WEBVTT 00:00:07.880 --> 00:00:10.759 You're in the bay. Once you get over to the bed, 00:00:10.919 --> 00:00:13.560 we'll give you the story. Everything's going 00:00:13.560 --> 00:00:17.339 to happen super fast. Welcome to the emergency 00:00:17.339 --> 00:00:45.219 room. So picture this. A 24 year old woman walks 00:00:45.219 --> 00:00:50.770 into your emergency department triage. she looks 00:00:50.770 --> 00:00:52.729 a little pale, she's holding her right shoulder, 00:00:52.909 --> 00:00:55.409 wincing, and tells you she's been having these 00:00:55.409 --> 00:00:58.810 dizzy spells since she woke up. Her blood pressure 00:00:58.810 --> 00:01:01.850 is 110 over 70, but her heart rate is sitting 00:01:01.850 --> 00:01:05.510 at a 115. So as the triage nurse, I mean, your 00:01:05.510 --> 00:01:07.849 first instinct might be to ask, did she lift 00:01:07.849 --> 00:01:10.670 something heavy? or maybe she just slept on her 00:01:10.670 --> 00:01:12.829 arm rod. Right, the orthopedic road. Exactly. 00:01:13.290 --> 00:01:14.670 You might think about sending her back to the 00:01:14.670 --> 00:01:16.409 waiting room with an ice pack and some ibuprofen, 00:01:16.670 --> 00:01:18.930 but if you do that, she might literally be dead 00:01:18.930 --> 00:01:21.390 in an hour. Yeah, she absolutely could be. Because 00:01:21.390 --> 00:01:24.129 that shoulder pain isn't... an orthopedic issue 00:01:24.129 --> 00:01:27.349 at all. It's actually a massive catastrophic 00:01:27.349 --> 00:01:29.950 obstetric hemorrhage. And she's actively bleeding 00:01:29.950 --> 00:01:32.290 out into her own abdomen. And see, that is the 00:01:32.290 --> 00:01:35.189 exact scenario that separates, you know, a task 00:01:35.189 --> 00:01:37.810 -oriented nurse from a real clinical thinker. 00:01:37.810 --> 00:01:39.689 Because what the patient is experiencing there 00:01:39.689 --> 00:01:43.290 is a ruptured ectopic pregnancy. And unless you 00:01:43.290 --> 00:01:46.030 have the clinical foresight to, like, ask about 00:01:46.030 --> 00:01:48.430 her last menstrual period and recognize that 00:01:48.430 --> 00:01:50.629 physiological connection, the pooling of free 00:01:50.629 --> 00:01:53.120 blood and the peritoneal cavity causing shoulder 00:01:53.120 --> 00:01:56.840 pain, you miss the window to save her life. It's 00:01:56.840 --> 00:01:59.579 terrifying how fast it happens and that's exactly 00:01:59.579 --> 00:02:04.239 the landscape we are navigating today. Welcome 00:02:04.239 --> 00:02:06.959 to the deep dive everybody. We are stepping straight 00:02:06.959 --> 00:02:09.300 into the clinical simulation lab for a really 00:02:09.300 --> 00:02:11.580 specialized mission today. We are indeed. We 00:02:11.580 --> 00:02:14.099 are acting as your elite OB nursing educators, 00:02:14.520 --> 00:02:16.719 your clinical mentors and honestly your exam 00:02:16.719 --> 00:02:19.699 coaches. Our focus today is obstetric emergencies. 00:02:20.420 --> 00:02:22.800 Specifically, complications of pregnancy and 00:02:22.800 --> 00:02:25.099 hemorrhagic disorders. And just to set the ground 00:02:25.099 --> 00:02:26.500 rules here, we aren't going to just sit here 00:02:26.500 --> 00:02:28.139 and read a textbook at you. No, please don't. 00:02:28.240 --> 00:02:30.340 Right. We are aggressively applying the Pareto 00:02:30.340 --> 00:02:32.919 principle. We are sifting through hundreds of 00:02:32.919 --> 00:02:35.659 pages of pathology, pharmacology, and nursing 00:02:35.659 --> 00:02:39.199 interventions to extract that critical 20 % of 00:02:39.199 --> 00:02:41.780 knowledge. A 20 % that yields 80 % of your exam 00:02:41.780 --> 00:02:45.110 value. Exactly. We're isolating the high -yield 00:02:45.110 --> 00:02:47.569 facts, the mechanisms, and the safety concepts 00:02:47.569 --> 00:02:50.069 that will make you a safe, prioritized, formidable 00:02:50.069 --> 00:02:52.930 clinician. Because to thrive on a real labor 00:02:52.930 --> 00:02:55.449 and delivery floor or, you know, in a high -stakes 00:02:55.449 --> 00:02:57.909 testing environment like the NCLEX, you have 00:02:57.909 --> 00:03:00.659 to establish a baseline of prioritization. You 00:03:00.659 --> 00:03:03.800 were just perpetually scanning for airway breathing, 00:03:03.900 --> 00:03:06.080 circulation, fetal distress, and hemorrhage. 00:03:06.240 --> 00:03:09.699 Right. And if you understand the underlying mechanism 00:03:09.699 --> 00:03:12.919 of why a disease process threatens one of those 00:03:12.919 --> 00:03:16.139 core priorities, the nursing actions just become 00:03:16.139 --> 00:03:19.020 intuitive. You won't have to memorize some long 00:03:19.020 --> 00:03:20.800 list of interventions. You'll just know what 00:03:20.800 --> 00:03:23.479 the body needs to survive. I love that. OK, let's 00:03:23.479 --> 00:03:24.960 start at the very beginning of the timeline, 00:03:25.039 --> 00:03:26.580 right back with that scenario we just mentioned, 00:03:26.939 --> 00:03:31.349 the atopic pregnancy. Let's do it. of early implantation 00:03:31.349 --> 00:03:34.530 are just wild. Trophoblastic tissue, which is 00:03:34.530 --> 00:03:37.189 the outer layer of the blastocyst, is essentially 00:03:37.189 --> 00:03:40.509 programmed to behave like, well, an invasive 00:03:40.509 --> 00:03:43.009 tumor. It really is. Its singular biological 00:03:43.009 --> 00:03:45.430 directive is to dig into tissue and establish 00:03:45.430 --> 00:03:48.360 a robust maternal blood supply. Right. And when 00:03:48.360 --> 00:03:50.659 it does that in the thick, nutrient -dense decidua 00:03:50.659 --> 00:03:53.460 of the uterus, we get a healthy placenta. But 00:03:53.460 --> 00:03:56.620 when that blastocyst gets delayed, which is often 00:03:56.620 --> 00:03:59.699 due to scar tissue or maybe inflammation from 00:03:59.699 --> 00:04:02.319 pelvic inflammatory disease or altered tubal 00:04:02.319 --> 00:04:05.060 motility, it implants outside the uterine cavity. 00:04:05.460 --> 00:04:07.300 And usually that's in the fallopian tube, right? 00:04:07.419 --> 00:04:10.639 Yeah. 95 % of the time, it nests in the ampulla, 00:04:10.759 --> 00:04:12.699 which is the widest section of the fallopian 00:04:12.699 --> 00:04:15.240 tube. And the problem there is purely structural. 00:04:15.460 --> 00:04:17.899 Because the tube is tiny. Exactly. The fallopian 00:04:17.899 --> 00:04:21.120 tube has this very thin muscularis layer and 00:04:21.120 --> 00:04:23.800 it completely lacks the protective adaptable 00:04:23.800 --> 00:04:25.980 lining of the uterus. It just cannot accommodate 00:04:25.980 --> 00:04:28.160 a growing embryo. But the invasion just continues 00:04:28.160 --> 00:04:31.899 anyway. The trophoblasts dig right into the tubal 00:04:31.899 --> 00:04:34.480 wall, eroding the blood vessels. And because 00:04:34.480 --> 00:04:37.100 the hormonal signals of pregnancy, specifically 00:04:37.100 --> 00:04:40.500 human chorionic gonadotropin, or ACG, are still 00:04:40.500 --> 00:04:42.860 firing, the maternal body doesn't even realize 00:04:42.860 --> 00:04:45.160 anything is structurally wrong. It's completely 00:04:45.160 --> 00:04:47.899 tricked. It continues to pump blood to that area. 00:04:48.240 --> 00:04:50.560 The tube stretches until it physically cannot 00:04:50.560 --> 00:04:53.480 take the tension anymore, and then it ruptures. 00:04:53.819 --> 00:04:56.000 Which brings us back to our 24 -year -old in 00:04:56.000 --> 00:04:59.519 triage. Ectopic pregnancy is literally the leading 00:04:59.519 --> 00:05:01.720 cause of first trimester maternal mortality. 00:05:02.519 --> 00:05:05.139 and it is entirely due to hypovolemic shock. 00:05:05.439 --> 00:05:07.319 Right. You have to suspect this in any patient 00:05:07.319 --> 00:05:09.519 of childbearing age presenting with abdominal 00:05:09.519 --> 00:05:12.899 pain and a positive pregnancy test. You do not, 00:05:12.899 --> 00:05:16.360 I repeat, do not wait for an ultrasound confirmation 00:05:16.360 --> 00:05:18.680 to start thinking about hemorrhage. Yeah, that's 00:05:18.680 --> 00:05:20.800 a massive priority right there. Yeah. So what's 00:05:20.800 --> 00:05:23.740 the expected versus the concerning here? Because 00:05:23.740 --> 00:05:26.139 a normal early pregnancy has some weird symptoms 00:05:26.139 --> 00:05:28.759 too. Sure. In a typical early pregnancy, you 00:05:28.759 --> 00:05:30.800 expect a missed period, some breast tenderness, 00:05:30.920 --> 00:05:33.079 maybe some mild nausea. That's all normal. Right. 00:05:33.339 --> 00:05:35.819 But the red flags for an ectopic, even before 00:05:35.819 --> 00:05:39.100 it ruptures, are unilateral abdominal pain, so 00:05:39.100 --> 00:05:41.779 pain isolated to one side of the pelvis, and 00:05:41.779 --> 00:05:44.480 dark vaginal spotting. This usually manifests 00:05:44.480 --> 00:05:46.459 around, I'd say, six to eight weeks after their 00:05:46.459 --> 00:05:48.680 last menstrual period. OK, wait. Let's unpack 00:05:48.680 --> 00:05:50.800 that dark spotting. Why is it dark? Is it active 00:05:50.800 --> 00:05:53.290 bleeding from the tube making its way out? Actually, 00:05:53.509 --> 00:05:56.550 no, not necessarily. Often the altered hormonal 00:05:56.550 --> 00:05:59.110 state causes the uterine lining to kind of slough 00:05:59.110 --> 00:06:02.050 off, resulting in that dark old blood. Ah, okay. 00:06:02.110 --> 00:06:05.050 But the real crisis, the urgent priority, is 00:06:05.050 --> 00:06:09.029 the abrupt onset of severe stabbing lower abdominal 00:06:09.029 --> 00:06:11.699 pain. We're talking about pain that literally 00:06:11.699 --> 00:06:14.160 doubles the patient over. That means the tube 00:06:14.160 --> 00:06:16.819 has burst. And this is where the anatomy of the 00:06:16.819 --> 00:06:19.139 nervous system gives us that brilliant though, 00:06:19.139 --> 00:06:21.879 you know, terrifying diagnostic clue, the referred 00:06:21.879 --> 00:06:25.160 shoulder pain. Cure sign. Yes. When that tube 00:06:25.160 --> 00:06:27.620 bursts, arterial blood pours into the peritoneal 00:06:27.620 --> 00:06:31.060 cavity. As the patient lies flat or even just 00:06:31.060 --> 00:06:34.139 shifts around, that highly irritating free blood 00:06:34.139 --> 00:06:36.639 pools upward under the diaphragm. And the diaphragm, 00:06:36.639 --> 00:06:38.540 as we know, is innervated by the phrenic nerve. 00:06:38.560 --> 00:06:41.009 Right. If we recall our neuroanatomy, the phrenic 00:06:41.009 --> 00:06:43.750 nerve arises from the cervical spinal roots C3, 00:06:43.829 --> 00:06:47.069 C4, and C5. And those exact same nerve roots 00:06:47.069 --> 00:06:49.490 also provide sensory innervation to the shoulder. 00:06:49.589 --> 00:06:52.069 So the brain gets confused? Completely. The brain 00:06:52.069 --> 00:06:54.569 struggles to isolate the origin of the visceral 00:06:54.569 --> 00:06:57.810 irritation, so it misinterprets the massive intraabdominal 00:06:57.810 --> 00:07:00.529 bleeding as acute shoulder pain. That is wild. 00:07:01.029 --> 00:07:04.069 So on an exam or in the clinic, if an early pregnancy 00:07:04.069 --> 00:07:06.569 patient complains of shoulder pain, you translate 00:07:06.569 --> 00:07:09.310 that instantly. Shoulder pain equals internal 00:07:09.310 --> 00:07:11.790 hemorrhage. They aren't sleeping wrong. They 00:07:11.790 --> 00:07:14.870 are bleeding internally. Exactly. You assess 00:07:14.870 --> 00:07:18.990 those vital signs immediately and Hey, the classic 00:07:18.990 --> 00:07:20.990 trap here for students is waiting for the blood 00:07:20.990 --> 00:07:23.189 pressure to drop to confirm shock. Oh, yeah. 00:07:23.189 --> 00:07:25.569 Don't do that. Never do that. Hemodynamically, 00:07:25.629 --> 00:07:27.610 the body compensates first by increasing the 00:07:27.610 --> 00:07:30.250 heart rate to maintain cardiac output. Tachycardia 00:07:30.250 --> 00:07:32.810 is your early warning system. Hypotension is 00:07:32.810 --> 00:07:35.550 a late decompensated sign. By the time the BP 00:07:35.550 --> 00:07:38.529 drops, you are way behind. Right. So once you 00:07:38.529 --> 00:07:41.050 suspect the rupture, your priority nursing actions 00:07:41.050 --> 00:07:43.649 have to be rapid. You are securing large bore 00:07:43.649 --> 00:07:46.750 IV access, at least an 18 gauge, because you 00:07:46.750 --> 00:07:49.220 need the capability to push fluids and potentially 00:07:49.220 --> 00:07:52.040 blood products. Yep. And you anticipate orders 00:07:52.040 --> 00:07:54.360 for a transvaginal ultrasound to locate the mass 00:07:54.360 --> 00:07:57.500 and serial quantitative beta HCG blood tests. 00:07:57.560 --> 00:07:59.879 And in an ectopic, those HCG levels are going 00:07:59.879 --> 00:08:01.819 to look weird, right? Right. They will be lower 00:08:01.819 --> 00:08:03.939 than expected, and they won't double every 48 00:08:03.939 --> 00:08:06.139 hours like they do in a normal, viable pregnancy. 00:08:06.279 --> 00:08:09.199 OK. And there is a massive contraindication here 00:08:09.199 --> 00:08:12.379 that examiners absolutely love to test. Oh, the 00:08:12.379 --> 00:08:16.019 digital exam. Yes. You absolutely never, under 00:08:16.019 --> 00:08:19.000 any circumstances, perform a digital vaginal 00:08:19.000 --> 00:08:22.060 exam on a patient with a suspected unruptured 00:08:22.060 --> 00:08:24.899 ectopic pregnancy. Because if you palpate that 00:08:24.899 --> 00:08:27.139 adenoxal mass, you can physically rupture the 00:08:27.139 --> 00:08:29.660 tube yourself. Right. You precipitate the exact 00:08:29.660 --> 00:08:31.670 hemorrhage you're trying to prevent. Just don't 00:08:31.670 --> 00:08:33.870 do it. You also have to think about the immunology 00:08:33.870 --> 00:08:36.750 of this patient. If the mother's blood type is 00:08:36.750 --> 00:08:40.009 Rh negative, the exposure to fetal blood during 00:08:40.009 --> 00:08:42.809 the rupture or the surgery requires the administration 00:08:42.809 --> 00:08:46.970 of Rh immune globulin or ROJAM. And that has 00:08:46.970 --> 00:08:49.809 to be within 72 hours. Exactly. This prevents 00:08:49.809 --> 00:08:52.190 the mother's immune system from forming antibodies 00:08:52.190 --> 00:08:55.090 against the Rh factor, which would cause hemolytic 00:08:55.090 --> 00:08:57.429 disease of the newborn in her future pregnancies. 00:08:57.610 --> 00:09:00.370 Perfect. Now, what have we catch the ectopic 00:09:00.370 --> 00:09:03.409 before it ruptures. Because the pharmacological 00:09:03.409 --> 00:09:05.649 neurosection here is kind of fascinating. We 00:09:05.649 --> 00:09:08.289 use methotrexate. Which always surprises students. 00:09:08.409 --> 00:09:10.889 Yeah, because it's a known chemotherapeutic agent. 00:09:11.029 --> 00:09:13.990 It's a highly toxic drug, and we are giving it 00:09:13.990 --> 00:09:16.509 to a pregnant patient. But the mechanism of action 00:09:16.509 --> 00:09:19.470 is precisely why it works. Methotrexate is a 00:09:19.470 --> 00:09:22.690 folic acid antagonist. It binds to the enzyme 00:09:22.690 --> 00:09:26.529 dihydrofolate reductase, which completely halts 00:09:26.529 --> 00:09:30.259 the synthesis of DNA and RNA. And because the 00:09:30.259 --> 00:09:32.759 trophoblastic cells of the ectopic pregnancy 00:09:32.759 --> 00:09:35.980 are dividing at this incredibly rapid exponential 00:09:35.980 --> 00:09:39.700 rate, they're uniquely susceptible to this targeted 00:09:39.700 --> 00:09:42.659 disruption. Exactly. By administering methotrexate, 00:09:42.679 --> 00:09:44.779 we can dissolve the pregnancy tissue medically, 00:09:45.379 --> 00:09:47.440 completely bypassing the need for surgery. Which 00:09:47.440 --> 00:09:49.899 is a huge clinical win because it preserves the 00:09:49.899 --> 00:09:52.200 integrity of the fallopian tube and safeguards 00:09:52.200 --> 00:09:54.860 the patient's future fertility. But the criteria 00:09:54.860 --> 00:09:57.259 for who gets methotrexate is a prime testing 00:09:57.259 --> 00:09:59.759 target because it requires really strict patient 00:09:59.759 --> 00:10:01.460 safety parameters. But you can't just give it 00:10:01.460 --> 00:10:04.559 to everyone? No. The mass must be unruptured 00:10:04.559 --> 00:10:07.460 and relatively small. typically less than four 00:10:07.460 --> 00:10:10.960 centimeters. The beta HCG must be under 5 ,000, 00:10:11.100 --> 00:10:14.120 but most critically, the patient must be hemodynamically 00:10:14.120 --> 00:10:17.200 stable. So if their heart rate is 120 and they 00:10:17.200 --> 00:10:20.320 are dizzy, then the tube has likely already compromised 00:10:20.320 --> 00:10:23.659 and a slow -acting drug like methotrexate is 00:10:23.659 --> 00:10:26.799 totally useless. They need a stat surgery. Makes 00:10:26.799 --> 00:10:29.379 sense. What about the nursing implications for 00:10:29.379 --> 00:10:31.200 methotrexate? There's a lot of patient teaching 00:10:31.200 --> 00:10:34.870 there. A ton. As a folic acid antagonist, Its 00:10:34.870 --> 00:10:37.409 efficacy can be completely neutralized if the 00:10:37.409 --> 00:10:40.549 patient consumes folic acid. You must explicitly 00:10:40.549 --> 00:10:42.590 teach them to stop taking their prenatal vitamins, 00:10:42.809 --> 00:10:44.769 because those are loaded with folic acid. Oh, 00:10:44.830 --> 00:10:46.730 that's a huge exam point, stop the prenatals. 00:10:46.909 --> 00:10:50.570 Yes. They also need to avoid alcohol, as methotrexate 00:10:50.570 --> 00:10:53.210 is hepatotoxic, and the liver is already working 00:10:53.210 --> 00:10:55.190 overtime to process the drug. And the follow 00:10:55.190 --> 00:10:58.090 up for this is non -negotiable. Absolute. They 00:10:58.090 --> 00:11:00.450 must return to the clinic on day four and day 00:11:00.450 --> 00:11:03.429 seven post -injection for follow -up quantitative 00:11:03.429 --> 00:11:06.590 HCG titers. We have to prove the drug actually 00:11:06.590 --> 00:11:08.850 arrested the cellular division. We are looking 00:11:08.850 --> 00:11:11.750 for a specific percentage drop. Right. Exactly. 00:11:12.370 --> 00:11:14.450 Furthermore, they need to use highly reliable 00:11:14.450 --> 00:11:16.750 contraception for at least three menstrual cycles 00:11:16.750 --> 00:11:19.570 afterward. The drug remains in the system and 00:11:19.570 --> 00:11:22.149 could cause severe teratogenic effects to a new 00:11:22.149 --> 00:11:24.889 embryo. Plus, the reproductive tract simply needs 00:11:24.889 --> 00:11:26.909 time to heal. Okay, so if we're coaching them 00:11:26.909 --> 00:11:29.049 for the exam, if you only remember five things 00:11:29.049 --> 00:11:31.509 about ectopic pregnancy, what are they? Okay, 00:11:31.669 --> 00:11:34.610 top five. One, unilateral abdominal pain with 00:11:34.610 --> 00:11:37.590 a missed period mandates high suspicion. Two, 00:11:37.909 --> 00:11:40.070 referred shoulder pain is the somatic alarm bell 00:11:40.070 --> 00:11:44.049 for intraperitoneal hemorrhage. Three, methotrexate 00:11:44.049 --> 00:11:46.389 is reserved strictly for the stable, unruptured 00:11:46.389 --> 00:11:50.049 patient. Four, follow -up HCG titers are mandatory. 00:11:50.490 --> 00:11:53.779 And five, Always give Rojam to Rh negative mothers. 00:11:54.000 --> 00:11:57.240 Love it. Clear and prioritized. OK, moving forward 00:11:57.240 --> 00:11:59.000 on our timeline, let's look at what happens when 00:11:59.000 --> 00:12:01.200 the embryo actually navigates the fallopian tube 00:12:01.200 --> 00:12:03.659 successfully and implants in the correct location, 00:12:03.860 --> 00:12:06.580 the uterus, but the pregnancy itself is biologically 00:12:06.580 --> 00:12:08.600 unviable. Right. Transitioning to the spectrum 00:12:08.600 --> 00:12:11.159 of spontaneous abortion, which clinically we 00:12:11.159 --> 00:12:14.059 refer to as miscarriage. This is an area that 00:12:14.059 --> 00:12:18.399 demands a really seamless blend of sharp physiological 00:12:18.399 --> 00:12:21.159 understanding and just profound psychological 00:12:21.159 --> 00:12:23.720 tact. Because from a purely clinical standpoint, 00:12:24.200 --> 00:12:26.399 the terminology can be really overwhelming. It's 00:12:26.399 --> 00:12:28.759 a lot of words, imminent, incipient, incomplete, 00:12:29.100 --> 00:12:32.179 complete, missed, septic. Right. So how is a 00:12:32.179 --> 00:12:33.700 nursing student supposed to keep these straight 00:12:33.700 --> 00:12:36.799 on a fast -paced exam? OK. So the physiological 00:12:36.799 --> 00:12:39.620 anchor here, the definitive diagnostic key, is 00:12:39.620 --> 00:12:42.299 the cervix. The state of the cervix. Yes. The 00:12:42.299 --> 00:12:45.200 cervix is a dense, fibrous ring of connective 00:12:45.200 --> 00:12:47.500 tissue that acts as the mechanical gatekeeper 00:12:47.500 --> 00:12:51.080 of the uterus. When we evaluate a patient experiencing 00:12:51.080 --> 00:12:53.980 early pregnancy bleeding, we are looking directly 00:12:53.980 --> 00:12:56.139 at that gate to determine what happens next. 00:12:56.379 --> 00:12:58.500 Okay, so let's break down the hemodynamics using 00:12:58.500 --> 00:13:01.480 that door analogy. What about an inevitable or 00:13:01.480 --> 00:13:04.179 incipient miscarriage? So the patient presents 00:13:04.179 --> 00:13:06.620 with moderate to heavy bleeding and cramping. 00:13:06.919 --> 00:13:09.059 When the provider visualizes the cervix with 00:13:09.059 --> 00:13:12.059 the speculum, the internal os is open. The structural 00:13:12.059 --> 00:13:14.120 integrity of the pregnancy has failed and the 00:13:14.120 --> 00:13:16.340 process cannot be reversed. The door is open. 00:13:16.600 --> 00:13:19.350 Got it. And when that progresses to an incomplete 00:13:19.350 --> 00:13:22.129 miscarriage, it becomes a severe hemorrhagic 00:13:22.129 --> 00:13:25.409 risk, right? Heavy bleeding, intense cramping, 00:13:25.789 --> 00:13:28.190 and partial passage of tissue. Yes. The cervix 00:13:28.190 --> 00:13:30.429 is open, but some of the products of conception, 00:13:30.870 --> 00:13:32.889 often fragments of the developing placenta, remain 00:13:32.889 --> 00:13:35.220 attached to the uterine wall. And the physiology 00:13:35.220 --> 00:13:37.940 of why retained tissue causes such massive bleeding 00:13:37.940 --> 00:13:40.700 is critical to understand, because the uterus 00:13:40.700 --> 00:13:43.240 normally controls bleeding by contracting its 00:13:43.240 --> 00:13:46.519 interlacing muscle fibers, the myometrium, around 00:13:46.519 --> 00:13:48.960 the spiral arteries that feed the placental site. 00:13:49.419 --> 00:13:51.519 It acts like a biological tourniquet. Right. 00:13:51.620 --> 00:13:53.639 But if a piece of tissue is retained, it acts 00:13:53.639 --> 00:13:55.899 like a wedge holding the door open. Exactly. 00:13:56.090 --> 00:13:58.629 The uterus cannot clamp down effectively. The 00:13:58.629 --> 00:14:00.690 spiral arteries remain open, and the patient 00:14:00.690 --> 00:14:03.269 just bleeds and bleeds. Which is exactly why 00:14:03.269 --> 00:14:05.330 an incomplete miscarriage requires immediate 00:14:05.330 --> 00:14:07.870 intervention, either medically or via a surgical 00:14:07.870 --> 00:14:11.190 dilation and curettage of DNC, to empty the cavity 00:14:11.190 --> 00:14:13.879 so the myometrine can finally contract. Now, 00:14:14.100 --> 00:14:16.559 if the process finishes naturally, we have a 00:14:16.559 --> 00:14:18.840 complete miscarriage. All tissue is expelled, 00:14:19.360 --> 00:14:22.100 the uterus is finally empty, the biological tourniquet 00:14:22.100 --> 00:14:24.960 works, the bleeding subsides, the cramping stops, 00:14:25.440 --> 00:14:28.860 and crucially, the cervix closes back up. The 00:14:28.860 --> 00:14:32.679 door is shut. Right. But the physiological outlier 00:14:32.679 --> 00:14:35.000 here, the one that is so devastating for patients, 00:14:35.720 --> 00:14:38.080 is the missed abortion. Because there are no 00:14:38.080 --> 00:14:41.840 outward alarm bells. None. The fetus loses viability 00:14:41.840 --> 00:14:44.919 in utero, but the maternal body fails to recognize 00:14:44.919 --> 00:14:47.549 the loss. The cervix remains tightly closed. 00:14:47.730 --> 00:14:49.710 There is no bleeding, no cramping. So how do 00:14:49.710 --> 00:14:51.870 they even know? The only clinical clue is that 00:14:51.870 --> 00:14:53.490 the patient might notice their early pregnancy 00:14:53.490 --> 00:14:55.549 symptoms, the nausea, the breast tenderness, 00:14:55.649 --> 00:14:58.690 just kind of slowly fading away as the ECG levels 00:14:58.690 --> 00:15:00.929 drop. And it's usually caught on a routine ultrasound 00:15:00.929 --> 00:15:03.049 when there's no fetal heart tone. Heartbreaking. 00:15:03.190 --> 00:15:05.590 And if a missed or incomplete abortion goes untreated, 00:15:06.009 --> 00:15:08.029 we face the risk of a septic miscarriage, which 00:15:08.029 --> 00:15:11.789 is incredibly dangerous. Extremely. The retainacrotic 00:15:11.789 --> 00:15:14.450 tissue becomes a highly vascularized petri dish 00:15:14.450 --> 00:15:17.279 for pathogens. often ascending from the vaginal 00:15:17.279 --> 00:15:20.259 flora. We start looking for systemic signs of 00:15:20.259 --> 00:15:24.200 infection, a fetid foul -smelling vaginal discharge, 00:15:24.840 --> 00:15:27.899 severe pelvic tenderness, and an escalating fever. 00:15:28.019 --> 00:15:31.340 And the microbiology here is scary. Often these 00:15:31.340 --> 00:15:34.159 are gram -negative bacteria that release endotoxins 00:15:34.159 --> 00:15:36.269 into the maternal bloodstream. This triggers 00:15:36.269 --> 00:15:39.129 a massive systemic inflammatory response. The 00:15:39.129 --> 00:15:41.830 capillaries become super permeable, fluid leaks 00:15:41.830 --> 00:15:44.370 out of the vascular space, and the patient goes 00:15:44.370 --> 00:15:47.649 into endotoxic shock. Their blood pressure plummets 00:15:47.649 --> 00:15:49.970 while their heart rate skyrockets, trying to 00:15:49.970 --> 00:15:52.529 perfuse vital organs with a depleted intravascular 00:15:52.529 --> 00:15:54.950 volume. So your priority nursing actions have 00:15:54.950 --> 00:15:57.409 to be focused on perfusion and quantitative assessment. 00:15:57.889 --> 00:15:59.710 You do not just ask the patient if the bleeding 00:15:59.710 --> 00:16:02.080 is heavy. That's subjective. Right. You count 00:16:02.080 --> 00:16:04.379 the pads. You weigh the Chucks pads. One gram 00:16:04.379 --> 00:16:06.679 of weight equals one milliliter of blood loss. 00:16:07.100 --> 00:16:09.200 You monitor the vital signs for that narrowing 00:16:09.200 --> 00:16:11.340 pulse pressure and rising heart rate that indicate 00:16:11.340 --> 00:16:14.440 compensatory shock. Now, regarding the pharmacology 00:16:14.440 --> 00:16:17.100 for a miscarriage, we frequently see a combination 00:16:17.100 --> 00:16:20.340 of myfopristone and misoprostol. The mechanism 00:16:20.340 --> 00:16:22.440 of these drugs is highly testable because the 00:16:22.440 --> 00:16:24.440 intended effects actually mimic an emergency. 00:16:24.759 --> 00:16:27.220 They really do. So, myphopristone is an anti 00:16:27.220 --> 00:16:30.139 -progestin. It blocks the progesterone receptors, 00:16:30.320 --> 00:16:32.500 essentially starving the pregnancy of the hormone 00:16:32.500 --> 00:16:35.169 it needs to stay attached. And then... 24 to 00:16:35.169 --> 00:16:37.710 48 hours later, they take misoprostol. Right, 00:16:37.850 --> 00:16:40.850 which is a synthetic prostaglandin E1 analog. 00:16:41.610 --> 00:16:44.350 Prostaglandins cause powerful rhythmic contractions 00:16:44.350 --> 00:16:47.250 of the myometrium and soften the cervix. And 00:16:47.250 --> 00:16:51.169 here's a classic NCLEX trap for students. A patient 00:16:51.169 --> 00:16:54.549 will call the clinic reporting intense, painful 00:16:54.549 --> 00:16:57.110 uterine cramping and heavy bleeding with clots 00:16:57.110 --> 00:17:00.100 after taking misoprostol. A novice might interpret 00:17:00.100 --> 00:17:02.620 this as an adverse reaction or a hemorrhage requiring 00:17:02.620 --> 00:17:05.259 the ER. But physiologically, this is the exact 00:17:05.259 --> 00:17:08.339 intended mechanism of the drug. It is artificially 00:17:08.339 --> 00:17:10.740 inducing the expulsion of the uterine contents. 00:17:11.220 --> 00:17:13.650 Right. You anticipate this, you prepare the patient 00:17:13.650 --> 00:17:16.309 for it with appropriate analgesics, and you educate 00:17:16.309 --> 00:17:18.970 them on the specific threshold of bleeding that 00:17:18.970 --> 00:17:21.630 actually warrants an ER visit, like soaking more 00:17:21.630 --> 00:17:23.910 than two maxi pads an hour for two consecutive 00:17:23.910 --> 00:17:26.970 hours. Exactly. And alongside the pharmacology, 00:17:27.230 --> 00:17:29.650 the psychosocial nursing interventions are paramount 00:17:29.650 --> 00:17:32.569 here. You must validate the profound emotional 00:17:32.569 --> 00:17:35.950 trauma of the loss. Avoid the platitudes. Please, 00:17:36.109 --> 00:17:38.329 do not tell them they are young and can try again. 00:17:38.349 --> 00:17:40.190 You meet them in the reality of their current 00:17:40.190 --> 00:17:43.069 grief. The physiological stabilization and the 00:17:43.069 --> 00:17:45.390 psychological support carry equal weight. Absolutely. 00:17:45.730 --> 00:17:47.549 Okay, let's bring it back to the exam coach mode. 00:17:48.029 --> 00:17:51.049 If you only remember five things about the spectrum 00:17:51.049 --> 00:17:54.369 of miscarriage. Okay, five things. One, open 00:17:54.369 --> 00:17:57.769 cervix means inevitable or incomplete loss. Two, 00:17:58.289 --> 00:18:00.809 closed cervix with a dead fetus is a misabortion. 00:18:01.269 --> 00:18:04.150 Three, retained products mean high risk for hemorrhage 00:18:04.150 --> 00:18:07.930 and sepsis. Four, Miceoprostol expels tissue. 00:18:08.250 --> 00:18:10.150 Expect heavy bleeding and cramping. It's not 00:18:10.150 --> 00:18:12.950 an adverse effect. And five, emotional support 00:18:12.950 --> 00:18:15.789 is a critical clinical intervention. Nailed it. 00:18:16.210 --> 00:18:18.990 OK, moving on. We've covered the embryo implanting 00:18:18.990 --> 00:18:21.650 in the wrong place and the embryo failing to 00:18:21.650 --> 00:18:24.509 survive in the right place. But there is a third 00:18:24.509 --> 00:18:27.549 really bizarre physiological fake out that occurs 00:18:27.549 --> 00:18:30.119 in early pregnancy. Oh, yes. The pregnancy test 00:18:30.119 --> 00:18:32.660 is positive. The uterus is expanding rapidly. 00:18:33.140 --> 00:18:36.339 The patient is experiencing severe debilitating 00:18:36.339 --> 00:18:40.240 nausea. But there is no viable embryo at all. 00:18:40.480 --> 00:18:43.359 It's gestational trafoblastic disease, or GTD, 00:18:43.420 --> 00:18:45.539 which everyone calls a molar pregnancy. It's 00:18:45.539 --> 00:18:47.559 like planting a seed, but instead of a flower, 00:18:47.700 --> 00:18:49.859 you get a rapidly expanding, aggressive weed 00:18:49.859 --> 00:18:51.859 that just takes over the entire garden. That's 00:18:51.859 --> 00:18:54.019 a great analogy. The cellular genesis of this 00:18:54.019 --> 00:18:56.960 condition is incredible. It is an abnormal, aggressive 00:18:56.960 --> 00:18:59.059 proliferation of that trophoblastic tissue we 00:18:59.059 --> 00:19:01.480 discussed earlier. But the genetic sequencing 00:19:01.480 --> 00:19:04.859 is entirely chaotic. Let's break down the complete 00:19:04.859 --> 00:19:07.519 mole, which is about 80 % of these cases. It 00:19:07.519 --> 00:19:10.339 starts with a nuclear ovum and egg. that for 00:19:10.339 --> 00:19:12.440 whatever reason has lost its maternal nucleus 00:19:12.440 --> 00:19:15.660 and contains no maternal DNA. It's an empty show. 00:19:16.079 --> 00:19:18.819 And this empty egg is fertilized by a normal 00:19:18.819 --> 00:19:22.500 sperm. Because the egg is empty, the sperm's 00:19:22.500 --> 00:19:25.240 genetic material simply duplicates itself to 00:19:25.240 --> 00:19:28.660 achieve the necessary 46 chromosomes. Resulting 00:19:28.660 --> 00:19:32.859 in a karyotype that is entirely 100 % of paternal 00:19:32.859 --> 00:19:36.299 origin. Right. And in human embryology, the paternal 00:19:36.299 --> 00:19:38.460 genes primarily drive the development of the 00:19:38.460 --> 00:19:40.980 placenta and the trophoblasts, while the maternal 00:19:40.980 --> 00:19:43.160 genes drive the development of the fetus. So 00:19:43.160 --> 00:19:46.029 in a complete mole, Because there is no maternal 00:19:46.029 --> 00:19:49.029 DNA to act as a biological counterweight, no 00:19:49.029 --> 00:19:51.710 fetus develops whatsoever. Exactly. Instead, 00:19:51.869 --> 00:19:54.509 the paternal genes go into absolute overdrive, 00:19:54.789 --> 00:19:57.490 creating a massive, rapidly proliferating tumor 00:19:57.490 --> 00:20:00.650 of chorionic villi that swell into transparent, 00:20:00.910 --> 00:20:03.269 fluid -filled, grape -like vesicles. Now, the 00:20:03.269 --> 00:20:05.750 partial mole, the other 20%, is slightly different. 00:20:05.990 --> 00:20:08.230 A normal egg with maternal DNA is fertilized 00:20:08.230 --> 00:20:10.710 simultaneously by two different sperm. So you 00:20:10.710 --> 00:20:13.869 get a triploid karyotype, 69 chromosomes. Because 00:20:13.869 --> 00:20:16.630 maternal DNA is present, there may be some disorganized 00:20:16.630 --> 00:20:19.529 fetal tissue, but the massive chromosomal anomaly 00:20:19.529 --> 00:20:22.049 makes it completely incompatible with life. The 00:20:22.049 --> 00:20:24.490 tissue still proliferates abnormally, just slightly 00:20:24.490 --> 00:20:26.690 less aggressively. The clinical presentation 00:20:26.690 --> 00:20:29.670 here is driven entirely by the endocrinology 00:20:29.670 --> 00:20:33.349 of that massive overgrown trophoblastic tissue. 00:20:34.109 --> 00:20:36.769 Trophoblasts secrete HCG. And because there are 00:20:36.769 --> 00:20:39.609 millions of these abnormal vesicles, the beta 00:20:39.609 --> 00:20:42.589 HCG HCG levels skyrocket to astronomical heights 00:20:42.589 --> 00:20:45.410 way beyond a normal pregnancy or even twins. 00:20:45.730 --> 00:20:48.390 And that astronomical HCG level is the domino 00:20:48.390 --> 00:20:50.630 that knocks over all the other clinical symptoms. 00:20:51.109 --> 00:20:53.750 First, it causes the uterus to expand much faster 00:20:53.750 --> 00:20:56.279 than normal. A patient who is 10 weeks pregnant 00:20:56.279 --> 00:20:58.859 might look like they are 20 weeks pregnant. Second, 00:20:59.180 --> 00:21:02.240 it causes severe intractable nausea and vomiting 00:21:02.240 --> 00:21:04.799 hyperemesis. The bleeding associated with GTD 00:21:04.799 --> 00:21:07.119 is also really unique. It's frequently described 00:21:07.119 --> 00:21:09.380 as dark brown, resembling prune juice. Yeah, 00:21:09.420 --> 00:21:12.119 that happens because the rapidly expanding vesicles 00:21:12.119 --> 00:21:14.539 rupture inside the uterus and the old blood eventually 00:21:14.539 --> 00:21:17.299 makes its way out. But the most critical, heavily 00:21:17.299 --> 00:21:19.920 tested red flag regarding molar pregnancy involves 00:21:19.920 --> 00:21:23.220 the cardiovascular system. specifically early 00:21:23.220 --> 00:21:25.940 onset preeclampsia. This is a vital connection 00:21:25.940 --> 00:21:28.779 to make for exams. Preeclampsia is classically 00:21:28.779 --> 00:21:31.279 a disease of the third trimester. It almost never 00:21:31.279 --> 00:21:33.960 occurs before 20 weeks of gestation. However, 00:21:34.359 --> 00:21:37.299 the massive abnormal trophoblastic tissue of 00:21:37.299 --> 00:21:40.539 a molar pregnancy releases massive amounts of 00:21:40.539 --> 00:21:43.559 anti -angiogenic factors into the maternal bloodstream, 00:21:44.180 --> 00:21:46.579 severely damaging the maternal endothelium much 00:21:46.579 --> 00:21:49.680 earlier than a normal placenta ever could. So 00:21:49.680 --> 00:21:52.339 the absolute rule is, if you have a pregnant 00:21:52.339 --> 00:21:55.000 patient presenting with hypertension and proteinuria 00:21:55.000 --> 00:21:58.440 at 14 or 16 weeks, it is a molar pregnancy until 00:21:58.440 --> 00:22:00.980 an ultrasound proves otherwise. Exactly. And 00:22:00.980 --> 00:22:03.079 when you perform that transvaginal ultrasound, 00:22:03.440 --> 00:22:05.660 the classic diagnostic finding isn't a gestational 00:22:05.660 --> 00:22:08.660 sac, it's a snowstorm pattern. The ultrasound 00:22:08.660 --> 00:22:11.180 waves hit the hundreds of tiny vesicles and bounce 00:22:11.180 --> 00:22:14.380 back, creating this dense, granular, static -like 00:22:14.380 --> 00:22:17.359 image on the screen. Right. Once that is identified, 00:22:17.539 --> 00:22:19.619 the priority nursing action is to prepare the 00:22:19.619 --> 00:22:21.660 patient for an immediate surgical evacuation 00:22:21.660 --> 00:22:24.480 of the uterus via suction -curatage. But the 00:22:24.480 --> 00:22:26.680 most critical phase of care actually happens 00:22:26.680 --> 00:22:28.819 after the surgery. The post -operative teaching 00:22:28.819 --> 00:22:30.700 is literally a matter of life and death because 00:22:30.700 --> 00:22:33.819 GTD is a pre -malignant condition. Up to 20 % 00:22:33.819 --> 00:22:36.119 of complete molar pregnancies will undergo a 00:22:36.119 --> 00:22:38.380 malignant transformation into choreocarcinoma. 00:22:38.750 --> 00:22:41.789 which is a highly virulent aggressive cancer 00:22:41.789 --> 00:22:44.190 of the trophoblastic cells that readily invades 00:22:44.190 --> 00:22:47.430 the myometrium and rapidly metastasizes most 00:22:47.430 --> 00:22:49.430 commonly straight to the lungs. And the only 00:22:49.430 --> 00:22:51.529 way we can track if this cancer is developing 00:22:51.529 --> 00:22:56.210 is by using beta HCG as a tumor marker. Right. 00:22:56.210 --> 00:22:58.410 If the tissue was completely removed and no cancer 00:22:58.410 --> 00:23:01.150 is developing, the HCG levels will steadily drop 00:23:01.150 --> 00:23:04.410 to zero. But if a few microscopic cells mutated 00:23:04.410 --> 00:23:07.049 into choreocarcinoma, they will continue to secrete 00:23:07.049 --> 00:23:10.119 HCG. and the blood levels will plateau or rise. 00:23:10.519 --> 00:23:13.019 Therefore, the patient must commit to a rigorous 00:23:13.019 --> 00:23:16.859 schedule of blood draws, weekly beta HCG monitoring, 00:23:17.160 --> 00:23:18.980 until the levels are completely undetectable 00:23:18.980 --> 00:23:21.279 for three consecutive weeks, followed by monthly 00:23:21.279 --> 00:23:24.099 draws for six to 12 full months. And the absolute 00:23:24.099 --> 00:23:26.559 non -negotiable rule during this entire monitoring 00:23:26.559 --> 00:23:29.359 period is strict, highly reliable contraception. 00:23:29.359 --> 00:23:31.680 They cannot get pregnant for one full year. Because 00:23:31.680 --> 00:23:34.579 if they do, a developing normal placenta will 00:23:34.579 --> 00:23:38.250 start secreting HCG. And if we see a rising HCG 00:23:38.250 --> 00:23:40.990 level on their lab report, we will have a terrifying 00:23:40.990 --> 00:23:44.109 diagnostic dilemma. We won't know if we are looking 00:23:44.109 --> 00:23:47.009 at a healthy new pregnancy or a massive resurgence 00:23:47.009 --> 00:23:49.970 of metastatic cancer. We lose our only reliable 00:23:49.970 --> 00:23:52.630 tumor marker. This is why examiners love to test 00:23:52.630 --> 00:23:54.970 therapeutic communication here. You might see 00:23:54.970 --> 00:23:56.809 a multiple choice option where the nurse says, 00:23:57.210 --> 00:23:59.170 you can try for another baby in a few months 00:23:59.170 --> 00:24:01.710 when you feel emotionally ready. It sounds empathetic, 00:24:01.910 --> 00:24:04.630 but Clinically, it is a lethal error. You must 00:24:04.630 --> 00:24:07.069 firmly educate them on the physiological necessity 00:24:07.069 --> 00:24:09.269 of a one -year delay. OK, hit me with the five 00:24:09.269 --> 00:24:11.730 things for molar pregnancy. Number one, complete 00:24:11.730 --> 00:24:15.509 mol equals no baby, only grape -like cysts, 100 00:24:15.509 --> 00:24:18.529 % paternal DNA. Two, Hallmark signs are prune 00:24:18.529 --> 00:24:20.829 juice bleeding, hyperemesis, and a huge uterus. 00:24:21.130 --> 00:24:23.730 Three, preeclampsia before 20 weeks is molar 00:24:23.730 --> 00:24:26.890 pregnancy until proven otherwise. Four, treatment 00:24:26.890 --> 00:24:30.609 is an immediate DNC. And five, One year of strict 00:24:30.609 --> 00:24:34.349 birth control and HCG tracking to watch for choreocarcinoma. 00:24:34.769 --> 00:24:38.130 Brilliant. Now, we noted earlier that the massive 00:24:38.130 --> 00:24:40.990 HCG levels in a molar pregnancy cause extreme 00:24:40.990 --> 00:24:43.829 nausea. Let's actually isolate that symptom and 00:24:43.829 --> 00:24:46.569 look at it as a primary pathology, hyperemesis 00:24:46.569 --> 00:24:49.789 gravidarum or HG. Yes, let's unpack that. Because 00:24:49.789 --> 00:24:51.809 this is a diagnosis that suffers from a lot of 00:24:51.809 --> 00:24:54.150 societal misunderstanding. People equate it with 00:24:54.150 --> 00:24:57.130 standard morning sickness, and they suggest like 00:24:57.130 --> 00:24:59.109 eating some saltines or drinking ginger ale. 00:24:59.230 --> 00:25:01.390 Which is incredibly frustrating for patients. 00:25:01.450 --> 00:25:03.769 Totally. As a clinician, you must understand 00:25:03.769 --> 00:25:06.809 that HG is not just nausea. It is a profound 00:25:06.809 --> 00:25:09.490 state of systemic depletion and starvation metabolism. 00:25:09.759 --> 00:25:13.200 So how do we definitively prove to an examiner 00:25:13.200 --> 00:25:16.359 or a skeptical relative that HG is entirely different? 00:25:16.680 --> 00:25:19.200 The physiological boundary is marked by objective, 00:25:19.519 --> 00:25:22.519 measurable deficits. Normal nausea usually revolves 00:25:22.519 --> 00:25:24.539 by the end of the first trimester, and the patient 00:25:24.539 --> 00:25:28.119 maintains their weight and hydration. HG is intractable. 00:25:28.339 --> 00:25:30.799 It is vomiting so severe that it leads to a fluid 00:25:30.799 --> 00:25:33.400 volume deficit, electrolyte imbalances, and clinical 00:25:33.400 --> 00:25:36.279 starvation. And the definitive, testable metric 00:25:36.279 --> 00:25:39.089 is what? Weight loss usually exceeding 5 % of 00:25:39.089 --> 00:25:41.609 their pre -pregnancy body weight. That's a massive 00:25:41.609 --> 00:25:43.809 number. Let's break down the exact metabolic 00:25:43.809 --> 00:25:47.930 cascade that makes HG so dangerous. First, the 00:25:47.930 --> 00:25:50.710 continuous vomiting violently expels hydrochloric 00:25:50.710 --> 00:25:53.130 acid from the stomach. You are actively losing 00:25:53.130 --> 00:25:56.150 hydrogen and chloride ions. This massive loss 00:25:56.150 --> 00:25:59.130 of acid forces the blood into a state of metabolic 00:25:59.130 --> 00:26:02.160 alkalosis. Right. And in response to this alkalosis, 00:26:02.339 --> 00:26:04.180 the kidneys attempt to compensate by holding 00:26:04.180 --> 00:26:06.740 onto hydrogen ions in the renal tubules. But 00:26:06.740 --> 00:26:08.759 to do that, they have to excrete potassium in 00:26:08.759 --> 00:26:11.200 exchange. Plus, the patient isn't taking in any 00:26:11.200 --> 00:26:12.819 dietary potassium because they can't keep food 00:26:12.819 --> 00:26:16.000 down. Exactly. This leads to severe hypokalemia. 00:26:16.220 --> 00:26:18.839 Yeah, hypokalemia is terrifying. Potassium is 00:26:18.839 --> 00:26:21.400 the primary intracellular ion responsible for 00:26:21.400 --> 00:26:23.809 the repolarization of the cardiac muscle. When 00:26:23.809 --> 00:26:26.349 potassium drops, the resting membrane potential 00:26:26.349 --> 00:26:28.930 of the heart becomes unstable. You start seeing 00:26:28.930 --> 00:26:31.710 prominent U waves on an ECG, and the patient 00:26:31.710 --> 00:26:34.670 is at immense risk for lethal ventricular arrhythmias. 00:26:34.839 --> 00:26:37.440 And on top of the electrolyte crisis, the patient 00:26:37.440 --> 00:26:40.319 is starting. Because they have no glucose intake, 00:26:40.660 --> 00:26:43.119 their hepatic glycogen stores are rapidly depleted. 00:26:43.480 --> 00:26:45.720 To keep the brain and vital organs functioning, 00:26:46.099 --> 00:26:48.920 the body shifts into lipolysis. It starts breaking 00:26:48.920 --> 00:26:51.980 down its own fat stores for energy. And the byproduct 00:26:51.980 --> 00:26:54.559 of this rapid fat metabolism is the production 00:26:54.559 --> 00:26:57.660 of ketone bodies. Right. Acetoacetate and beta 00:26:57.660 --> 00:27:00.180 -hydroxybutyrate. So, when a patient presents 00:27:00.180 --> 00:27:04.000 to triage with suspected HG, a simple urinalysis 00:27:04.000 --> 00:27:07.119 provides a wealth of data. You are looking specifically 00:27:07.119 --> 00:27:10.240 for ketonuria. High ketones in the urine confirm 00:27:10.240 --> 00:27:12.099 that the patient has exhausted their glucose 00:27:12.099 --> 00:27:15.079 and is actively consuming their own fat. You 00:27:15.079 --> 00:27:17.720 also look at the urine -specific gravity. A high 00:27:17.720 --> 00:27:19.400 reading indicates the kidneys are desperately 00:27:19.400 --> 00:27:22.079 conserving water because the intravascular volume 00:27:22.079 --> 00:27:24.680 is critically low. The clinical presentation 00:27:24.680 --> 00:27:27.819 will reflect this profound dehydration. Poor 00:27:27.819 --> 00:27:31.240 skin turgor, dry mucus membranes, and a compensatory 00:27:31.240 --> 00:27:33.740 tachycardia as the heart tries to circulate a 00:27:33.740 --> 00:27:36.420 reduced blood volume. So priority nursing actions. 00:27:36.619 --> 00:27:38.720 This is a common trap for novice nurses. You 00:27:38.720 --> 00:27:40.660 see a dehydrated patient and think, I need to 00:27:40.660 --> 00:27:42.720 get her to drink some water. Oh yeah, choosing 00:27:42.720 --> 00:27:45.599 encourage oral fluids as the first action. Trap. 00:27:45.779 --> 00:27:48.599 Huge trap. Introducing anything into a highly 00:27:48.599 --> 00:27:51.440 sensitized spastic gastrointestinal tract will 00:27:51.440 --> 00:27:54.279 only trigger more vomiting, worsening the alkalosis 00:27:54.279 --> 00:27:57.039 and potassium loss. The immediate priority is 00:27:57.039 --> 00:27:59.940 NPO status initially to completely rest the GI 00:27:59.940 --> 00:28:03.579 tract. Simultaneously, you start IV fluids, usually 00:28:03.579 --> 00:28:06.000 lactated ringers or normal saline, and administer 00:28:06.000 --> 00:28:08.440 5E antibiotics. And you never start with a dextrous 00:28:08.440 --> 00:28:11.400 solution like DFIW. Right, because administering 00:28:11.400 --> 00:28:14.279 glucose to a severely malnourished patient without 00:28:14.279 --> 00:28:17.380 concomitant thiamine can trigger Wernicke's encephalopathy, 00:28:17.460 --> 00:28:19.920 a severe neurological complication. Wow. Okay, 00:28:19.980 --> 00:28:21.680 so once the vomiting is controlled, then what? 00:28:21.950 --> 00:28:24.910 Only then do you slowly introduce clear liquids, 00:28:25.470 --> 00:28:28.869 then small, frequent, bland meals. Check urine 00:28:28.869 --> 00:28:31.089 for ketones, monitor electrolytes, and again, 00:28:31.309 --> 00:28:33.710 provide intense emotional support. It severely 00:28:33.710 --> 00:28:35.910 impacts mental health. OK, five things for HG. 00:28:36.069 --> 00:28:39.029 One, defined by greater than 5 % weight loss 00:28:39.029 --> 00:28:42.289 and dehydration. Two, look for ketonuria as a 00:28:42.289 --> 00:28:45.950 sign of starvation. Three, priority intervention 00:28:45.950 --> 00:28:50.029 is IV fluid replacement, not oral feeding. Four. 00:28:50.190 --> 00:28:53.089 Keep patient NPO until vomiting is controlled. 00:28:53.490 --> 00:28:56.609 And five, emotional support is critical. Excellent. 00:28:57.029 --> 00:28:59.730 Okay, moving along the timeline, nausea is fading, 00:29:00.049 --> 00:29:02.430 first trimester is over, but a new structural 00:29:02.430 --> 00:29:05.029 problem can emerge in the second trimester, cervical 00:29:05.029 --> 00:29:07.829 insufficiency. Historically called an incompetent 00:29:07.829 --> 00:29:09.920 cervix. Right. And this is terrifying because 00:29:09.920 --> 00:29:12.099 it lacks the dramatic alarm bells. Labor is supposed 00:29:12.099 --> 00:29:14.519 to be painful, right? So how can someone dilate 00:29:14.519 --> 00:29:16.720 and lose a pregnancy without even realizing they 00:29:16.720 --> 00:29:18.759 are in labor? Well, the physiology comes down 00:29:18.759 --> 00:29:20.680 to the microscopic composition of the cervical 00:29:20.680 --> 00:29:23.339 tissue. The cervix is not primarily muscle. It 00:29:23.339 --> 00:29:25.720 is a dense matrix of connective tissue, mainly 00:29:25.720 --> 00:29:28.279 collagen and elastin. It acts as a biological 00:29:28.279 --> 00:29:30.539 drawstring. Holding the heavy uterus closed. 00:29:31.039 --> 00:29:34.109 Exactly. In a patient with cervical insufficiency, 00:29:34.410 --> 00:29:36.329 there is a structural defect in that collagen 00:29:36.329 --> 00:29:39.849 matrix. The tissue simply lacks the tensile strength 00:29:39.849 --> 00:29:42.450 to withstand the increasing hydrostatic pressure 00:29:42.450 --> 00:29:45.269 of the amniotic sac and the gravitational weight 00:29:45.269 --> 00:29:48.049 of the developing fetus. The tissue just mechanically 00:29:48.049 --> 00:29:50.769 yields. The cervix silently effaces and dilates 00:29:50.769 --> 00:29:52.369 right in the middle of the second trimester. 00:29:52.559 --> 00:29:55.339 typically 14 to 20 weeks. And the patient might 00:29:55.339 --> 00:29:58.039 present with incredibly vague symptoms, pelvic 00:29:58.039 --> 00:30:01.039 pressure, pink tinged discharge, or feeling like 00:30:01.039 --> 00:30:03.359 something is in the vagina, which is actually 00:30:03.359 --> 00:30:06.119 the amniotic sac bulging out. The diagnostic 00:30:06.119 --> 00:30:08.160 distinction here is crucial, and it relies on 00:30:08.160 --> 00:30:11.220 the TOCO dynamometer. Yes. The TOCO measures 00:30:11.220 --> 00:30:13.519 the tension of the maternal abdominal wall to 00:30:13.519 --> 00:30:16.420 detect uterine contractions. In true preterm 00:30:16.420 --> 00:30:19.200 labor, the TOCO shows distinct mountain peaks. 00:30:19.519 --> 00:30:21.940 But in cervical insufficiency, the TOCO shows 00:30:21.930 --> 00:30:25.190 a completely flat line. Zero contractions. Right. 00:30:25.410 --> 00:30:27.390 The uterus is perfectly relaxed. The dilation 00:30:27.390 --> 00:30:30.329 is purely mechanical. And the definitive diagnostic 00:30:30.329 --> 00:30:32.970 tool is the transvaginal ultrasound, which measures 00:30:32.970 --> 00:30:35.690 cervical length. Less than 25 millimeters is 00:30:35.690 --> 00:30:38.410 a huge red flag, and it also detects funneling. 00:30:38.519 --> 00:30:40.599 Funneling is fascinating because the pressure 00:30:40.599 --> 00:30:43.319 is coming from above. The internal osse starts 00:30:43.319 --> 00:30:46.180 to open first, while the external osse remains 00:30:46.180 --> 00:30:49.299 closed. On ultrasound, it looks like a V -shape 00:30:49.299 --> 00:30:52.220 or a funnel. If we catch it early, the intervention 00:30:52.220 --> 00:30:55.420 is a cervical sirclash. Right, a physical fix 00:30:55.420 --> 00:30:58.400 for a physical problem. The surgeon weaves a 00:30:58.400 --> 00:31:00.759 heavy suture around the cervix in a purse string 00:31:00.759 --> 00:31:03.779 fashion, tying it shut. But the contraindications 00:31:03.779 --> 00:31:06.619 for placing a circlage are intensely tested. 00:31:06.900 --> 00:31:09.279 You cannot place one if the amniotic membranes 00:31:09.279 --> 00:31:11.700 have already ruptured. No, if the water is broken, 00:31:11.839 --> 00:31:14.460 sowing the cervix shut will trap ascending bacteria 00:31:14.460 --> 00:31:18.160 inside the uterus, guaranteeing a severe chorioamnionitis. 00:31:18.559 --> 00:31:20.880 And you absolutely cannot place a circlage if 00:31:20.880 --> 00:31:23.119 the patient is having actual uterine contractions. 00:31:23.500 --> 00:31:25.819 If the uterus is actively trying to push the 00:31:25.819 --> 00:31:29.140 baby out and you sow the only exit shut, the 00:31:29.140 --> 00:31:31.440 immense force will cause the uterus itself to 00:31:31.440 --> 00:31:34.619 rupture, massive internal hemorrhage. So on an 00:31:34.619 --> 00:31:36.819 exam, you have to differentiate premature labor, 00:31:36.980 --> 00:31:39.240 which needs tycolytics to stop contractions, 00:31:39.559 --> 00:31:42.119 from cervical insufficiency, which needs a circle 00:31:42.119 --> 00:31:44.680 -ish. Okay, five things for cervical insufficiency. 00:31:44.980 --> 00:31:47.720 One, painless dilation in the second trimester. 00:31:48.339 --> 00:31:52.640 Two, TOCO will show NO contractions. Three, ultrasound 00:31:52.640 --> 00:31:55.299 shows cervical length under 25 millimeters and 00:31:55.299 --> 00:31:59.349 funneling. Four, Treatment is a cervical cercluge. 00:31:59.809 --> 00:32:02.789 Five, cannot perform circulage if membranes are 00:32:02.789 --> 00:32:04.970 ruptured or infection is present. Okay, we've 00:32:04.970 --> 00:32:07.109 reached the third trimester. This is the Super 00:32:07.109 --> 00:32:09.869 Bowl of OB nursing exams. If you don't know the 00:32:09.869 --> 00:32:12.250 difference between placenta previa and placental 00:32:12.250 --> 00:32:15.309 abruption, you will fail the exam, and more importantly, 00:32:15.309 --> 00:32:17.549 you could really harm a patient. Oh, absolutely. 00:32:17.670 --> 00:32:20.269 The hemodynamics, the pain pathways, the nursing 00:32:20.269 --> 00:32:22.750 actions, they are entirely distinct. I picture 00:32:22.750 --> 00:32:25.470 previa as a blocked doorway. The placenta is 00:32:25.470 --> 00:32:28.250 sitting right over the exit. and I picture abruption 00:32:28.250 --> 00:32:31.109 as wallpaper violently tearing off a wall before 00:32:31.109 --> 00:32:33.170 the room is empty. That's a perfect visual. Let's 00:32:33.170 --> 00:32:35.509 start with the anatomy. Placenta previa is a 00:32:35.509 --> 00:32:38.359 positional pathology. The blastocyst implanted 00:32:38.359 --> 00:32:40.460 abnormally low in the uterine cavity. Right, 00:32:40.480 --> 00:32:42.660 so as the lower uterine segment naturally thins 00:32:42.660 --> 00:32:45.160 and stretches to prepare for labor, the physical 00:32:45.160 --> 00:32:47.380 shearing forces tear the fragile placental blood 00:32:47.380 --> 00:32:49.680 vessels away from the uterine wall. Exactly. 00:32:50.140 --> 00:32:52.039 Placental abruption, on the other hand, is when 00:32:52.039 --> 00:32:54.339 the placenta implants in a healthy location, 00:32:54.619 --> 00:32:57.839 but a sudden, violent physiological event causes 00:32:57.839 --> 00:32:59.920 it to prematurely tear away from the uterine 00:32:59.920 --> 00:33:02.960 wall after 20 weeks. Often linked to profound 00:33:02.960 --> 00:33:06.509 vasoconstriction or vascular trauma. Severe hypertension, 00:33:06.829 --> 00:33:09.789 preeclampsia, or cocaine use causes the spiral 00:33:09.789 --> 00:33:13.190 arteries to spasm violently, rupture, and create 00:33:13.190 --> 00:33:15.289 a high pressure hematoma behind the placenta 00:33:15.289 --> 00:33:17.470 that forcefully rips it off the wall. Now the 00:33:17.470 --> 00:33:20.089 clinical presentation is a study in contrasts. 00:33:20.109 --> 00:33:22.650 Let's look at the bleeding. In Previa, the bleeding 00:33:22.650 --> 00:33:25.789 is bright red. It's fresh oxygenated blood flowing 00:33:25.789 --> 00:33:28.109 directly out of the cervical opening. But in 00:33:28.109 --> 00:33:30.869 abruption, it's often dark red, court wine color. 00:33:31.150 --> 00:33:33.250 It's old blood that has been trapped behind the 00:33:33.250 --> 00:33:35.529 placenta. But the most defining diagnostic clue 00:33:35.529 --> 00:33:39.069 is the pain. Placenta previa is completely, 100 00:33:39.069 --> 00:33:41.890 % painless. A patient might just wake up lying 00:33:41.890 --> 00:33:43.950 in a pool of bright red blood feeling perfectly 00:33:43.950 --> 00:33:46.970 fine. Conversely, placental abruption is brutally 00:33:46.970 --> 00:33:49.769 painful. Patients describe it as a tearing, knife 00:33:49.769 --> 00:33:52.930 -like pain. Unrelenting. And that pain is related 00:33:52.930 --> 00:33:56.609 to uterine tone. In previa, the uterus is soft 00:33:56.609 --> 00:34:00.049 and relaxed, but in an abruption, blood is forced 00:34:00.049 --> 00:34:02.990 into the myometrium causing it to spasm. The 00:34:02.990 --> 00:34:06.009 uterus feels as rigid and hard as a wooden board 00:34:06.009 --> 00:34:08.429 and is highly tender. The impact on the fetus 00:34:08.429 --> 00:34:11.809 is immediate. In previa, fetal heart rate is 00:34:11.809 --> 00:34:14.909 usually normal. But in an abruption, the fetal 00:34:14.909 --> 00:34:17.130 monitor will almost instantly display signs of 00:34:17.130 --> 00:34:20.769 profound hypoxia, severe fetal distress. Because 00:34:20.769 --> 00:34:23.090 of these differences, your priority nursing interventions 00:34:23.090 --> 00:34:25.230 are completely different. For placenta previa, 00:34:25.369 --> 00:34:27.889 the absolute rule, never do a vaginal exam. If 00:34:27.889 --> 00:34:29.670 you stick your fingers through the cervix, you 00:34:29.670 --> 00:34:31.789 will puncture the placenta and cause catastrophic 00:34:31.789 --> 00:34:34.670 exsanguination, instant failure on an exam. The 00:34:34.670 --> 00:34:36.889 intervention for previa is bed rest, monitor 00:34:36.889 --> 00:34:39.409 bleeding, prep for C -section. But for an abruption, 00:34:39.730 --> 00:34:42.269 you are in a crash code level emergency. Your 00:34:42.269 --> 00:34:45.150 immediate priority is massive volume resuscitation. 00:34:45.650 --> 00:34:48.889 Start TDO large bore IVs, left lateral position, 00:34:49.030 --> 00:34:51.070 high flow oxygen, continuous fetal monitoring. 00:34:51.409 --> 00:34:54.309 Prep for stat C -section. And beware the vital 00:34:54.309 --> 00:34:57.170 signs trap here. Pregnant women have 30 to 40 00:34:57.170 --> 00:34:59.349 percent more blood volume. They can lose massive 00:34:59.349 --> 00:35:01.989 amounts before BP drops. Tachycardia is your 00:35:01.989 --> 00:35:03.869 first sign of shock. Exactly. All right. Five 00:35:03.869 --> 00:35:07.409 things. One. Previa equals painless bright red 00:35:07.409 --> 00:35:11.849 blood, soft uterus. Two, abruption equals painful 00:35:11.849 --> 00:35:15.909 dark red blood, rigid board -like uterus. Three, 00:35:16.599 --> 00:35:20.059 Absolutely no vaginal exams for previa. Four, 00:35:20.380 --> 00:35:23.179 abruption requires two large boar IVs and rapid 00:35:23.179 --> 00:35:25.699 volume resuscitation. Five, watch the heart rate, 00:35:25.719 --> 00:35:27.440 not just the blood pressure, for early shock. 00:35:27.679 --> 00:35:29.619 Now, if a placental abduction is severe enough, 00:35:29.780 --> 00:35:32.300 it triggers a terrifying systemic cascade called 00:35:32.300 --> 00:35:34.800 DIC -disseminated intravascular coagulation. 00:35:35.079 --> 00:35:36.860 Yes. And this confuses students. The patient 00:35:36.860 --> 00:35:38.820 is bleeding to death, but the disease is called 00:35:38.820 --> 00:35:41.519 intravascular coagulation. How can they be clotting 00:35:41.519 --> 00:35:43.119 and bleeding at the same time? Well, massive 00:35:43.119 --> 00:35:45.760 tissue trauma dumps tissue factor or thrombo... 00:35:45.739 --> 00:35:48.699 into the blood. The body panics and creates millions 00:35:48.699 --> 00:35:50.860 of microclots everywhere. And because it used 00:35:50.860 --> 00:35:52.639 up all the clotting factors and platelets to 00:35:52.639 --> 00:35:55.420 make these useless microclots, the tank is empty. 00:35:55.780 --> 00:35:58.300 There's nothing left. So the patient then bleeds 00:35:58.300 --> 00:36:01.139 out from every orifice. It's a consumption coagulopathy. 00:36:01.260 --> 00:36:04.079 Exactly. You'll see bleeding from IV sites, bleeding 00:36:04.079 --> 00:36:07.760 gums, petechiae. Labs will show decreased fibrinogen 00:36:07.760 --> 00:36:11.579 in platelets. Prolonged PT and 8 -PT and a hugely 00:36:11.579 --> 00:36:14.900 positive D -dimer, which shows massive clot breakdown. 00:36:15.159 --> 00:36:17.679 The priority nursing action. You must treat the 00:36:17.679 --> 00:36:20.360 underlying cause. DIC is never a primary disease. 00:36:20.699 --> 00:36:22.559 You have to fix the trigger, deliver the baby 00:36:22.559 --> 00:36:24.440 and placenta immediately if it's an abruption. 00:36:24.659 --> 00:36:26.679 While doing that, administer blood products. 00:36:27.139 --> 00:36:30.460 FFP, cryoprecipitate, packed RBCs, and platelets. 00:36:30.760 --> 00:36:33.099 And monitor for renal failure. Five things for 00:36:33.099 --> 00:36:36.559 DIC. One, it's a consumption coagulopathy. Two, 00:36:36.920 --> 00:36:38.900 first physical signs are bleeding from gums and 00:36:38.900 --> 00:36:42.300 IV sites. Three, labs show low platelets, fibrinogen, 00:36:42.480 --> 00:36:45.559 high PTT and D -dimer. Four, never a primary 00:36:45.559 --> 00:36:48.440 disease fix the trigger. Five, replace what is 00:36:48.440 --> 00:36:51.659 lost with FFP cryo blood platelets. Okay, for 00:36:51.659 --> 00:36:53.699 our final deep dive into the simulation lab, 00:36:53.780 --> 00:36:56.139 let's look at placental implantation abnormalities, 00:36:56.400 --> 00:36:58.519 accretive spectrum, and vossa previa. Previa 00:36:58.519 --> 00:37:00.739 is about where it attaches. Accretive is about 00:37:00.739 --> 00:37:03.840 how deeply it attaches. A normal placenta peels 00:37:03.840 --> 00:37:06.500 off cleanly. But with the predius C -section 00:37:06.500 --> 00:37:09.420 scar, the placenta invades too deeply. Right. 00:37:09.659 --> 00:37:12.340 Accreta is into the myometrium. Increta is deep 00:37:12.340 --> 00:37:14.320 into the myometrium. Procreta is through the 00:37:14.320 --> 00:37:16.400 myometrium, sometimes into the bladder. And the 00:37:16.400 --> 00:37:19.559 danger is massive postpartum hemorrhage, because 00:37:19.559 --> 00:37:23.219 it won't detach naturally. A massive NCLEX trap 00:37:23.219 --> 00:37:25.340 is thinking you can just pull harder on the umbilical 00:37:25.340 --> 00:37:28.469 cord. If you do that, you cause uterine inversion 00:37:28.469 --> 00:37:31.889 and catastrophic bleeding. Exactly. A CRETA often 00:37:31.889 --> 00:37:34.030 requires a planned scheduled C -section with 00:37:34.030 --> 00:37:36.829 a massive transfusion protocol and a likely immediate 00:37:36.829 --> 00:37:39.829 hysterectomy. And vasoprevia. Fetal blood vessels 00:37:39.829 --> 00:37:42.670 cross the amniotic membranes directly over the 00:37:42.670 --> 00:37:45.190 internal cervical os. When the water breaks, 00:37:45.510 --> 00:37:48.329 the fetal vessels tear. And the bleeding is entirely 00:37:48.329 --> 00:37:51.650 fetal blood. The baby can exsanguinate in minutes. 00:37:52.059 --> 00:37:54.360 you'll see painless vaginal bleeding immediately 00:37:54.360 --> 00:37:57.320 following rupture of membranes with severe variable 00:37:57.320 --> 00:38:00.519 decelerations. Stat C -section is required. Right, 00:38:00.579 --> 00:38:03.940 so five things. One, prior C -sections massively 00:38:03.940 --> 00:38:07.420 increase accretal risk. Two, accretal often requires 00:38:07.420 --> 00:38:10.800 planned C -section hysterectomy. Three, do not 00:38:10.800 --> 00:38:14.559 manually force an accretal out. Four, vasoprevia 00:38:14.559 --> 00:38:17.820 equals fetal vessels crossing the cervix. Five, 00:38:18.179 --> 00:38:20.840 rupture of membranes and vasoprevia means immediate 00:38:20.840 --> 00:38:23.230 fetal hemorrhage. We have covered incredible 00:38:23.230 --> 00:38:26.030 ground today. From the explosive risk of an ectopic 00:38:26.030 --> 00:38:28.550 to the mechanical failure of the cervix, the 00:38:28.550 --> 00:38:30.949 cancer -linked endocrinology of a molar pregnancy, 00:38:31.309 --> 00:38:33.510 and the violent hemorrhagic battlegrounds of 00:38:33.510 --> 00:38:36.190 the third trimester. And mastering this physiological 00:38:36.190 --> 00:38:37.969 knowledge is what elevates you from a student 00:38:37.969 --> 00:38:40.010 trying to pass a test to a clinician who commands 00:38:40.010 --> 00:38:42.269 a room. You become the nurse who catches the 00:38:42.269 --> 00:38:44.769 subtle drop in fibrinogen, who stops the resident 00:38:44.769 --> 00:38:47.170 from doing a vaginal exam on a previa. You save 00:38:47.170 --> 00:38:50.460 lives. That is exactly why we dive so deep. And 00:38:50.460 --> 00:38:53.139 before we close, a final thought to ponder. We 00:38:53.139 --> 00:38:55.860 marvel at the fetus, but the placenta is a temporary 00:38:55.860 --> 00:38:58.139 organ that acts like a cancer -invading tissue 00:38:58.139 --> 00:39:00.639 to get blood supply. But in a healthy pregnancy, 00:39:01.000 --> 00:39:03.880 it knows exactly when to stop invading. If we 00:39:03.880 --> 00:39:06.179 can fully unlock how truffoblastic cells know 00:39:06.179 --> 00:39:08.420 when to stop, like they fail to do in acreta 00:39:08.420 --> 00:39:10.699 or molar pregnancies, could we unlock the cure 00:39:10.699 --> 00:39:13.360 for cancer metastasis itself, something to chew 00:39:13.360 --> 00:39:15.800 on during your next clinical shift? Keep thinking 00:39:15.800 --> 00:39:18.340 critically, keep prioritizing, and we will catch 00:39:18.340 --> 00:39:19.460 you on the next deep dive.