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Introduction There is no clear guidance for the optimal setting for dilation and curettage (D&C) for the management of first-trimester pregnancy failure. Identifying patients at risk of clinically significant blood loss at the time of D&C may inform a provider's decision regarding the setting for the procedure. We aimed to identify risk factors predictive for blood loss of 200mL or greater at the time of D&C. Methods This is a retrospective cohort study of patients diagnosed with first-trimester pregnancy failure at gestational age less than 11 weeks who underwent surgical management with D&C at a single safety net academic institution between 4/2016 and 4/2021. Patient characteristics and procedural outcomes were abstracted. Women with less than 200mL versus greater than or equal to 200mL blood loss were compared using descriptive statistics, chi-square for categorical variables, and Satterthwaite t-tests for continuous variables. Results A total of 350 patients were identified; 233 met inclusion criteria, and 228 had non-missing outcome data. Mean gestational age was 55 days (SD 9.4). Thirty-one percent (n=70) had estimated blood loss (EBL) ≥200mL. Younger patients (mean 28.7 years vs. 30.9, p=0.038), Latina patients (67.1% vs. 51.9%, p=0.006), patients with higher body mass index (BMI, mean 30.6 vs. 27.3 kg/m2, p=0.006), and patients with pregnancies at greater gestational age (59.5 days vs. 53.6 days, p<0.001) were more likely to have EBL ≥200mL. Additionally, patients with pregnancies dated by ultrasound (34.3% vs. 18.4%, p=0.007), those who underwent D&C in the operating room (81.4% vs. 48.7%, p<0.001), and those who underwent general anesthesia (81.4% vs. 44.3%, p<0.001) were more likely to have EBL ≥200mL. Discussion In this study, patients with EBL ≥200mL at the time of D&C differed significantly from those with EBL<200mL. This information can assist providers in planning the best setting for their patients' procedures.
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INTRODUCTION: High-altitude (>2500 m) residence augments the risk of intrauterine growth restriction (IUGR) and preeclampsia likely due, in part, to uteroplacental hypoperfusion. Previous genomic and transcriptomic studies in humans and functional studies in mice and humans suggest a role for AMP-activated protein kinase (AMPK) pathway in protecting against hypoxia-associated IUGR. AMPK is a metabolic sensor activated by hypoxia that is ubiquitously expressed in vascular beds and placenta. METHODS: We measured gene expression and protein levels of AMPK and its upstream regulators and downstream targets in human placentas from high (>2500 m) vs. moderate (~1700 m) and low (~100 m) altitude. RESULTS: We found that phosphorylated AMPK protein levels and its downstream target TSC2 were increased in placentas from high and moderate vs. low altitude, whereas the phosphorylated form of the downstream target translation repressor protein 4E-BP1 was increased in high compared to moderate as well as low altitude placentas. Mean birth weights progressively fell with increasing altitude but no infants, by study design, were clinically growth-restricted. Gene expression analysis showed moderate increases in PRKAG2, encoding the AMPK γ2 subunit, and mechanistic target of rapamycin, MTOR, expression. DISCUSSION: These results highlight a differential regulation of placental AMPK pathway activation in women residing at low, moderate or high altitude during pregnancy, suggesting AMPK may be serving as a metabolic regulator for integrating hypoxic stimuli with placental function.