Aspirin Treatment for Women at Risk for Preeclampsia – ACOG and USPSTF Recommendations
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.
Recommended (high risk)
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
Diabetes (Type 1 or Type 2)
Autoimmune disease (for example, systematic lupus erythematosus, antiphospholipid syndrome)
Consider Prophylaxis (moderate risk)
Offer low-dose aspirin (81 mg/day) to women with >1 moderate risk factors for preeclampsia, which include
The systematic review (Ann Intern Med, 2014), performed on behalf of the USPSTF, demonstrated the following benefits of low-dose aspirin 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
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
The USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy (‘B’ grade’ – offer or provide this service)
The USPSTF recommends providers offer low-dose aspirin to women at high risk for preeclampsia (‘B’ grade’ – offer or provide this service)
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
…biomarkers and ultrasonography cannot accurately predict preeclampsia and should remain investigational.
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