Aspirin Treatment for Women at Risk for Preeclampsia – ACOG, SMFM and USPSTF Recommendations
ACOG/SMFM have released guidance aligned with USPSTF regarding 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
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)
Moderate Risk Factors
Offer low-dose aspirin (81 mg/day) to women with ≥2 moderate risk factors
Obesity (BMI >30)
Low birthweight or SGA
Previous adverse pregnancy outcome
>10-year pregnancy interval
Family history of preeclampsia
Sister or mother
Social and demographic characteristics
Black race (as a proxy for underlying racism)
Maternal age ≥35 years
Note: USPSTF does allow for consideration of aspirin prophylaxis if ≥1 moderate risk factor is present and states “Clinicians should use clinical judgment in assessing the risk for preeclampsia and discuss the benefits and harms of low-dose aspirin use with their patients”
Evidence supports a risk-based approach
ACOG/SMFM acknowledges that in some settings, a majority of patients will fall in to either high or moderate risk categories, and therefore
In these instances, universal implementation (eg, offering low-dose aspirin to all patients within such practices or institutions) may be medically reasonable
The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication for preeclampsia after 12 weeks of gestation in persons who are at high risk for preeclampsia as per categories above (B recommendation – offer or provide this service)
The most recent systematic evidence review (see ‘Learn More – Primary Sources) provided more precise estimate of the association between aspirin and the prevention of perinatal mortality (4% to 44% reduction in fetal and neonatal deaths)
Otherwise, benefits of low-dose aspirin for women at risk for preeclampsia were similar to previous reviews with lower risks for the following (moderate certainty)
Preeclampsia: Pooled relative risk (RR) 0.85 (95% CI, 0.75-0.95)
Perinatal mortality: Pooled RR 0.79 (95% CI, 0.66-0.96)
Preterm birth: Pooled RR 0.80 (95% CI, 0.67-0.95)
Intrauterine growth restriction: Pooled RR 0.82 (95% CI, 0.68-0.99)
No significant association was found for
PPH or other bleeding-related harms
Rare perinatal or longer-term harms
Long-term child developmental outcomes in offspring from in utero exposure to low-dose aspirin
Follow-up data from the Collaborative Low-dose Aspirin Study in Pregnancy (CLASP), found no differences in physical or developmental outcomes at 12 to 18 months
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/SMFM 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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