The Better Birth podcast is back and we kick off season 10 with a must listen episode for anyone expecting identical twins!
In this episode I chat to Stephanie Ernst, founder of the TAPS Support Foundation, about monochorionic twins and the complications they may experience. Monochorionic twins, often referred to as identical twins, can experience more complications compared to dichorionic twins (fraternal), and Stephanie talks us through the chances of these twins experiencing conditions such as TTTS, TAPS and fetal growth restriction. We discuss the ways these babies may be monitored for these conditions, the pathways of care if they're diagnosed, and the potential outcomes.
Stephanie Ernst facilitates conversations between parents and professionals about the unique needs of complicated twins and multiple birth families and their challenges. Founder of TAPS Support, and experienced twin parent, her passion is breaking down medical jargon and ensuring that people have quality information about multiple births from before birth, to beyond the NICU. You can find her charity at https://www.tapssupport.com
Welcome to the Better Birth podcast.
My name's Erin and I'm a hypno birthing and antenatal instructor, birth activist and all round birth geek.
In this podcast, I chat to experts in the field of pregnancy and birth, debunking myths around birth, diving into the research around maternity care, and exploring what is it that means you're more likely to have a positive birthing experience.
0:28
If you enjoy this podcast, do feel free to buy me a coffee and fund my caffeine habits.
Link to my Buy Me a Coffee page is in the podcast info.
Enjoy this episode.
Welcome to the Better Birth podcast.
0:47
This week I'm talking to the lovely Stephanie Ernst, who facilitates conversations between parents and professionals about the unique needs of complicated twins and multiple birth families and their challenges.
She's the founder of TAP Support.
1:02
She's an experienced twin parent herself, and her passion is breaking through medical jargon and ensuring that people have quality information about multiple births from before birth to beyond the NICU.
Welcome, Stephanie.
Hi, Erin.
It's so great to be with you today.
I'm super excited to chat to you.
1:19
Twins is a is a topic that I get asked a lot about and I feel like there's not a lot of easily accessible information, which is in kind of layman's terms for twins parents.
1:35
So it's fantastic that you're here today to kind of talk about some of these things and help educate families that are expecting multiple pregnancies.
Yeah.
It is.
And that's exactly something that I found.
And like my girls are now 10, almost 11.
And you know, when I was looking 10 years ago for information, specifically, we were looking for information about taps, which I'll come to, but there was not a lot of information outside of the the medical journals.
2:02
And then you have some sites that are set up, but they're kind of like a little bit more either dismissive or no dismissive is not the right word.
It's kind of like it's a very brief overview.
And for people who want to get into it and in depth, there's not really a lot outside of the medical jargon.
2:20
And you kind of want to find the balance between the light and the fluffy and the heavy and dark and kind of find that middle meeting point.
And that's really what I try to do when it comes to twin pregnancy complications.
2:35
That kind of thing is not hiding the realities.
But not drowning at all in those overwhelming words.
Yeah, and I think it can be overwhelming if you, if you found out you're having twins, there's probably a million questions going around somebody's head, right?
2:50
Yeah, exactly.
And I mean, you walk into the doctor's office and I mean this is, or into your provider's office and you say hey, and they say, hey, you're having twins.
Congratulations.
And then they start, it starts out with this big congratulations, and then it moves into this conversation about risk and determination and reduction.
3:09
And quite often these families are having conversations that parents of singletons to even visit.
And, you know, you come out of there and your head is so full of information and it's really hard to sort out.
And, you know, we're human.
Often we'll just take away that bad side of the thing.
3:26
And so, you know, where is the balance I think is a really good way to start.
And then you sort of start turning to social media and Googling and what quality information can you find or how do you know what it is?
What is quality information?
3:41
Yeah, yeah, it's, it's it's one thing I tell my clients.
Don't Google stuff sometimes what you're going to find or you just terrify yourself Googling things right because you end up reading the worst case scenarios.
Yeah, I think that's it.
I mean, we'll probably disagree on the don't Google things because I always encourage people to Google things.
3:59
But then I also encourage them to take that information back and talk about it with someone with a bit of knowledge because you will find yourself up a tree.
I absolutely agree with you on that.
You will find the worst case scenarios and you'll be in the tree.
But you need that person who's going to talk you out of that tree, be it your doula, your midwife, your consultant.
4:19
Those people are going to help you understand that information.
But again, where do you find the information without the clinical jargon or the, you know, how do you understand it?
Because you know, a doula is going to explain it in their terms, a consultant is going to explain it in technical terms.
4:36
And that, again, is still very scary and overwhelming.
So yeah.
It's a minefield, right?
And then we bring in people's individual biases and opinions like adds a whole another layer of complication to kind of digesting that information, I think.
4:53
That's exactly it.
We have that, you know, we all have our own ideas.
And, you know, when you think about it and if you talk about, you know, let's talk about between pregnancy being labeled high risk, but your next door neighbour, her, her daughter had twins and they had no problems.
5:10
They went to 40 weeks and everything was fine.
And so you kind of, and they're saying, but why do you need all this extra testing?
Why do you need all these extra follow-ups?
And you're kind of like thinking, well, you know, they did it, why can't I?
And I think that's really, yeah, you've got to move.
You've got to look at everything analytically and without a sense of judgmental bias either way.
5:32
But the problem is how do you do that?
Yeah, it's hard, right?
Because it's, it's a highly emotive topic.
So, so before we start talking about some of these tests and scans and procedures and, and different things that we may be looking for between pregnancy, should we, should we just start right at the at the beginning and just talk about the different types of, of twins that you may experience if you're having a multiple pregnancy?
6:00
Yeah, absolutely.
And I think it's really important to understand that there is 2 main types of twins and that is dichorionic or two placenta, fraternal twins, sorry, dichorionic diamniotic, I should say.
That's 2 placentas, 2 amniotic sacs, 2 babies, and they have their own placentas, they have their own amniotic sacs, They grow.
6:21
They're basically no more genetically alike than siblings.
So if you've got a 2 year old and a three-year old, they have the same genetic relationship, you then those are there.
Yeah, this word risk gets right around.
They're a lower risk than the next type of twins, but you know, you still have some increased chances of complications.
6:44
But in the scale of things, if you are having twins with two placentas, they are a lesser risk than twins with one placenta, which is the area that I usually focus on, which is monochorionic twins, 1 placenta and either one or two amniotic sacs.
7:02
Now, the biggest complication with these twins is that they do share a placenta and in about 75% of cases, everything is hunky Dory.
They share that placenta nice and equally.
They have nice shared circulation because again, that's the biggest problem, is that shared circulation.
7:20
So they're sending blood backwards and forwards to each other.
They've got nice equal shares.
Their cords are put in the right places.
Everything is going great.
In about 25% of cases, give or take, there can be complications.
And these are things on twin to twin transfusion syndrome, which everyone knows.
7:38
And that's where 1 twin has more fluid than the other twin.
You have selective fetal growth restriction, which is where 1 twin is not, hasn't got quite enough of the placenta and the other one has a bigger share of the placenta.
And then you have something called TAPS, which is twin anemia, polycythemia sequence, which is where I like to spend my time in the, in the role of things.
8:00
But.
And that is where 1 twin has too many red blood cells and the other twin does not have enough.
And that's all caused by shonky connections in the placenta.
So think of it as faulty wiring.
Not everything is working properly.
And that's around 25% of cases in general, those diseases or those complications that can happen in any combination.
8:24
And they're not forms of each other, but they are rather all separate distinct diseases, which is why they can happen in any combination.
If you're super lucky, like a friend of mine, you get all three.
We were just lucky that we had taps in that regard.
And there's during pregnancy, these can also lead it to later in life complications, which is also something that I'm very passionate about raising awareness of.
8:50
It's not just prematurity, but there are things like neurodevelopmental complications, learning delays, deafness that can be associated with some of these.
But, you know, it sounds all doom and gloom.
And I promise it's not because you really have to look out on this case side, the side of 75% of these twins are not going to have serious complications, but we just have to be conscious that it could happen.
9:16
Sorry.
Yeah.
And.
So if it's so if you have twins and you have one O clock, one O clock twins.
Identical.
It's a good word.
9:34
How?
How would they identify that there may be one of these complications in your twins?
That's a really good question in relation to some of the diseases.
So like for selective fetal growth restriction and TAPS, there is only signs on ultrasound.
9:51
So when they're doing ultrasound with twin to twin transfusion syndrome, you can have symptoms as a parent.
And that's actually from personal experience I can tell you that is you can have a tight stomach, you can feel like you got bigger overnight, a really sudden increase in weight and a backache.
10:10
And for me, my signs, because clarifying here, I was first diagnosed with T2TS, but that's spontaneously resolved.
So my, for me, my personal signs were my belly just got really, really tight.
It was just, it felt really like a rock.
10:28
And I just thought, oh, it's twin pregnancy.
They're going through a growth spurt.
And I had a backache and it was kind of, yeah, really low down in my back.
And that was all the symptoms I had.
And that was about two days before my scan.
But these are all signs.
And so a parent can have those symptoms when with TTTS, but with TAPS and selective fetal growth restriction, they may not be signs and that's why they are detected on ultrasound.
10:56
So how I'm assuming if you're having a twin pregnancy you're going to be offered additional scans compared to a Singleton pregnancy where you'd probably have a 12 and 20 week scan?
Yeah, precisely from like we'll talk about, I think like the ESAWOG guidelines, which is the International Society of Obstetrics and Ultrasound, Ultrasound and Obstetrics and Gynecology long term ESAWOG, they have a set of guidelines out for fraternal twins and identical twins.
11:25
And for fraternal twins, you probably will have an additional scan each month and they'll be tracking the growth.
They'll be looking at all the different things along the way.
With identical twins, you'll be offered a scan every two weeks from around 16 weeks, and that's going to include a lot of ultrasound and Doppler readings.
11:44
And they will be checking the fluid levels of the babies.
They'll be checking the blood flow in both the umbilical artery and also in the brain of the babies to look for taps.
They'll do size charts every two, every four weeks.
12:01
I know growth charts are controversial, very controversial, and it depends on who you speak to, but they will track at least the growth to monitor what's going on.
And they'll look at the general health of the placenta.
They'll look at flow, flow of the blood through the liver of both babies.
12:19
This is all the kind of things I'll look at through Doppler.
But they will offer that every single two weeks.
And that is honestly just to monitor to make sure that complications aren't developing.
And if, if there are complications developing, what does that mean?
12:35
Like what, what's the next steps?
How how do we how do we plan for for the safe birth of the babies?
That's a really good and I will use the UK guidelines as a moment because I know you're based in the UK and probably your listener base is based in the UK, but it it does vary from country to country.
12:52
But in relation to complications, what will happen is initially your consultant will have a look at the ultrasound and they will refer you that.
Well, according to NICE guidelines, they should refer you to a tertiary centre and that is a bigger hospital.
13:08
And within the UKI know there is Liverpool, there is London, there's several centres in London.
There is, I believe Cambridge has a bigger centre.
Birmingham is another big center.
13:23
Newcastle, they will refer you to a bit a tertiary center and then they will make an assessment, confirm the diagnosis and then they will sit you down and go through treatment options and the treatments for each complication vary, but they'll talk you through the different complications.
13:39
But again, you can be hit with a lot of jargon and a lot of like a lot of information in one go.
And unfortunately, sometimes they will also start talking about depending on the course on how early it's detected, selective termination or reduction of the pregnancy.
13:57
And that can get quite mind blowing as well I guess is the best way to put it.
And so if if you decide to go down the route of treatment or interventions, what does that look like for a for a family don't decide to go ahead.
14:20
Yeah, it can be absolutely terrifying time and because you have to make decisions and you have to make them quickly.
In particular in the case of twin to twin transfusion syndrome, it is something that happens very quickly and unfortunately the repercussions are also very quick and untreated.
14:39
Around 90% of types of TTS twins will die and that's being a realist with the intervention you kind of get up to this point of around 7580% of babies will survive, at least one will survive in the pregnancy.
14:58
So it it with TTTS, you really have to make snap and fast decisions and that is in itself is very overwhelming.
When you come to things like selective fetal growth restriction and TAPS, it can be as a slower decision making process because the types of selective fetal growth restriction, there's three different types and all have three have different diagnostic criteria.
15:22
But you can make a choice to watch and wait in there.
However, again, it can have serious repercussions with taps.
Watch and wait is a perfectly legitimate treatment method, but all three situations you kind of get a lot of information thrown at you and so you really have to make good decisions fast based on limited information and.
15:49
I guess This is why they offer all these additional scans, right?
Because I know, you know, lots of people myself as well will say that quite a lot of the time additional scans maybe aren't necessary or they come with the risks, they come at risk of inaccuracies and further medical intervention.
16:05
But perhaps in the case of twins, having those additional scans because of the time, the, the, the criticalness of the, of the timing of interventions, those additional scans are probably a good idea and they are advisable because then we're picking things up earlier and we can intervene and, and, and do something proactive.
16:24
Yeah, that's exactly it.
And like I said, we just literally said growth charts are so controversial.
But what it is, it's not about saying that your baby is this size at this time.
It is tracking that they're growing and that things are happening.
16:39
And that's one of the big things, particularly with selective fetal growth restriction is if that baby is growing and tracking along that line their own line, it may not be necessary to intervene.
However, it's good that they are growing and again, a lot of the things around TAPS and using mid cerebral artery Doppler, the brain Doppler, a lot of the things about screening with that is that it's inaccurate because you have to get it at a certain angle and you have to get exactly the right spot.
17:08
The inaccuracies exist.
However, TAPS is about tracking patterns.
It's not about having a precise measurement.
Well, in a way it is, sorry, but it, you know, it's more about tracking the pattern and watching if that anemia or that polycythemia worsens.
17:24
And so, yeah, all these scans may seem intimidating and daunting and maybe even you feel pressured to go into having more scans when it's not necessarily necessary.
But the reality is, is that it's just really about tracking progress and just keeping a close eye so that you have the best possible outcome.
17:43
Yeah, it's about trends, right.
And I think maybe that's, I think that potentially is one of the issues with Singleton pregnancies and a lot of scans and things because we're comparing 2 points on a graph, you have no trend, right?
There's nothing, there's no real comparison.
You have a higher margin of error for, for, you know, 1 erroneous measurement to kind of, you know, indicate that there's, there's need for intervention.
18:09
Whereas when you when you are having those multiple touch points and those multiple check insurance, it's one erroneous measurement.
It's less likely to skew things and send you off on a different trajectory because you've got more reference points, right?
Yeah, exactly.
And even in the TAPS world, we actually say 1 bad reading means try again in a couple of days.
18:28
That's literally what we tell people is that, you know, don't panic when you get that first reading.
It's going to be off the chart.
And it's usually one one twin is really high and they have like an anemia a reading that goes into the anemia category.
And we're like, OK, well, let's think about it logically.
18:45
Where was the baby positioned?
Where they down low?
And because even as they get later in pregnancy, if that baby A is like right down in the pelvis, it is really hard to find that little special spot.
If you have, were they moving a lot is another thing, because we always use the analogy too, is that finding that spot to take that reading is kind of like, you know, those X-ray glasses from the joke shop?
19:10
You're wearing a pair of those and you've got to hit a moving target at 100 paces and you know, it's all underwater.
Did we tell you that bit?
And so it can be quite challenging.
So that's why we say, look, go back at a different time of day when the babies feel more arrested or things like that.
19:29
Because quite often you'll find that initial alarm is just just a an outlier, at least a digital outlier like you said.
And I think actually that's really good advice for all pregnancies.
Anyone that gets a scan and gets told potentially that their babies, you know, their growth is dropping off or their growth going, you know, way off the charts, Maybe it is kind of like, take it a pinch of salt, ask for another scan, you know, yeah.
19:56
And see see if there is a trend there or if actually it was just baby was just not playing ball.
Yeah, exactly.
And I mean, that's the whole thing.
And like, you know, we know that they're unpredictable.
I mean, they're unpredictable on the inside, they're unpredictable on the outside.
You don't know what's going to happen.
20:11
And so, you know, in relation to TTS, I would actually say, yeah, look, absolutely, 100% make your decisions then and there because it's very clear on the ultrasound what's happening.
But you know, with a lot of other things, it's kind of like a case of, you know what, taking that second reading, taking a moment to breathe.
Don't run out and Google everything.
20:29
Or if you do Google, take the questions back to your next appointment.
Don't ask them first, ask them second because you never know what's going to happen.
You can be prepared, but you don't have to be panicked.
I think I just want to circle back and just reiterate that I know it sounds really scary some of these some of these complications, but let's not lose the sight that actually out of all of the twins, we're talking about a really small percentage that may have these complications and all of those that have complications, another percentage of those are going to be fine, right?
21:02
So it's an even smaller percentage that we're going to have poorer outcomes with.
Yeah, that's exactly it.
And I mean, it's not like saying that everyone has to go out and immediately like and down the hatches and lock the doors that this is going to happen to you.
It doesn't.
It's really not.
21:19
It's really not common.
And the reason that, you know, TTTSFGR, taps, trap, all those things are called rare diseases is because they are rare.
But being that having that just because of their red doesn't mean we shouldn't look for them.
21:35
Sorry.
It's about finding that balance.
And when you go into that initial appointment and you get hit with all those words and all those options and hear all those negative things that can happen, take it away, process, write it down.
And then when you go back to your next appointment, ask questions.
21:52
You can Google, write it down, ask questions.
What can I do?
How, what will happen?
Make a strategy, make a plan of attack and you may never need it.
But if you're kind of like me and you get hit with all this overwhelming information, the first thing you want to do is like, write.
22:09
I've got to make a plan.
I've got to make a shit, you know, I, I've got to write it.
I've got to find out as much as I can.
But the reality is, of course, is that you may never need that information, but if you have it written down, it feels like you've got a sense of control.
So with that, with that in mind, what would your advice be to somebody that's been told they're having twins?
22:32
Like what would you think, what would you suggest are the key, key questions to ask their obstetrician, if they've been, if they've just been told they're having twins, is there, is there certain things that you would suggest would be a really good idea to ask?
Yeah, absolutely.
I would actually 1st and for almost say OK, having and now we know that how many sets of twins have you delivered?
22:54
And the reason is, is that then you have an interval of knowing how much confidence they have.
You know, in my case, they I was diagnosed with having twins.
I was immediately referred to a specialist consultant in my local hospital who had experience with twins and had studied with twin researchers.
23:11
So he was kind of cool.
Also incredibly good looking, but that's another story.
Yeah, you know, but I would ask how much experience, like what are the possible complications that can happen if something does go wrong?
23:33
What is your plan of attack?
Next one is probably one that no one thinks of.
Is there, is there any support like social work, mental health support?
Because this is a really big life changing moment.
23:49
Do you have recommendations for services, people, groups, organizations that I can contact?
And I know within the UK you have the Twins Trust who are excellent.
They've been doing this for over 40 years.
They know what they're talking about.
24:05
So they will be able to connect you with support groups.
These are all probably, that's my big top five.
Don't ask me to repeat them because I couldn't, but that would be what I would suggest.
Yes, it's recorded, it's fine.
But you know, that would be my big questions.
24:22
But you know, specifically how much experience do you have?
What if something goes wrong?
What's going to happen and what kind of support is available?
Yeah, OK.
That's that's, I mean that and that's really, really helpful.
So you've mentioned the Twins Trust, which I'll link in the in in the show notes.
24:42
You obviously founded an organization.
Do you want to talk a little bit about that as well?
Yeah, I, I'm always happy to talk about that.
You can't see the smile and the look on my eyes, but it's quite demonic.
No, literally what I do is I founded TAP Support which is a charity and we look after, we are specifically focused on twin anemia, polycythemia sequence.
25:07
However, we do also support and offer support and information for related complications.
So that's TTS SFTR.
When my girls were born nearly 11 years ago, I got a diagnosis and there was only one website in Dutch and a lot of medical papers that explained what TAPS was.
25:28
So for me, it was a matter of piercing together my own information.
I was very fortunate.
I got sent to a hospital.
When I got my referral, I got sent to a hospital where they were researching TAPS.
And hey, shout out to Leiden University Medical Center.
You guys are up.
25:44
But yeah, if you, They were very great at explaining things and I maintained a relationship with them and particularly the neonatologist who took after my girl, looked after my girls.
And then over the years, I have found more information online.
And I started joining twin groups because I joined groups after my girls were born and I saw a lot of misinformation out there.
26:06
So I started going, hey, no, that's actually not correct.
And I was like, what if I made a website where I could put all this information?
And then that kind of just escalated to running a fairly successful charity now.
So yeah, basically we offer support for families information, so we'll give you research papers and how to use it.
26:27
We also talk with doctors quite a lot and on how to counsel patients in relation to a diagnosis and TAPS.
We do a lot of stuff around raising awareness.
We have an International Awareness Day on March 3rd.
Yeah, basically that's pretty much what we do.
26:45
Oh, and we raise money for research.
So we've actually funded 2 research projects.
One was on hypoglycemia in TAPS donors.
We are trying to actually fund a mental health study at the moment, which is about the impact of complicated twin pregnancies on families.
27:03
And then we are also like, we offer support to PhD students, so if they want to publish their thesis, they can ask us for a grant and we give them a little bit of money.
We've given projects, we helped kick start getting the TAPS trial, which is a very important trial in the UK to the UK, to the Liverpool Women's Hospital.
27:23
And we've given money for ultrasound equipment.
Like there's little bits and pieces that we've done over the years.
So basically we're all about like we raise money, but we give it straight out to projects and people and things like that.
It's huge.
Like, yeah, it feels like when you do, you sort of like sit there and you're going, Oh my God, we don't do anything.
27:41
And then when you describe it, it's like, Oh my God, we do so much.
I mean, the impact of all of that would be.
Yeah, it feels.
Idea going oh just put a website to go ahead.
Yeah, but I think you can relate to this as like, you know, you have one idea and then it goes, oh, but then we can do this and then we can do this.
27:58
And that's literally what happened.
And I may have some fantastic support behind the screen scenes.
The people from Lied and obviously are very supportive because we support a lot of their projects.
But you know, we have, so they're great and fantastic to have a team of researchers behind us as well and what we're doing.
28:16
And, but also we have support from families.
And that feels amazing to know that we're making a positive difference and making an impact in that way.
And it's like I said, I'm doing this because 10 years ago I had no information.
And now if I can just share a little bit of what I've learned or share amazing researches with the world or help fund more research, then I'm doing my little bit.
28:41
Because I have two survivors and I always get a little bit emotional talking about this.
I have two surviving children and we do have complications, but it is so important to have that, have them, have them here with me and to know that, you know, without research and help they wouldn't have been here.
29:01
And that's not being doom and gloom, that's reality.
If they hadn't been born where they were born and we hadn't had the intervention we had, they would not be here.
Yeah, yeah.
And I'm sure thanks to your your, your charity, there are multiple other families who are happy and whole because of the things that you've worked on and you've funded and you've supported so.
29:26
Yeah, and that that gives a good feeling, but it's kind of like it's not the purpose.
The purpose is really to make sure that no one else feels is alone that I did when my girls are there.
And you know, we also like as much as we talk about the positive side of things, we also like to talk about the negative side of things.
29:43
And so we're also very realistic is that there can be lots and that's we also partner with people like the Purple Butterfly Project, the Sky High Foundation to raise awareness of twin loss footprints.
Baby Loss are another amazing organization that I absolutely love who are really working out there in the twin loss community.
30:05
And so that's also a very important part is to say, yes, there are fantastic outcomes, but we also look after and nurture the families who don't have the fantastic outcomes.
And that's one of the reasons why we're so adamant about the well-being study is that it's going to focus not only on the good side, but it's going to help with the mental health side and supporting the families who don't have positive outcomes.
30:30
So I will make sure that I've included all of those you might have to.
What name dropping?
I'm just so I just love these organizations so much, particularly footprints and purple butterfly sky high.
I think there's such wonderful organizations who do amazing things and I'm like, I feel like I want to be them when I grow up so.
30:50
But I'll make sure they're that they're all, all those I'll.
Make sure you get the links as well, yeah?
Included if anybody wants to find you on social media and your foundation, where can they find you?
OK, you can find us on all pretty much all social media platforms at tap support.
31:08
So just your little at sign and tap support.
And then for myself, I'm on Facebook and Instagram and LinkedIn.
On LinkedIn, you can just find me as Stephanie Ernst as and on Instagram and Facebook, it's at Stephanie Ernst writer.
31:24
I just post lots of like cool pictures of.
I have a great illustrator friend who I'm not named up as well, Amanda Gautier.
She makes great illustrations of twins and pregnancies.
So I use her, I work use her illustrations a lot.
So I just try and breakdown the wording and that's where you'll find me.
31:44
And I usually am talking about something.
Thank you so much for your time today, Seth.
It's been really, really interesting, really, really useful.
And I'm sure that everybody listening is will have will have learned a lot.
And I'll make sure that I include all of your wonderful resources and links in the show notes.
32:01
We will.
Thank you and thank you so much for letting me speak.
It's been great.
No, you're welcome.
Thank you.
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