 --> 1:11:11.680 Not to throw a spotlight weight relaxes. 1:11:11.280 --> 1:11:14.960 Spotlight it, I know, give it some cred. But with 1:11:15.120 --> 1:11:17.959 all of these changes combined, by the end of pregnancy, 1:11:18.320 --> 1:11:22.880 your total lung capacity decreases by about five percent, which 1:11:23.000 --> 1:11:29.200 isn't huge. However, because of increased demand, both because the 1:11:29.320 --> 1:11:31.920 fetus has increased demand, right you have to share with 1:11:32.040 --> 1:11:37.040 the fetus, and because your own basal metabolic rate during 1:11:37.080 --> 1:11:42.719 pregnancy increases by about fifteen percent. Your total oxygen consumption 1:11:42.920 --> 1:11:45.679 and need goes up by twenty to thirty percent. 1:11:46.120 --> 1:11:50.120 Okay, so you've got first of all, you're breathing more 1:11:50.320 --> 1:11:52.360 because progesterone is telling me to breathe more. 1:11:52.479 --> 1:11:54.559 Yep, that's how it goes. 1:11:54.560 --> 1:11:58.639 We're somehow dig deeper into that. You've got less room 1:11:58.680 --> 1:12:01.280 for your lungs to expand, and you. 1:12:01.400 --> 1:12:03.599 Need to breathe more, need more oxygen. 1:12:03.760 --> 1:12:06.360 And so you're you're like just like panting. 1:12:06.479 --> 1:12:08.760 You feel a little bit shorter breath, short breath. Yes, yeah, 1:12:09.160 --> 1:12:10.639 you're not panting, but you feel. 1:12:13.320 --> 1:12:16.600 Okay, And then and then there's like is that and 1:12:16.680 --> 1:12:19.800 then also the metal ball. Yeah, okay, there's a lot 1:12:19.840 --> 1:12:20.639 of a lot of things. 1:12:20.720 --> 1:12:22.320 There's a lot of reasons to feel a little bit 1:12:22.320 --> 1:12:26.160 shorter breath, especially towards the end of pregnancy. Now you 1:12:26.320 --> 1:12:29.599 also have, because of everything going on in your abdomen, right, 1:12:30.720 --> 1:12:33.240 you also have just a lot of pressure inside of 1:12:33.280 --> 1:12:36.559 your abdomen. And what this can do, especially if somebody 1:12:36.760 --> 1:12:39.320 ends up lying down flat on their back, is it 1:12:39.400 --> 1:12:42.639 can put pressure on the blood vessel that sends blood 1:12:42.680 --> 1:12:46.320 back to your heart. Called the inferior vena cava, and 1:12:46.560 --> 1:12:48.880 that because it's a vein, it has floppy walls, so 1:12:48.920 --> 1:12:52.800 it can actually become compressed later in pregnancy by the 1:12:52.880 --> 1:12:55.040 weight of the fetus and the uterus and everything else 1:12:55.120 --> 1:13:00.120 in there, and that can potentially be problematic, mostly for 1:13:00.520 --> 1:13:03.320 the fetus, because it can kind of reduce the blood 1:13:03.320 --> 1:13:06.839 flow back to the heart, thus reducing your cardiac output. 1:13:07.439 --> 1:13:09.960 And then you can have this drop in blood pressure 1:13:10.280 --> 1:13:13.120 that affects the profusion to the fetus. Okay, so that's 1:13:13.160 --> 1:13:15.360 why a lot of times late in pregnancy people are 1:13:15.400 --> 1:13:17.960 told like, don't lay flat on your back. Yeah, that's 1:13:18.000 --> 1:13:20.880 the reason why. Okay, yeah, we have so many more 1:13:20.880 --> 1:13:24.920 body systems. Okay, ready, blood in general, going back a 1:13:24.960 --> 1:13:29.679 little bit, I guess blood clotting factors completely changed during pregnancy. 1:13:29.880 --> 1:13:33.360 Nearly all of our clotting factors increase except for our 1:13:33.400 --> 1:13:36.800 platelet count. And we think this is helpful in terms 1:13:36.840 --> 1:13:40.400 of preventing postpartum hemorrhage. Oh, but it also means that 1:13:40.479 --> 1:13:43.160 people are at higher risk of a thrombotic event of 1:13:43.200 --> 1:13:44.759 a blood clot forming when it shouldn't. 1:13:44.800 --> 1:13:46.559 But I thought that our blood was less viscous. 1:13:46.680 --> 1:13:50.000 Oh my gosh, it is, but our clotting factors are higher. 1:13:50.200 --> 1:13:52.760 Okay, so we're just sort of compensating for that in 1:13:52.840 --> 1:13:57.599 different viscosity and then it's like the clotting factors, I mean, really, 1:13:57.640 --> 1:14:00.320 we're getting to the same end result. Yeah, yeah, yeah, 1:14:00.920 --> 1:14:02.440 more clots, potential. 1:14:02.120 --> 1:14:05.280 Potential for more clots. And the mechanism there, don't ask 1:14:05.360 --> 1:14:08.160 me exactly, is probably related to estrogen because some reason, 1:14:08.200 --> 1:14:10.240 if you're on estrogen birth control, you're at higher risk, 1:14:10.479 --> 1:14:12.519 which but not as high risk as when you're pregnant. 1:14:12.600 --> 1:14:13.680 How have we not talked about that? 1:14:13.880 --> 1:14:16.160 Okay we did, I thought during our birth control upsote. 1:14:16.160 --> 1:14:17.080 Oh yeah we did, Yeah, we did. 1:14:18.479 --> 1:14:20.200 Okay, But all of this I've talked about so far, 1:14:20.240 --> 1:14:22.800 which was a lot and I've already skipped over what 1:14:23.000 --> 1:14:26.880 is a lot of people's first indication symptom wise that 1:14:27.040 --> 1:14:29.080 they might be pregnant, and that is the changes to 1:14:29.160 --> 1:14:30.040 our GI track. 1:14:30.360 --> 1:14:30.639 Yeah. 1:14:31.439 --> 1:14:35.080 So from the very beginning of pregnancy, hormones again like 1:14:35.160 --> 1:14:39.280 progesterone and others are causing smooth muscle relaxation. That's how 1:14:39.320 --> 1:14:41.360 we get dilation of our blood vessels. That's why we 1:14:41.439 --> 1:14:44.880 get the stasis in our bladder. All these things, and 1:14:45.280 --> 1:14:49.240 this results in a decrease in tone of our esophageal sphincter, 1:14:49.680 --> 1:14:52.640 which goes from our esophagus into our stomach, and that 1:14:52.840 --> 1:14:54.680 can mean that you get an increase of things like 1:14:54.720 --> 1:15:00.160 acid reflux. And we think that it's also related to nausea. Right, 1:15:00.280 --> 1:15:02.160 you have just like slow down of your GI tract 1:15:02.200 --> 1:15:04.680 and opening of your esophagus and going in so it 1:15:04.840 --> 1:15:06.240 just makes you feel more nauseous. 1:15:06.560 --> 1:15:09.320 Why does why does the slow down happen. 1:15:09.560 --> 1:15:10.520 Because of progesterone? 1:15:10.640 --> 1:15:10.840 Yeah? 1:15:10.840 --> 1:15:11.479 But why? 1:15:11.840 --> 1:15:12.080 Yeah? 1:15:12.320 --> 1:15:14.320 Is it just a consequence of the fact that like 1:15:14.400 --> 1:15:17.880 progesterone is causing this overall relaxation probably, like it. 1:15:17.920 --> 1:15:19.599 Does it have a purpose? I don't know, Okay? 1:15:19.720 --> 1:15:22.200 And then why does that lead to nausea? Like what 1:15:22.400 --> 1:15:22.920 is nausea? 1:15:23.240 --> 1:15:23.400 Oh? 1:15:23.479 --> 1:15:25.400 My, sorry, I. 1:15:25.400 --> 1:15:28.040 Can't believe the questions you're asking me right now. Well, 1:15:28.080 --> 1:15:30.160 I'm sorry, it's like what is itch? 1:15:30.280 --> 1:15:32.640 Oh my gosh, I still want to know what it is? 1:15:34.080 --> 1:15:37.440 It's yeah, I mean, I mean I know what nausea. 1:15:37.280 --> 1:15:38.880 Is, right, you know what it feels like? 1:15:39.040 --> 1:15:39.160 Right? 1:15:39.240 --> 1:15:42.479 Like why does having I mean you can think about 1:15:42.479 --> 1:15:44.120 it too, as like your food is not able to 1:15:44.240 --> 1:15:46.200 move through as quickly so it's going to be sitting 1:15:46.240 --> 1:15:49.479 there for longer. You have things that are in you're 1:15:49.479 --> 1:15:51.679 supposed to be staying in your stomach coming up into 1:15:51.680 --> 1:15:52.960 your esophagus more readily. 1:15:53.240 --> 1:15:53.360 OK. 1:15:53.640 --> 1:15:56.200 Like, I don't I don't know a better answer than that, 1:15:56.320 --> 1:15:58.080 And there's probably a better answer out there, like a 1:15:58.160 --> 1:16:05.360 GI doc is like rolling right now. Sorry, No, I'm sorry, No, 1:16:05.479 --> 1:16:09.240 don't be sorry. But but yes, so this this happens. 1:16:09.360 --> 1:16:14.639 And what's interesting is that mild nausea and vomiting early 1:16:14.720 --> 1:16:17.760 in pregnancy is actually associated with a lower risk of 1:16:18.080 --> 1:16:20.599 miscarriage or early pregnancy loss in the first trimester. 1:16:20.920 --> 1:16:22.519 Yes, I have heard that. 1:16:22.840 --> 1:16:24.840 Yes, and so we think that it's that is a 1:16:25.120 --> 1:16:26.599 big part of the reason that we think it's very 1:16:26.760 --> 1:16:30.960 progesterone mediated, right, is that when you have adequate levels 1:16:31.000 --> 1:16:34.640 of progesterone, then your pregnancy is able to continue. And 1:16:34.800 --> 1:16:37.200 so if you have lesser then you might have less nausea. 1:16:37.760 --> 1:16:39.040 But then it also might mean. 1:16:39.400 --> 1:16:40.680 You know what I'm saying, Yeah, I do know what 1:16:40.680 --> 1:16:42.360 you're saying, but it's not it's not cut and dry. 1:16:42.479 --> 1:16:45.240 It's just like a slight association. Okay, But as you 1:16:45.320 --> 1:16:47.759 can also hear in several of our first hand accounts. 1:16:48.200 --> 1:16:51.720 Sometimes this nausea and vomiting can become very severe, and 1:16:51.840 --> 1:16:56.360 that's called hyperremesis gravidarum. We do not fully understand the 1:16:56.479 --> 1:16:59.960 cause of hyperemesis. We think that it's probably in part 1:17:00.240 --> 1:17:03.040 these changes to the gastrointestinal tract and the mobility of 1:17:03.080 --> 1:17:06.960 our gaster intestinal tract, but also like some contribution of 1:17:07.160 --> 1:17:10.320 is it maybe other hormones, like independent of their effect 1:17:10.400 --> 1:17:14.000 on the GI tract, there's probably some degree of genetic susceptibility. 1:17:14.360 --> 1:17:14.800 We don't know. 1:17:15.320 --> 1:17:17.800 In short, Okay, yeah, we don't fully understand that one 1:17:17.840 --> 1:17:21.479 at all. Yeah, but this slowdown of the GI tract 1:17:21.560 --> 1:17:25.479 can also, especially later in pregnancy, end up affecting the 1:17:25.600 --> 1:17:28.400 liver and the gall bladder, and that is what can 1:17:28.479 --> 1:17:32.000 result in intrahepatic colistasis of pregnancy or colas stasis. 1:17:32.160 --> 1:17:34.120 Yes, I want to know more about this. This is 1:17:34.240 --> 1:17:35.240 I had only heard. 1:17:35.360 --> 1:17:39.080 Yeah, yeah, yeah, so this is it's more rare than 1:17:39.240 --> 1:17:42.519 some of the other complications like maybe anemia or something 1:17:42.600 --> 1:17:44.640 like that. It's estimated at zero point two to two 1:17:44.720 --> 1:17:47.680 percent of pregnancies, depending on which studies you're looking at. 1:17:48.320 --> 1:17:50.720 But colostasis is when we see a build up of 1:17:50.880 --> 1:17:54.720 bile acids because bio acids are supposed to be they're 1:17:54.760 --> 1:17:56.800 made in the liver and then they have to be 1:17:56.920 --> 1:18:00.759 transported through a duct into the gall bladder. They're stored, 1:18:01.160 --> 1:18:02.600 and then from the gall bladder they have to be 1:18:02.680 --> 1:18:05.840 squeezed out and then squirted into our small intestine. Okay, 1:18:06.080 --> 1:18:08.120 And so we see a build up of these bile 1:18:08.160 --> 1:18:10.960 acid because they're not being squirted out and excreted by 1:18:10.960 --> 1:18:11.559 the gall bladder. 1:18:11.600 --> 1:18:13.519 They're stuck in the gall blader. Their stup latter is 1:18:13.560 --> 1:18:15.640 the source of so much issue. 1:18:15.560 --> 1:18:18.720 Like right, and so they're also then just they're not 1:18:19.080 --> 1:18:21.080 they're building up in general. So it's like the liver, 1:18:21.280 --> 1:18:24.080 the gallbladder, the whole situation. They're not going down the 1:18:24.160 --> 1:18:25.240 track like they're supposed to. 1:18:25.760 --> 1:18:28.519 Okay, and so the salts are stuck in the liver, 1:18:28.680 --> 1:18:30.120 stuck in the gall it's just sort of like a 1:18:30.479 --> 1:18:33.040 again the slow down, slow down. It's a slow down, yeah, 1:18:33.240 --> 1:18:34.400 traffic jam in the gall blade. 1:18:34.520 --> 1:18:35.040 Traffic jam. 1:18:35.240 --> 1:18:38.560 And so then this bile acid accumulation will then be 1:18:38.880 --> 1:18:42.160 essentially like transported out of just the liver gall bladder 1:18:42.200 --> 1:18:44.519 situation and can potentially end up in our bloodstream. So 1:18:44.600 --> 1:18:47.000 then we see an increase in bio salts in our bloodstream. 1:18:47.600 --> 1:18:50.679 The symptoms of that end up being really really severe itching, 1:18:50.920 --> 1:18:53.040 and it's usually like whole body itching. Don't ask me 1:18:53.160 --> 1:18:54.080 why it causes itching? 1:18:55.000 --> 1:18:58.240 What is itch? How does it get in the bloodstream. 1:18:57.960 --> 1:19:00.240 Because it's not able to be transported out, so then 1:19:00.240 --> 1:19:04.000 there's just too much of it, and it's just like, ah, okay, okay, 1:19:04.280 --> 1:19:07.080 because your liver like has so much blood supply, and 1:19:07.160 --> 1:19:09.200 so if it's just backed up into your liver. 1:19:09.200 --> 1:19:11.719 Then it's gonna be it's gonna go okay. 1:19:13.040 --> 1:19:16.960 And so yeah, and the that does not pose a 1:19:17.040 --> 1:19:21.920 problem to the pregnant person, but those bile salts can 1:19:22.080 --> 1:19:25.400 pass through the placenta and be toxic to the fetus 1:19:26.080 --> 1:19:29.800 because these are cytotoxic compounds, right, That's why they're usually 1:19:29.840 --> 1:19:35.160 stored in our gall bladder where they're not causing problems. Usually, Okay, 1:19:35.439 --> 1:19:38.000 I've gone through a lot of physiologic changes so far. 1:19:38.280 --> 1:19:40.719 Try to think of other don't ask me more questions. 1:19:40.720 --> 1:19:41.479 I'm gonna keep going. 1:19:42.000 --> 1:19:43.840 I don't think of other body parts, like or what 1:19:43.960 --> 1:19:46.000 other body system. They're not the ones you would think 1:19:46.040 --> 1:19:51.000 of necessarily. Yeah, brain is interesting your brain definitely changes 1:19:51.080 --> 1:19:53.559 during pregnancy, and there are like fetal cells that make 1:19:53.600 --> 1:19:54.679 it all the way into your brain. 1:19:54.960 --> 1:19:56.960 Yeah, but we don't I don't have data on like 1:19:57.000 --> 1:19:57.639 what are the changes. 1:19:57.680 --> 1:19:59.080 We have no idea but the feel cell. 1:20:00.240 --> 1:20:03.080 Okay, But here's what I'm going to do is now 1:20:03.280 --> 1:20:07.439 focus more on the two other major complications that we 1:20:07.600 --> 1:20:12.200 see and the body systems that they're involved in. So diabetes, 1:20:12.680 --> 1:20:16.000 h Okay, this is our endocrine system. And we already 1:20:16.120 --> 1:20:18.719 know that our endocrine system, which is our hormone system. 1:20:18.800 --> 1:20:23.559 You defined it last episode. I could be at some point. 1:20:24.800 --> 1:20:27.720 Oh yeah, it was last episode. Because we've talked about hCG. 1:20:28.080 --> 1:20:33.120 So our entire hormonal milieu is changed during pregnancy, and 1:20:33.280 --> 1:20:36.519 people end up susceptible to diabetes during pregnancy in large 1:20:36.560 --> 1:20:39.439 part because of a hormone that the placenta is secreting 1:20:39.880 --> 1:20:43.120 that's called human placental lactogen. There's other stuff that it's 1:20:43.160 --> 1:20:45.080 involved as well. But this is what I'm going to 1:20:45.120 --> 1:20:48.280 focus on, because what this does is it makes our 1:20:48.439 --> 1:20:52.919 pregnant bodies less sensitive to insulin. We have an increased 1:20:52.960 --> 1:20:56.759 insulin resistance. Okay, why do we need an increased insulence resistance? 1:20:57.080 --> 1:21:00.320 If we remember back to our diabetes episode, insulince job. 1:21:00.479 --> 1:21:02.640 What it does in our body is when we have 1:21:02.880 --> 1:21:05.160 high glucose and are like we eat something, right, and 1:21:05.200 --> 1:21:07.759 we have high glucose in our bloodstream, Insulin is secreted 1:21:07.840 --> 1:21:10.880 and it tells the glucose like, get away from here, 1:21:11.320 --> 1:21:13.880 pack yourself away so that we can store you and 1:21:14.040 --> 1:21:18.160 use you later. Okay, So insulin puts glucose into our cells. 1:21:18.680 --> 1:21:21.960 But a fetus needs glucose and they get it from 1:21:22.040 --> 1:21:22.960 our blood stream. 1:21:23.040 --> 1:21:23.280 Got it. 1:21:23.600 --> 1:21:27.000 So by making our insulin less effective, you can have 1:21:27.200 --> 1:21:30.920 more glucose to be available for the developing fetus. But 1:21:31.160 --> 1:21:35.240 if this process goes too far, like if are pancreas, 1:21:35.280 --> 1:21:37.160 because we're going to have this insulin resistance, right, so 1:21:37.240 --> 1:21:39.599 our cells are going to recognize, hey, glucose is too high, 1:21:39.640 --> 1:21:42.519 we need to make more insulin. If you're pincreas can't 1:21:42.600 --> 1:21:45.559 keep up with that increased demand, then you end up 1:21:45.600 --> 1:21:49.720 with gestational diabetes where we see too much glucose in 1:21:49.760 --> 1:21:54.640 our bloodstream. Levels get too high, and that has a 1:21:54.720 --> 1:21:58.360 couple of big consequences. One is it can cause increased 1:21:58.439 --> 1:22:00.439 growth of the fetus. Right, because the fed is just 1:22:00.520 --> 1:22:04.000 like getting a glucose pipeline. Yeah, yeah, okay, and that 1:22:04.320 --> 1:22:07.559 is called macrostomia. So it ends up being large. Babies 1:22:07.600 --> 1:22:10.120 are large for gestational age babies, and that can make 1:22:10.240 --> 1:22:11.320 delivery very risky. 1:22:11.560 --> 1:22:12.240 Yes, okay. 1:22:12.880 --> 1:22:15.320 But the second complication that I don't think people talk 1:22:15.320 --> 1:22:20.680 about as much is that while our glucose that's in 1:22:20.720 --> 1:22:24.000 our bloodstream passes through the placenta and into the fetus, 1:22:24.360 --> 1:22:28.639 our insulin does not. So if our glucose levels get 1:22:28.720 --> 1:22:32.720 really really high, fetus inside of us has to make 1:22:32.840 --> 1:22:35.360 more and more insulin because their body is also like, whoa, 1:22:35.560 --> 1:22:38.559 this is a lot of glucose. So they're having an 1:22:38.640 --> 1:22:41.680 increase amount of fetal insulin that they're making. And then 1:22:41.800 --> 1:22:46.120 after they're born, that sugar syrup bloodstream pipeline is cut off, 1:22:46.760 --> 1:22:49.720 and now they can get severely hypoglycemic because of how 1:22:49.800 --> 1:22:51.240 much insulin they've made in their bodies. 1:22:51.400 --> 1:22:52.840 And so then what does that look like? 1:22:53.000 --> 1:22:55.320 That can end up with seizures or coma or death. 1:22:55.479 --> 1:22:58.720 And that is like to imediately immediately following birth right 1:22:58.800 --> 1:23:01.160 or when yeah, exactly in the neonate in the new 1:23:01.240 --> 1:23:04.120 moral they can have really severe hypogacemia. And so that's 1:23:04.120 --> 1:23:07.320 why Babies that are born when the mom has had 1:23:07.439 --> 1:23:10.000 just national diabetes have to be monitored really closely, especially 1:23:10.040 --> 1:23:11.880 in the first like twenty four to forty eight hours. 1:23:12.080 --> 1:23:16.040 Okay, so interesting. Can I ask some questions or you 1:23:16.080 --> 1:23:20.720 can try yeah, okay, okay, okay, okay. When typically do 1:23:20.920 --> 1:23:25.000 we see uh, gestational diabetes appear? 1:23:25.160 --> 1:23:27.680 Okay, we usually test for it around weeks twenty four 1:23:27.720 --> 1:23:29.920 to twenty eight Okay. Doesn't mean it can't happen before 1:23:29.960 --> 1:23:32.400 that or after that, but that's usually in most places, 1:23:32.439 --> 1:23:33.880 that's the timeline that we test for it. 1:23:34.080 --> 1:23:36.960 Okay. My second question is then what do you do 1:23:37.040 --> 1:23:37.320 about it? 1:23:37.439 --> 1:23:37.599 Yeah? 1:23:37.640 --> 1:23:40.280 Great question. Okay, do you have more that you want 1:23:40.320 --> 1:23:40.720 to keep going? 1:23:40.960 --> 1:23:41.160 Yeah? 1:23:41.200 --> 1:23:43.000 No, no, but you answer that okay, yeah. 1:23:43.640 --> 1:23:43.720 Uh. 1:23:43.920 --> 1:23:45.760 There's a few different things a lot of times that 1:23:45.800 --> 1:23:48.120 can be managed with just dietary changes alone, and so 1:23:48.360 --> 1:23:50.599 figuring out like what do you what are you eating 1:23:50.680 --> 1:23:53.360 that's maybe causing really big glucose spikes and can you 1:23:53.520 --> 1:23:55.800 just modify your diet to be able to have not 1:23:55.960 --> 1:23:59.160 have that and then you're good. Otherwise it's usually insulin, 1:23:59.280 --> 1:23:59.920 so we manage it with it. 1:24:01.400 --> 1:24:04.280 My third question, and you may maybe I should just 1:24:04.400 --> 1:24:08.880 let you finish talking about the other complication. What are 1:24:08.920 --> 1:24:12.960 the differences between first pregnancies and subsequent pregnancies and the 1:24:13.520 --> 1:24:17.080 path this big, big picture question, you know, because I 1:24:17.240 --> 1:24:21.400 would I would imagine that like, Okay, first pregnancies, your 1:24:21.520 --> 1:24:24.680 body is like responding and doing all these things that 1:24:24.760 --> 1:24:26.599 it's doing for the first has never done it right, 1:24:26.640 --> 1:24:28.920 and the second time, it's like are those pathways carved out? 1:24:29.000 --> 1:24:32.720 How different are the hormone levels? How likely are same 1:24:32.800 --> 1:24:36.400 complications to occur between one pregnancy and subsequent pregnancies. 1:24:36.520 --> 1:24:39.640 That's interesting. So we'll talk definitely more about that with preclamcya, 1:24:39.680 --> 1:24:42.080 which is what I'm going to do next. But I 1:24:42.200 --> 1:24:44.639 don't know when it comes to just stational diabetes. Certainly, 1:24:44.680 --> 1:24:46.920 if you've had just stational diabetes in one pregnancy, you 1:24:47.000 --> 1:24:48.919 are at higher risk for having it in another pregnancy. 1:24:49.520 --> 1:24:52.200 Just stational diabetes is also associated with an increased risk 1:24:52.240 --> 1:24:54.559 of type two diabetes later in life. So it's thought 1:24:54.600 --> 1:24:57.320 to be kind of like a marker. There's a lot 1:24:57.360 --> 1:24:59.040 of things that happen in pregnancy that are thought to 1:24:59.120 --> 1:25:00.559 kind of be markers, and we I don't know are 1:25:00.640 --> 1:25:04.120 they like causal or are they just like a kind 1:25:04.120 --> 1:25:06.360 of a snapshot in time where we're like, oh, maybe 1:25:06.439 --> 1:25:09.760 you are at higher risk for these complications later in life, 1:25:09.800 --> 1:25:11.960 but it's not like because you had it during pregnancy. 1:25:12.160 --> 1:25:12.760 Does that make sense? 1:25:12.880 --> 1:25:13.040 Yes? 1:25:14.400 --> 1:25:17.400 But yeah, I don't. I don't know data on like 1:25:17.640 --> 1:25:19.920 what are the rates first pregnancy, second third. It also 1:25:20.000 --> 1:25:22.599 is going to vary with age as well too, so yeah, 1:25:22.640 --> 1:25:24.320 I don't know. That's an interesting question though. When it 1:25:24.400 --> 1:25:25.200 comes to diabetes. 1:25:25.320 --> 1:25:25.840 Yeah, I don't know. 1:25:26.560 --> 1:25:30.599 Overall though, the rate the estimates of like how many 1:25:30.680 --> 1:25:33.479 pregnancies are complicated by diabetes are like all over the map. 1:25:33.360 --> 1:25:35.639 From like one to thirty percent depending on your studies. 1:25:35.640 --> 1:25:37.800 So it's like what's food, what's the threshold? Like how 1:25:37.840 --> 1:25:38.880 do you? How do you? 1:25:39.120 --> 1:25:39.799 How do you diagnose? 1:25:39.840 --> 1:25:40.599 How do you diagnosed? 1:25:40.680 --> 1:25:43.400 I really wanted to bring in a glue coola for you, 1:25:44.080 --> 1:25:45.479 but I couldn't get my hands on ones. 1:25:45.520 --> 1:25:46.000 I'm sorry. 1:25:46.840 --> 1:25:50.360 And it does differ different countries and different guidelines are 1:25:50.360 --> 1:25:52.240 a little bit different in terms of what how you 1:25:52.400 --> 1:25:54.320 how exactly you diagnose it. But most of the time 1:25:54.439 --> 1:25:57.040 it's by doing a glucose tolerance test, and so you 1:25:57.120 --> 1:26:01.559 give somebody a fixed volume of glucose seventy five grams whatever, 1:26:01.960 --> 1:26:04.479 and then you test their blood at intervals either one hour, 1:26:04.560 --> 1:26:07.719 two hours, three hours, or multiple times, and then see 1:26:07.760 --> 1:26:10.800 what their numbers are. Got it, what their glucose level 1:26:10.880 --> 1:26:13.240 is Okay, And there's different cutoffs, and that part's pouring. 1:26:13.280 --> 1:26:14.200 So let's move on, shall we. 1:26:14.600 --> 1:26:18.240 Yeah, I want to pre aclampsia. Ye, big one, So 1:26:18.360 --> 1:26:19.960 that is it is the biggest. 1:26:20.000 --> 1:26:22.280 It is a doozy and it can be for sure 1:26:22.560 --> 1:26:24.639 probably the most severe complication of pregnancy. 1:26:24.960 --> 1:26:26.840 That might not be true, but it's a big one. 1:26:26.920 --> 1:26:27.519 It's a big one. 1:26:27.920 --> 1:26:31.400 So this is really truly not just it doesn't fit 1:26:31.479 --> 1:26:34.000 as neatly in a single organ system, because it is, 1:26:34.200 --> 1:26:36.880 like you mentioned Aaron, the result of a kind of 1:26:37.000 --> 1:26:43.759 dysfunctional relationship really between the placenta and our own cardiovascular system, 1:26:44.360 --> 1:26:46.760 and it can result in a whole spectrum of disorders 1:26:46.800 --> 1:26:49.920 that we call hypertensive disorders of pregnancy. So it's not 1:26:50.160 --> 1:26:54.800 just preaclamsia. It also includes gestational hypertension. So just high 1:26:54.840 --> 1:26:59.760 blood pressure, okay, preeclampsia and aclampsia, and then also help 1:27:00.040 --> 1:27:05.240 which is hemolysis, elevated liver enzymes, and low platelets. But 1:27:05.479 --> 1:27:08.800 often we think about and focus on preeclampsia, because that 1:27:09.120 --> 1:27:12.560 is a kind of point at which if this kicks in, 1:27:13.400 --> 1:27:16.800 if it's officially preeclampsia, then that's when the risks to 1:27:16.920 --> 1:27:22.639 both fetus and mom become pretty significant. Okay, preeclampsia overall 1:27:22.880 --> 1:27:26.000 is estimated to complicate between four and five percent of 1:27:26.080 --> 1:27:27.440 all pregnancies worldwide. 1:27:27.520 --> 1:27:28.720 That's such a high rate. 1:27:28.840 --> 1:27:32.840 It's pretty high, and it's estimated and estimason This really 1:27:32.880 --> 1:27:36.200 did vary in several papers that I read, but most 1:27:36.520 --> 1:27:39.360 reliably the papers that I read said it's estimated to 1:27:39.400 --> 1:27:45.120 result in seventy thousand maternal deaths every year. Seventy thousand 1:27:45.360 --> 1:27:50.240 maternal deaths every year, and five hundred thousand steel births 1:27:50.360 --> 1:27:53.400 or neonatal deaths, oh my gosh, which is just like 1:27:53.800 --> 1:27:59.040 heartbreakingly massive numbers. On top of that, for every maternal 1:27:59.160 --> 1:28:02.560 death that's really to preeclampsia, it's estimated that fifty to 1:28:02.600 --> 1:28:06.120 one hundred women are having significant morbidity as a result 1:28:06.200 --> 1:28:10.519 of it. So it's like affecting a huge number of people. Yeah, 1:28:11.120 --> 1:28:13.599 and I'm sorry that that started off like so heavy, 1:28:13.640 --> 1:28:14.639 but preclamsy can. 1:28:14.560 --> 1:28:15.200 Get really scary. 1:28:15.320 --> 1:28:18.000 Yeah, absolutely so, in terms of like what is when 1:28:18.000 --> 1:28:22.200 I say preclamcy, what does that mean? It's defined as hypertension, 1:28:22.240 --> 1:28:26.800 so elevated blood pressures and at least one of a 1:28:26.880 --> 1:28:30.559 few other features symptoms that we see. One big one 1:28:30.680 --> 1:28:33.320 is protein in the urine, because that's a sign that 1:28:33.400 --> 1:28:37.280 your kidney is being affected, okay, or sometimes other signs, 1:28:37.320 --> 1:28:39.519 other lab values that we see that tell us that 1:28:39.600 --> 1:28:42.040 your kidney is having kidney dysfunction, and that's like it's 1:28:42.120 --> 1:28:48.080 not filtering exactly exactly, or liver dysfunction, all right, and 1:28:48.360 --> 1:28:51.000 all of those we do like laboratory values to see 1:28:51.040 --> 1:28:55.880 what those numbers are. Or sometimes it's diagnosed by neurologic complications, 1:28:55.920 --> 1:29:01.479 which can be severe persistent headaches, visual changes, stroke or 1:29:01.600 --> 1:29:08.280 abnormal reflexes. Or sometimes it's hematologic complications, especially platelet abnormalities. 1:29:08.720 --> 1:29:12.560 Okay, So there are a multitude of ways to dultitude. 1:29:11.840 --> 1:29:15.120 Of criteria that you kind of like check the boxes, 1:29:15.360 --> 1:29:18.000 and if you're meeting these then it's called preeclampsia rather 1:29:18.120 --> 1:29:19.800 than just hypertension. 1:29:20.880 --> 1:29:23.320 Interesting, Yeah, So that it would have to be like 1:29:23.560 --> 1:29:27.000 these neurological changes in addition to high blood pressure exactly, 1:29:27.080 --> 1:29:28.680 and you would also have to have protein in the 1:29:28.840 --> 1:29:32.439 urine or exact other liver enzyme elevation, okay. 1:29:33.760 --> 1:29:38.000 And what it can cause is a number of different things. 1:29:38.600 --> 1:29:41.960 From the fetal perspective, it can cause fetal growth restriction 1:29:42.400 --> 1:29:47.400 because of abnormal blood flow into the placenta. But when preeclampsia, 1:29:47.479 --> 1:29:51.240 especially if it goes untreated or unchecked, it can result 1:29:51.360 --> 1:29:54.560 in a number of really severe complications, including a clampsia, 1:29:54.680 --> 1:29:58.639 which is preeclampsia but with seizures. So that's the line 1:29:58.680 --> 1:30:01.440 at which it becomes a clampsy Yeah, right, than preeclampsia 1:30:02.160 --> 1:30:04.360 down to down to nabby, I know, I think of 1:30:04.439 --> 1:30:08.280 that too. And then it also can sometimes cause stroke, 1:30:08.439 --> 1:30:11.120 especially a hemorrhagic stroke, which would be a very severe 1:30:11.200 --> 1:30:15.640 complication of preeclampsia. Sometimes it's not the nervous system, but 1:30:15.760 --> 1:30:18.400 it's a different organ that gets mainly affected. So it 1:30:18.479 --> 1:30:21.640 can cause severe liver damage and that often results in 1:30:21.720 --> 1:30:25.160 that HELP syndrome. Okay, because it's causing damage to the liver. 1:30:25.479 --> 1:30:29.599 Yeah, So help is A is A is A. It's 1:30:29.640 --> 1:30:33.559 on the spectrum what so Okay, So what is that spectrum? 1:30:33.600 --> 1:30:36.160 I know there's there's high hypertension. 1:30:35.840 --> 1:30:42.280 Gestational hypertension, preeclampsia, eclampsia, help, okay, Yeah, that's like the 1:30:42.439 --> 1:30:46.240 main spectrum, okay, But then within preeclampsia, we can also 1:30:46.360 --> 1:30:49.760 see these other companies and they're not discrete events necessarily, 1:30:49.960 --> 1:30:52.960 like it's not like help or this sure, right, okay, yeah, 1:30:55.160 --> 1:30:58.400 And pre eclampsia also, it doesn't discriminate. It can cause 1:30:58.479 --> 1:31:02.719 severe complications to your kidneys and end up causing renal failure. 1:31:03.640 --> 1:31:07.519 It can cause flash pulmonary edema, meaning fluid onto the lungs, 1:31:07.680 --> 1:31:10.599 largely from just such high blood pressures, because that's something 1:31:10.680 --> 1:31:14.040 we see with severely elevated blood pressures outside of pregnancy 1:31:14.080 --> 1:31:16.599 as well. And then, like I said, for the fetus, 1:31:16.640 --> 1:31:19.680 it can cause placental abruption as well, which is where 1:31:19.720 --> 1:31:24.080 the placenta detaches spontaneously before the baby has been delivered, 1:31:24.360 --> 1:31:27.839 and that can be potentially catastrophic and then also premature 1:31:27.880 --> 1:31:32.560 delivery or still birth. And we don't fully understand the 1:31:32.720 --> 1:31:37.040 mechanisms of preoclampsia, but you talked a lot Aarin about 1:31:37.120 --> 1:31:40.439 what we know about the placenta and this relationship between 1:31:40.960 --> 1:31:44.479 abnormal or whether it's inadequate, like not deep enough or 1:31:44.600 --> 1:31:48.840 too deep placentation and what we think is that that 1:31:50.160 --> 1:31:56.920 process results in these anti angiogenic factors that float around 1:31:56.960 --> 1:31:59.680 in our maternal bloodstream and end up causing damage to 1:31:59.720 --> 1:32:03.439 our blood vessels, and that causes us to have this 1:32:03.680 --> 1:32:07.720 increase in blood pressure and that is what ultimately leads 1:32:07.760 --> 1:32:12.840 to preeclampsia. So it's like inflammation and these like anti 1:32:12.920 --> 1:32:15.840 angiogenics like not making enough blood vessels, not getting enough 1:32:15.920 --> 1:32:19.080 remodeling in the uterus, and this whole like kind of 1:32:19.120 --> 1:32:20.040 perfect storm. 1:32:19.800 --> 1:32:23.120 Almost signaling like, hey, there's not enough going on here, 1:32:23.320 --> 1:32:24.479 Send more, send more. 1:32:24.479 --> 1:32:25.479 Exactly exactly. 1:32:26.479 --> 1:32:29.120 And there are there is of course, a lot of 1:32:29.240 --> 1:32:33.040 interest in understanding like are there biomarkers. Are there things 1:32:33.080 --> 1:32:35.840 that we can identify, like in your blood to say 1:32:36.000 --> 1:32:39.120 either you definitely have preoclampsia or you are at higher 1:32:39.240 --> 1:32:42.920 risk of developing preeclampsia. And in several countries they actually 1:32:43.000 --> 1:32:46.040 do use a few different blood tests that test for 1:32:46.200 --> 1:32:48.120 a few different specific things. And I think I forgot 1:32:48.120 --> 1:32:50.840 to write down their names, but they're like PIF blah 1:32:50.880 --> 1:32:55.280 blah blah, some biomarkers exactly biomarkers. So far, as of 1:32:55.320 --> 1:32:57.160 twenty twenty four, we don't use those yet in the 1:32:57.280 --> 1:33:02.760 United States. So what we mostly look at in terms 1:33:02.800 --> 1:33:05.759 of trying to identify who is at risk for developing 1:33:05.800 --> 1:33:09.960 preeclampsia is what we know from the epidemiological data, and 1:33:10.080 --> 1:33:12.760 we know a lot about what the risk factors are 1:33:13.280 --> 1:33:17.080 that make someone higher risk for developing preeclampsia. We know 1:33:17.200 --> 1:33:19.439 that one of the biggest ones is having a previous 1:33:19.479 --> 1:33:20.600 pregnancy with preoclamsia. 1:33:20.800 --> 1:33:20.920 Right. 1:33:21.520 --> 1:33:24.920 The other huge one is having a first pregnancy. So 1:33:25.040 --> 1:33:27.200 you asked about the difference between like first pregnancies and 1:33:27.200 --> 1:33:32.280 subsequent pregnancies. First pregnancies are generally higher risk for preeclampsia 1:33:32.439 --> 1:33:36.520 compared to second, third, fourth pregnancies unless you had preoclamsia 1:33:36.560 --> 1:33:38.439 in your first one, right, And then you're at higher 1:33:38.520 --> 1:33:40.960 risk during the other ones as well too, And we 1:33:41.000 --> 1:33:42.960 don't fully understand that, but we think that it's related 1:33:43.000 --> 1:33:46.040 again to this immune tolerance thing, where your body has 1:33:46.479 --> 1:33:50.360 never seen these cells from this fetus floating around and 1:33:50.439 --> 1:33:53.320 you develop this immune response to it. Whereas if you've 1:33:53.320 --> 1:33:56.280 had a pregnancy before and your immune system tolerated it, 1:33:56.920 --> 1:33:59.639 you are at lower risk of having an abnormal reaction 1:33:59.760 --> 1:34:02.360 to them that in the future pregnancies. Yeah, if they're 1:34:02.439 --> 1:34:05.640 with the same paternal DNA that so. 1:34:05.840 --> 1:34:08.120 That I find fascinating and I didn't get into this, 1:34:08.280 --> 1:34:11.560 but there is a lot about paternal DNA and like 1:34:12.200 --> 1:34:17.040 pre like exposure to paternal DNA before ye pregnancy. 1:34:17.160 --> 1:34:20.400 Yeah, so like IVF pregnancies, especially those with donor sperm, 1:34:20.479 --> 1:34:23.519 are also a little bit higher risk than non IVF 1:34:23.560 --> 1:34:26.240 pregnancies or IVF without donor sperm. So it's really that's 1:34:26.320 --> 1:34:28.280 part of what lends support to this idea that there's 1:34:28.360 --> 1:34:31.680 like an immune tolerance spectrum kind of a thing. 1:34:31.960 --> 1:34:34.719 Well, and it also makes sense then where why subsequent 1:34:34.800 --> 1:34:39.360 pregnancies where the first pregnancy there's preeclampsy, I would have 1:34:39.479 --> 1:34:43.080 pre eclamsy because it's almost sensitized exactly. Well, I've seen 1:34:43.120 --> 1:34:43.840 this before, right. 1:34:44.280 --> 1:34:47.679 And I know what to do, Yeah, right, exactly. There's 1:34:47.680 --> 1:34:50.600 a lot of other risk factors though, having chronic hypertension 1:34:50.640 --> 1:34:55.840 prior to pregnancy, maternal age, so increasing age increases our 1:34:55.880 --> 1:34:59.120 risk why we do not know. And then a lot 1:34:59.160 --> 1:35:02.519 of other like complications that might affect the functioning of 1:35:02.680 --> 1:35:07.160 your organs prior to pregnancy, like kidney disease, things like lupus, 1:35:07.240 --> 1:35:09.960 which can affect blood clotting factors and things like that, 1:35:11.479 --> 1:35:15.040 having a family history of preeclampsia. And then this part's 1:35:15.080 --> 1:35:20.400 really important, especially in the United States, race is a 1:35:20.520 --> 1:35:25.240 risk factor for preeclampsia. Specifically, Black people who are pregnant 1:35:25.280 --> 1:35:28.040 are at significantly higher risk of pre eclamsia compared to 1:35:28.080 --> 1:35:31.960 white people who are pregnant. But that is not a 1:35:32.200 --> 1:35:36.640 biologic difference, and that this is specified in the ACOG guidelines. 1:35:36.760 --> 1:35:40.800 This is due to systemic racism. Because we also see 1:35:40.840 --> 1:35:44.560 that low income, regardless of race, which causes increase in 1:35:44.640 --> 1:35:48.360 life stressors, is also associated with an increased risk of preeclampsia. 1:35:48.800 --> 1:35:50.439 And so these are the kinds of differences that are 1:35:50.479 --> 1:35:54.400 really important to understand because by recognizing who is at risk, 1:35:55.040 --> 1:35:58.200 we can can we hopefully prevent preeclampsia. 1:35:58.960 --> 1:36:01.280 How would prevent preeclampsia? 1:36:01.400 --> 1:36:04.080 So glad that you asked, Darren right now, The only 1:36:04.200 --> 1:36:07.559 thing that we have to help prevent preeclampsia is low 1:36:07.600 --> 1:36:11.599 dose aspirin, of all things. Okay, So taking aspirin, which 1:36:11.680 --> 1:36:13.639 we did a whole episode on and you might remember, 1:36:14.200 --> 1:36:19.920 is an anti inflammatory agent that also irreversibly inhibits platelets 1:36:20.080 --> 1:36:24.280 from aggregating, so it stops your platelets from forming clots. 1:36:24.880 --> 1:36:30.120 And we think that these, like microthrombotic events are involved 1:36:30.160 --> 1:36:34.559 in the pathogenesis of preeclampsia and so by irreversibly inhibiting 1:36:34.600 --> 1:36:37.480 this platelet aggregation, we've shown through a lot of epidemiological 1:36:37.520 --> 1:36:39.880 studies that's what we think the mechanism is. But we 1:36:40.040 --> 1:36:42.920 know that starting low dose aspirin early in pregnancy, usually 1:36:43.040 --> 1:36:46.639 first or early second trimester, and continuing it until term 1:36:46.760 --> 1:36:50.439 can significantly reduce someone's risk of developing pre eclampsia, not 1:36:50.600 --> 1:36:53.599 make it zero. And the risks are different for whether 1:36:53.720 --> 1:36:58.600 it's term preeclamsia, pre term preclamsia, or postpartum preeclamsia. 1:36:59.400 --> 1:37:04.000 So what are those I don't have like they sound. 1:37:03.920 --> 1:37:04.280 Like they are. 1:37:04.479 --> 1:37:07.360 They sound like it's like when in whin in pregnancy, 1:37:07.439 --> 1:37:09.680 does it develop? Yeah, most of the time, this is 1:37:09.760 --> 1:37:11.880 something that does not develop, or at least we don't 1:37:12.000 --> 1:37:15.320 see it. Can't recognize it clinically until after twenty weeks 1:37:15.360 --> 1:37:18.439 of pregnancy, okay, but it can potentially develop any time. 1:37:18.479 --> 1:37:20.240 We might just not like you might just not see 1:37:20.280 --> 1:37:21.960 the signs it might be. That's part of why people 1:37:21.960 --> 1:37:24.200 are looking for biomarkers. Can we find it. Can we 1:37:24.280 --> 1:37:27.439 find evidence of this super early on? Yeah, but usually 1:37:27.479 --> 1:37:30.240 it's after twenty weeks, the earlier that you start to 1:37:30.280 --> 1:37:33.679 see pre aclamsia. Usually the worst the outcomes are, which 1:37:33.760 --> 1:37:35.519 makes sense, yeah, because you're just going to have a 1:37:35.520 --> 1:37:37.080 bigger effect on the fetus and you're gonna have a 1:37:37.160 --> 1:37:40.280 longer time that you're having potentially complications to the mother 1:37:40.360 --> 1:37:44.679 as well, and postpartum and postpartum we really do not understand. 1:37:44.960 --> 1:37:47.960 But you can develop preclamsia for the first time postpartum, 1:37:48.040 --> 1:37:50.519 even if you did not have high blood pressure during pregnancy. 1:37:51.760 --> 1:37:55.200 We have no idea, no, And it is thought that 1:37:55.560 --> 1:37:58.400 like term, because some people also don't develop preclamsy until 1:37:58.400 --> 1:38:00.200 like right at the end, right they're after term, you're 1:38:00.200 --> 1:38:04.040 after thirty seven weeks, and you now all of a 1:38:04.080 --> 1:38:07.519 sudden have high blood pressure and then potentially preeclamsia. And 1:38:07.680 --> 1:38:11.360 we think that maybe those two entities are slightly different 1:38:11.479 --> 1:38:15.719 and less related to inadequate placentation early on, but maybe 1:38:15.800 --> 1:38:18.280 some other mechanism, but we don't know what that mechanism 1:38:18.400 --> 1:38:18.840 is yet, Like. 1:38:19.120 --> 1:38:22.160 Is that the same, Is it related to any bits 1:38:22.200 --> 1:38:25.240 of the placenta remaining or like getting stuck. 1:38:25.040 --> 1:38:28.640 To Sometimes, yes, it can be from the placenta not 1:38:28.720 --> 1:38:31.240 fully detaching or something like that, but not always. So 1:38:31.320 --> 1:38:32.720 it's not as like clear cut as that. 1:38:32.920 --> 1:38:35.920 Right, Okay, there's still something that's sending that the signal 1:38:36.040 --> 1:38:38.280 of there's not enough foxygen exactly. 1:38:38.479 --> 1:38:40.920 Okay, yeah, but we don't know exactly how it works. 1:38:41.240 --> 1:38:43.000 How is it different or is it not different? 1:38:43.280 --> 1:38:44.040 And that kind of a thing. 1:38:45.160 --> 1:38:47.280 In terms of other ways that we have to reduce 1:38:47.320 --> 1:38:50.240 the risk of preaclamsia, there's some evidence that maybe calcium 1:38:50.280 --> 1:38:54.519 supplementation might help, but it's not as clear cut as aspirin. 1:38:55.560 --> 1:38:58.640 And then in terms of if someone has preclamsia, how 1:38:58.680 --> 1:39:00.600 can we prevent it from getting severe or how do 1:39:00.680 --> 1:39:05.879 we cure it? Magnesium sulfate is given to prevent seizures, 1:39:05.920 --> 1:39:09.200 so specifically to prevent eclampsia. We don't know the mechanism 1:39:09.320 --> 1:39:12.120 or why it works, but it does. But the only 1:39:12.479 --> 1:39:16.839 cure for preclamsia is delivery of the fetus and the placenta. 1:39:18.240 --> 1:39:20.640 But that is not only something that you have to 1:39:20.760 --> 1:39:24.280 balance getting to a gestational age where the fetus can 1:39:24.400 --> 1:39:28.120 survive and hopefully thrive and also ensuring the health of 1:39:28.200 --> 1:39:31.880 the pregnant person. And of course that's not always the 1:39:32.040 --> 1:39:35.880 case because postpart in preclamsia does still exist. So it's 1:39:35.960 --> 1:39:39.080 a little bit complicated and we don't fully understand it. 1:39:40.160 --> 1:39:42.720 Do you have a breakdown for the percentages of you. 1:39:43.320 --> 1:39:44.840 And I really tried to find that, but I don't. 1:39:44.960 --> 1:39:46.519 I don't have a I don't have a good breakdown 1:39:46.560 --> 1:39:51.640 of that. Yeah, so that's preclamsia. And really, like the 1:39:51.800 --> 1:39:57.120 overall physiology of pregnancy, what about breasts. I wasn't gonna 1:39:57.120 --> 1:40:01.280 talk about breast until two episodes. They do start to 1:40:01.400 --> 1:40:03.680 change early on in pregnancy. Yeah, you actually start to 1:40:03.720 --> 1:40:07.040 make colostrum in like the second trimester, which is the 1:40:07.200 --> 1:40:10.200 first like stuff that you secrete. Right after that, the 1:40:10.280 --> 1:40:12.559 newborn usually eats for the first couple of days before 1:40:12.600 --> 1:40:13.960 your actual milk comes in. 1:40:14.720 --> 1:40:16.680 Food aversions, food cravings. 1:40:16.640 --> 1:40:17.040 I don't know. 1:40:17.760 --> 1:40:20.440 Okay, there's a lot of talk about like the evolutionary 1:40:20.520 --> 1:40:23.160 significance of nausea and vomiting and food cravings. 1:40:23.200 --> 1:40:24.800 And is it so that we speaks at the time 1:40:24.880 --> 1:40:28.640 that the fetus is most vulnerable to toxins crossing the 1:40:28.720 --> 1:40:31.360 placental Yeah, but I don't know. I mean, there seems 1:40:31.400 --> 1:40:36.040 to be some basis to that, like Darwinian medicine or whatever, but. 1:40:36.920 --> 1:40:38.080 I don't know more about it than that. 1:40:38.840 --> 1:40:40.840 But what I think is so interesting and part of 1:40:40.880 --> 1:40:45.280 the reason that I am so astounded by and fascinated 1:40:45.439 --> 1:40:51.080 by the physiology of pregnancy is that despite all of 1:40:51.160 --> 1:40:55.280 these changes to literally every organ system in our body, 1:40:55.680 --> 1:40:59.479 and despite all of the possible complications, some of which 1:40:59.560 --> 1:41:02.880 might be minor and not result in severe harm, and 1:41:02.960 --> 1:41:06.160 some of which can be very severe, despite all of that, 1:41:07.200 --> 1:41:11.599 the majority of pregnancies progress all the way to term 1:41:12.280 --> 1:41:18.960 and delivery without major complication, which is just astounding. 1:41:19.120 --> 1:41:19.320 It is. 1:41:19.520 --> 1:41:23.840 It is mind blowing that our bodies can change so dramatically. 1:41:24.640 --> 1:41:29.000 I have a question about that, Okay, permanent changes, What 1:41:29.320 --> 1:41:33.800 are there? And then how like what you can tell 1:41:33.840 --> 1:41:37.960 whether someone has been pregnant before anatom like looking at 1:41:38.840 --> 1:41:39.280 a lot. 1:41:39.160 --> 1:41:41.240 Of times, I mean not all the time, h not 1:41:41.280 --> 1:41:41.760 all the time? 1:41:41.960 --> 1:41:44.600 Yeah, what what are those things that give that that 1:41:44.720 --> 1:41:45.719 like signal that We'll. 1:41:45.640 --> 1:41:47.400 Talk probably more about that in the fourth episode when 1:41:47.400 --> 1:41:51.320 we talk about postpartum stuff. Okay, So yeah, I don't 1:41:51.320 --> 1:41:53.599 have like an easy answer to that question. Okay, but yeah, 1:41:53.600 --> 1:41:56.799 I mean things change, like in terms of cervix changes 1:41:56.880 --> 1:41:58.639 and things like that that you can like maybe see 1:41:58.720 --> 1:42:02.680 on physical exam. There are there is evidence that like 1:42:02.800 --> 1:42:05.960 fetal cells remain in our tissues for like potentially the 1:42:06.000 --> 1:42:08.760 rest of our lives, which is crazy to think about it. 1:42:08.760 --> 1:42:10.840 I mean again, it kind of is that relationship with 1:42:10.960 --> 1:42:14.120 cancer where it's like yeah, yeah, yeah, interesting, it's really 1:42:14.160 --> 1:42:14.759 really interesting. 1:42:15.560 --> 1:42:18.360 But yeah, that's pregnancy erin. 1:42:21.320 --> 1:42:25.000 In a short short and a half years that I've 1:42:25.439 --> 1:42:27.479 took to explain all of that, we went from a 1:42:27.560 --> 1:42:30.759 deep time. We've really crossed hundreds of millions of years. 1:42:30.960 --> 1:42:34.320 Deep time all the way until delivery, which is deep 1:42:34.360 --> 1:42:35.120 time delivery. 1:42:35.560 --> 1:42:35.760 Yeah. 1:42:37.120 --> 1:42:41.160 So so if you'd like to learn more sources, boy, howdy, 1:42:41.479 --> 1:42:46.400 boy howdy, Okay, I have some sources here. Oh I bet. 1:42:46.560 --> 1:42:48.599 There are two books that I read. One is called 1:42:48.640 --> 1:42:51.200 The Evolution of the Human Placenta, which is what it 1:42:51.280 --> 1:42:54.559 sounds like by Michael Power and Jay Schulkin. And then 1:42:54.680 --> 1:42:57.559 there's Life's Vital Link The Astonishing Role of the Placenta 1:42:57.680 --> 1:43:01.160 by Young Look. Then, uh, those are the books. I 1:43:01.160 --> 1:43:04.200 think they were pretty good overviews of what's going on. 1:43:04.800 --> 1:43:07.280 It is an overwhelming amount of information. If you want 1:43:07.280 --> 1:43:09.799 to learn more about retroviruses, there are a few papers 1:43:09.960 --> 1:43:12.519 that I have posted. One is by Chung from twenty 1:43:12.560 --> 1:43:16.439 thirteen called Retroviruses facilitate the rapid evolution of the mammalian placenta. 1:43:16.600 --> 1:43:16.840 Love it. 1:43:17.960 --> 1:43:20.280 There are some other ones too about retroviruses that are good. 1:43:20.439 --> 1:43:24.479 Then there's shits at All from twenty nineteen, Evolution of 1:43:24.520 --> 1:43:28.439 placental invasion and cancer metastasis are causally linked. 1:43:28.560 --> 1:43:31.360 Ooh yeah, interesting, interesting, bold statement. 1:43:31.600 --> 1:43:35.719 Bold statement. Then from twenty thirteen by Crosley Placental invasion, 1:43:35.800 --> 1:43:39.080 preeclampsia risk, and adaptive molecular evolution at the origin of 1:43:39.160 --> 1:43:43.000 the Great apes evidence from genome wide analyzes because humans 1:43:43.000 --> 1:43:46.840 are not the only species to get preeclampsia, which we 1:43:47.000 --> 1:43:48.479 thought for the longest time that we were. 1:43:49.000 --> 1:43:49.280 But no. 1:43:49.439 --> 1:43:52.439 I think there was a gorilla at the Houston Zoo 1:43:53.760 --> 1:43:56.479 last year the year before something that had preeclampsia or 1:43:56.560 --> 1:43:57.479 baby I know, she. 1:43:57.600 --> 1:43:59.280 Okay, I think, so, okay good. 1:44:00.720 --> 1:44:02.800 I have a number of sources for this, some of 1:44:02.880 --> 1:44:05.960 which focus more on just the basic physiology of pregnancy. 1:44:06.280 --> 1:44:08.160 One that I liked that was easy to read was 1:44:08.200 --> 1:44:11.280 called Physiology of Pregnancy from Anesthesion Intensive Care Medicine from 1:44:11.280 --> 1:44:12.960 twenty nineteen. I had a few others that were more 1:44:13.000 --> 1:44:16.200 focused on the cardiovascular physiology of pregnancy too that were great. 1:44:17.200 --> 1:44:21.320 A review paper on just stational diabetes called Justational Diabetes 1:44:21.320 --> 1:44:25.559 melodis really creative title from Nature Reviews Disease Primers twenty nineteen, 1:44:25.920 --> 1:44:28.680 and another from Nature Reviews Disease Primers on pre acclamsia 1:44:29.080 --> 1:44:32.920 called preaclamsia not really creative titling. I mean, I feel 1:44:32.920 --> 1:44:34.880 like it's pretty easy to understand what the is, what 1:44:34.960 --> 1:44:36.240 the papers are that know what you're getting. 1:44:36.280 --> 1:44:38.320 It's real puns puns. 1:44:38.040 --> 1:44:40.360 In this and then there was a bunch more so 1:44:40.439 --> 1:44:42.320 listen check out our website this podcast will Kill You 1:44:42.360 --> 1:44:44.679 dot com under the episode's tab, where you can find 1:44:44.680 --> 1:44:46.599 the list of all of the sources that we used 1:44:46.600 --> 1:44:49.280 from this episode in every single one of our episodes. 1:44:48.840 --> 1:44:53.240 Single one. A huge thank you again to everyone who 1:44:53.320 --> 1:44:55.280 sent in their first hand account and shared them with us. 1:44:55.360 --> 1:44:57.320 We really can't thank you enough. Thank you, thank you, 1:44:57.479 --> 1:44:57.960 thank you, thank you. 1:44:58.120 --> 1:44:58.760 We'll try though. 1:45:00.880 --> 1:45:03.800 Thank you again to everybody here at Exactly Right Studios 1:45:03.880 --> 1:45:07.280 for having us. We're super excited about it. Thank you Tom, 1:45:07.320 --> 1:45:09.120 thank you Leana, thank you Jessica, thank you Brent, thank you, 1:45:09.240 --> 1:45:10.320 Craig everyone. 1:45:10.360 --> 1:45:12.200 Thank you everyone. There's so many other people's do so 1:45:12.280 --> 1:45:13.200 much fun it has. 1:45:13.439 --> 1:45:13.639 Yeah. 1:45:14.560 --> 1:45:16.840 Thank you to Bloodmobile for providing the music for this 1:45:16.960 --> 1:45:18.439 episode and all of our episodes. 1:45:18.479 --> 1:45:21.080 And thank you to all of you for listening and watching. 1:45:21.360 --> 1:45:23.560 And we hope that you enjoyed this episode and that 1:45:23.600 --> 1:45:25.960 you're ready for two more to more. 1:45:26.479 --> 1:45:28.320 I know we still have so much to cover its 1:45:28.640 --> 1:45:32.000 wow yea. And thank you to our patrons. You really 1:45:32.439 --> 1:45:34.400 you mean a lot to us. We really appreciate you. 1:45:34.520 --> 1:45:35.000 Yeah, thank you. 1:45:35.280 --> 1:45:35.479 Yeah. 1:45:35.920 --> 1:46:03.479 Well, until next time, wash your handsalthy animals, U.