Consensus Statement: Screening for Early-Onset Preeclampsia and Aspirin Prophylaxis in the US
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Discuss the various professional guidelines regarding screening for preeclampsia and use of prophylactic aspirin 2. Restate the conclusion of the Gottesfeld-Hohler Memorial Foundation consensus statement regarding screening for preeclampsia
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 1/15/2020 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
Under the auspices of the Gottesfeld-Hohler Memorial Foundation, a Consensus Statement was developed to address the multiple guidelines regarding screening for early-onset preeclampsia (open access summaries of these recommendations can be found below in ‘Related ObG Topics’). This ‘Think Tank Summary’ was comprised of expert participants, including representatives from ACOG, NICHD, SMFM, AIUM, FMF and ISUOG. The Consensus Statement recognizes that while there are differences regarding approach, there is consensus regarding the importance of screening and use of prophylactic aspirin when appropriate. The authors conclude with the following
…it is strongly advised to identify patients at high risk for preeclampsia at least by the guidelines of ACOG, SMFM, the U.S. Preventative Services Task Force, or the Fetal Medicine Foundation criteria.
Offering prophylactic low-dose aspirin starting in the late first or early second trimester, and close scrutiny of these women throughout pregnancy, may help to avert or mitigate the severe complications for the mother, fetus, and neonate that can result from preeclampsia.
Summary of Professional Recommendations
USPSTF and ACOG/SMFM
Recommend screening for preeclampsia using personal and family history risk factors
Support the use of low-dose aspirin (81 mg), optimally beginning early in pregnancy <16 weeks (per ACOG)
FMF (aligned with ISUOG and FIGO recommendations)
Based on results from the ASPRE trial (see summary below in ‘Related ObG Topics’), these organizations recommend combined screening
The early-preeclampsia screening algorithm includes
Maternal factors (history, demographics, CVD and metabolic profile)
Maternal arterial BP (MAP)
Placental growth factor (PlGF)
Pulsatility index (PI) to assess uterine artery resistance
For women at high risk, aspirin should be started early in pregnancy
Ideally between 11w0d and 14w6d
150 mg every night until 36 weeks, delivery or preeclampsia is diagnosed
Several studies have duplicated the success of ASPRE regarding test performance
However, the Consensus Statement points out that some other investigators have not demonstrated similar results
“Reason for the discrepancy is unclear” but could be due to different populations and/or quality of MAP and ultrasound technique
Review of Aspirin Data
The Consensus Statement provides a literature review of prophylactic aspirin for the prevention of preeclampsia
Prophylactic aspirin impacts early-onset and not term preeclampsia
ASPRE study outcome was preeclampsia diagnosis <37 weeks
The study did not show an overall difference in rates of preeclampsia but rather preeclampsia that led to delivery <37 weeks
The above may explain those studies that could not duplicate ASPRE performance | Delivery protocols and standards can vary by region
The Consensus Statement recognizes data to support aspirin doses >100 mg
Higher dose does not appear to increase maternal risk
Data regarding potential fetal/newborn risks related to altered platelet function are ‘limited’
Universal aspirin prophylaxis
There has been literature suggesting that universal aspirin prophylaxis is the most cost-effective strategy (for study review, see ‘Related ObG Topics’ below)
Results are based on modeling and not ‘real world’ usage
Complications that would occur in approximately 4 million pregnancies is unknown (although authors acknowledge maternal safety for low-dose aspirin)
Compliance rates are not known
The Consensus Statement calls for further trials
The Consensus Statement recognizes that the FMF model may detect >80% of early-onset preeclampsia
However, hurdles related to US implementation include
Addition of new expenses
Training and availability of sonologists with appropriate skill set for assessment of uterine artery PI
“Uncertainty remains regarding optimal dosage (81 vs 162 vs 150)”
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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