Alerts

Aspirin Treatment for Women at Risk for Preeclampsia – ACOG and USPSTF Recommendations

FINDINGS:

ACOG and SMFM have released guidance, stating that they “support the USPSTF guideline criteria for prevention of preeclampsia” on the use of low-dose aspirin during pregnancy to prevent preeclampsia. When indicated, low-dose aspirin should be started between 12 to 28 weeks and continued until delivery. Optimally, aspirin usage should begin <16 weeks.

Offer low-dose aspirin (81 mg/day) to women with ≥1 high risk factors for preeclampsia, which include
- History of preeclampsia, especially if accompanied by an adverse outcome
- Multifetal gestation
- Chronic hypertension
- Diabetes (Type 1 or Type 2)
- Renal disease
- Autoimmune disease (for example, systematic lupus erythematosus, antiphospholipid syndrome)

Consider Prophylaxis

Offer low-dose aspirin (81 mg/day) to women with >1 moderate risk factors for preeclampsia, which include
- Nulliparity
- Obesity (BMI >30)
- Personal history
  - low birthweight or SGA
  - Previous adverse pregnancy outcome
- Family history of preeclampsia
  - Sister or mother
- Social and demographic characteristics
  - African American race | low socioeconomic status
- Maternal age ≥35 years
- >10 year interpregnancy interval

Not Recommended Without Preeclampsia Risk Factors

Low risk: Previous uncomplicated full-term delivery
Insufficient Evidence
- Prior unexplained stillbirth (insufficient evidence)
- Prevention of fetal growth restriction
- Prevention of spontaneous PTB
No Benefit
- Prevention of early pregnancy loss

USPSTF Guidance

The systematic review (Ann Intern Med, 2014), performed on behalf of the USPSTF, demonstrated the following benefits for women at risk for preeclampsia
- 14% risk reduction for preterm birth (< 37 weeks)
- 20% risk reduction for IUGR
- Increase in average birthweight of 130 g
- 24% risk reduction for preeclampsia
- Only 1 paper had follow up (18 months) on children; no developmental harms were identified
Harms
- No harms from low-dose aspirin were identified, however some events were sufficiently rare that possible negative outcomes from aspirin use, such as abruption, cannot be completely ruled out
USPSTF updated recommendations
- Based on the above findings, the USPSTF recommends providers offer low-dose aspirin to women at high risk for preeclampsia (‘B’ grade’ – offer or provide this service)

KEY POINTS:

The USPSTF states that “the harms of low-dose aspirin in pregnancy are considered to be no greater than small”
Risk factors used for ACOG/SMFM recommendations only include factors obtained from the medical record
- Uterine artery Doppler ultrasonography and biochemical markers are not included
- ACOG/SMFM acknowledge that other studies, in particular the ASPRE trial (see ‘Related ObG Topics’ below), have incorporated ultrasound and maternal serum markers as well as doses >81 mg, but state

Further, the screening algorithm used includes first-trimester serum markers, including placental growth factor and pregnancy-associated plasma protein-A, as well as uterine artery dopplers, which limits the generalizability to a U.S. population. Therefore, a higher dose or doubling of the available 81-mg dose cannot be recommended at this time.

Screening for Preeclampsia

Various studies have incorporated not only clinical risk factors but also biochemical markers and ultrasound to determine which women are at risk for early onset preeclampsia and may benefit from aspirin prevention (see ‘Related ObG Topics’)
ACOG considers the supporting data for the use of such combined risk assessment algorithms to be limited and without more prospective clinical utility trials, states that