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Rottenstreich A. Controversies and Clarifications Regarding the Role of Aspirin in Preeclampsia Prevention: A Focused Review. J Clin Med 2024; 13:4427. [PMID: 39124694 PMCID: PMC11312818 DOI: 10.3390/jcm13154427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Revised: 07/23/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Preeclampsia is one of the leading causes of maternal and perinatal morbidity and mortality worldwide. In recent decades, many studies have evaluated different interventions in order to prevent the occurrence of preeclampsia. Among these, administration of low-dose aspirin from early pregnancy showed consistent evidence of its prophylactic role. In this article, we review the scientific literature on this topic, highlighting the rationale for aspirin use, who should be treated, the timing of initiation and cessation of therapy, the importance of proper dosing, and its role in the prevention of other adverse outcomes.
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Affiliation(s)
- Amihai Rottenstreich
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, NY 10065, USA; ; Tel.: +1-212-327-7494; Fax: +1-212-327-7493
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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Ngene NC, Moodley J. Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102473. [PMID: 38513504 DOI: 10.1016/j.bpobgyn.2024.102473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 03/23/2024]
Abstract
Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.
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Affiliation(s)
- Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, Rahima Moosa Mother and Child Hospital, Johannesburg, Gauteng, South Africa; Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Gauteng, South Africa.
| | - Jagidesa Moodley
- Women's Health and HIV Research Group, Department of Obstetrics and Gynecology, School of Clinical Medicine, Faculty of Health Sciences, University of Kwa Zulu-Natal, Durban, South Africa.
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Kupka E, Roberts JM, Mahdy ZA, Escudero C, Bergman L, De Oliveira L. Aspirin for preeclampsia prevention in low- and middle-income countries: mind the gaps. AJOG GLOBAL REPORTS 2024; 4:100352. [PMID: 38694484 PMCID: PMC11061325 DOI: 10.1016/j.xagr.2024.100352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
Preeclampsia is a syndrome that continues to be a major contributor to maternal and neonatal mortality, especially in low-income countries. Low-dose aspirin reduces the risk of preeclampsia, but the mechanism is still unknown. Risk factors to identify women at risk of preeclampsia are based on clinical characteristics. Women identified as high-risk would benefit from aspirin treatment initiated, preferably at the end of the first trimester. Current efforts have largely focused on developing screening algorithms that incorporate clinical risk factors, maternal biomarkers, and uterine artery Doppler evaluated in the first trimester. However, most studies on preeclampsia are conducted in high-income settings, raising uncertainties about whether the information gained can be totally applied in low-resource settings. In low- and middle-income countries, lack of adequate antenatal care and late commencement of antenatal care visits pose significant challenges for both screening for preeclampsia and initiating aspirin treatment. Furthermore, the preventive effect of first-trimester screening based on algorithms and subsequent aspirin treatment is primarily seen for preterm preeclampsia, and reviews indicate minimal or no impact on reducing the risk of term preeclampsia. The lack of evidence regarding the effectiveness of aspirin in preventing term preeclampsia is a crucial concern, as 75% of women will develop this subtype of the syndrome. Regarding adverse outcomes, low-dose aspirin has been linked to a possible higher risk of postpartum hemorrhage, a condition as deadly as preeclampsia in many low- and middle-income countries. The increased risk of postpartum hemorrhage among women in low-income settings should be taken into consideration when discussing which pregnant women would benefit from the use of aspirin and the ideal aspirin dosage for preventing preeclampsia. In addition, women's adherence to aspirin during pregnancy is crucial for determining its effectiveness and complications, an aspect often overlooked in trials. In this review, we analyze the knowledge gaps that must be addressed to safely increase low-dose aspirin use in low- and middle-income countries, and we propose directions for future research.
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Affiliation(s)
| | - James M. Roberts
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Zaleha A. Mahdy
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Carlos Escudero
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Lina Bergman
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Leandro De Oliveira
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Global Pregnancy Collaboration
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
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Myers SO, Luke S, Ramey-Collier KL, Truong T, Weaver K, Swamy GK, Wheeler SM. Factors Associated with Guideline Concordant Clinician Counseling about Low-Dose Aspirin to Prevent Preeclampsia in Nulliparous Patients. Am J Perinatol 2024; 41:e2004-e2009. [PMID: 37207675 PMCID: PMC10764634 DOI: 10.1055/a-2096-3466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
OBJECTIVE The primary aim of this study was to examine the United States Preventative Services Task Force (USPSTF) guidelines concordant low-dose aspirin (LDA) counseling and factors associated with counseling in nulliparous birthing individuals. STUDY DESIGN We conducted a retrospective cohort study of nulliparous birthing individuals who delivered between January 1, 2019 and June 30, 2020 and received prenatal care at the Duke High Risk Obstetrical Clinics (HROB). All nulliparous patients over 18 years old who established or transferred care to HROB by 16 weeks, 6 days were included in the analysis. We excluded patients with more than two previous first-trimester pregnancy losses, multiple gestation, a known contraindication to LDA, initiation of LDA prior to their prenatal care, or documented medical history of coagulation disorder. Bivariate associations between demographic/medical characteristics and our primary outcome, receipt of counseling (yes/no), were assessed using two-sample t-tests for continuous variables and chi-square or Fisher's exact test for categorical variables. Factors significantly associated with the primary outcome (p < 0.05) were entered into the multivariable logistic regression model. RESULTS Among 391 birthing individuals included in the final analysis cohort, 51.7% of eligible patients received guideline consistent LDA counseling. Factors associated with increased odds of LDA counseling were advanced maternal age (adjusted odds ratio [aOR]: 1.05, 95% confidence interval [CI]: 1.01-1.09), Black race compared with White race (aOR:1.75, 95% CI: 1.03-2.98), chronic hypertension (aOR: 4.17, 95% CI: 1.82-9.55), and obesity (aOR: 5.02, 95% CI: 3.12-8.08). CONCLUSION Approximately half of all nulliparous birthing individuals had appropriately documented LDA counseling. The USPSTF guidelines on LDA for preeclampsia risk reduction are complex, which may lead to ineffective provider adherence. Efforts to simplify guidelines and improve LDA counseling are vital to ensuring this low-cost, evidence-based preeclampsia prevention is used in a consistent and equitable manner. KEY POINTS · A total of 51.7% of eligible patients received guideline consistent LDA counseling.. · Advanced maternal age , body mass index > 30, Black race, and chronic hypertension associated with increased odds of counseling.. · Among patients most likely to be counseled, high numbers did not receive LDA counseling..
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Affiliation(s)
| | - Shauntell Luke
- Duke University School of Medicine, Durham, North Carolina
| | | | - Tracy Truong
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kristin Weaver
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Geeta K. Swamy
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Sarahn M. Wheeler
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Duke University School of Medicine, Durham, North Carolina
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Yan X, Zheng W, Wang J, Yuan X, Li G. Low-dose aspirin for the prevention of preterm birth in nulliparous women: systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:260. [PMID: 38605330 PMCID: PMC11008052 DOI: 10.1186/s12884-024-06413-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/12/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVE The objective was to assess the efficacy and safety of low-dose aspirin for the prevention of preterm birth in nulliparous women. DATA SOURCES We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to June 2022. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared aspirin to placebo in nulliparous women were eligible. METHODS This study was reported in accordance with the PRISMA 2020 checklist. The primary outcomes of this study were the rates of preterm birth at less than 37 weeks and less than 34 weeks of gestation. The secondary outcomes included postpartum hemorrhage, placental abruption, cesarean section, any hypertensive disorder of pregnancy and small for gestational age. Relative risks with their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed by Cochran's Q test and Higgins's I2. A random-effects model was used when I2 was > 50% to generate the RR and 95% CI; otherwise, a fixed-effects model was used. The risk of publication bias was assessed by funnel plots. We performed sensitivity analysis by sequentially omitting each included study to confirm the robustness of the analysis. RESULTS Seven studies with a total of 29,029 participants were included in this review. Six studies were assessed as having a low risk of bias or an unclear risk of bias, and one study was judged as having a high risk of bias. In nulliparous women, low-dose aspirin was associated with a significant reduction in the rate of preterm birth at less than 34 weeks of gestational age (RR 0.84,95% CI: 0.71-0.99; I2 = 0%; P = 0.04), but we did not observe a significant difference in the rate of preterm birth at less than 37 weeks of gestation (RR 0.96,95% CI: 0.90-1.02; I2 = 31%; P = 0.18). Low-dose aspirin was associated with a significant increase in the rates of postpartum hemorrhage (RR 1.32,95% CI: 1.14-1.54; I2 = 0%; P = 0.0003), placental abruption (RR 2.18,95% CI: 1.10-4.32; I2 = 16%; P = 0.02) and cesarean section (RR 1.053, 95% CI: 1.001-1.108; I2 = 0%; P = 0.05) in nulliparous women. We also did not observe a significant effect of low-dose aspirin on the rates of any hypertensive disorder of pregnancy (RR 1.05, 95% CI: 0.96-1.14; I2 = 9%; P = 0.28) or small for gestational age (RR 0.96, 95% CI: 0.91-1.02; I2 = 0%; P = 0.16) in nulliparous women. Funnel plots indicated that no significant publication bias existed in this meta-analysis. Except for preterm birth at less than 34 weeks of gestation, placental abruption and cesarean section, the sensitivity analysis showed similar results, which confirmed the robustness of this meta-analysis. CONCLUSIONS Low-dose aspirin might reduce the risk of preterm birth at less than 34 weeks of gestation in nulliparous women. The use of low-dose aspirin in nulliparous women increased the risk of postpartum hemorrhage and might increase the risk of placental abruption and cesarean section.
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Affiliation(s)
- Xin Yan
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Wei Zheng
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Jia Wang
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Xianxian Yuan
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Guanghui Li
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China.
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Nzelu D, Palmer T, Stott D, Pandya P, Napolitano R, Casagrandi D, Ammari C, Hillman S. First trimester screening for pre-eclampsia and targeted aspirin prophylaxis: a cost-effectiveness cohort study. BJOG 2024; 131:222-230. [PMID: 37431533 DOI: 10.1111/1471-0528.17598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE Investigate cost-effectiveness of first trimester pre-eclampsia screening using the Fetal Medicine Foundation (FMF) algorithm and targeted aspirin prophylaxis in comparison with standard care. DESIGN Retrospective observational study. SETTING London tertiary hospital. POPULATION 5957 pregnancies screened for pre-eclampsia using the National Institute for Health and Care Excellence (NICE) method. METHODS Differences in pregnancy outcomes between those who developed pre-eclampsia, term pre-eclampsia and preterm pre-eclampsia were compared by the Kruskal-Wallis and Chi-square tests. The FMF algorithm was applied retrospectively to the cohort. A decision analytic model was used to estimate costs and outcomes for pregnancies screened using NICE and those screened using the FMF algorithm. The decision point probabilities were calculated using the included cohort. MAIN OUTCOME MEASURES Incremental healthcare costs and QALY gained per pregnancy screened. RESULTS Of 5957 pregnancies, 12.8% and 15.9% were screen-positive for development of pre-eclampsia using the NICE and FMF methods, respectively. Of those who were screen-positive by NICE recommendations, aspirin was not prescribed in 25%. Across the three groups, namely, pregnancies without pre-eclampsia, term pre-eclampsia and preterm pre-eclampsia there was a statistically significant trend in rates of emergency caesarean (respectively 21%, 43% and 71.4%; P < 0.001), admission to neonatal intensive care unit (NICU) (5.9%, 9.4%, 41%; P < 0.001) and length of stay in NICU. The FMF algorithm was associated with seven fewer cases of preterm pre-eclampsia, cost saving of £9.06 and QALY gain of 0.00006/pregnancy screened. CONCLUSIONS Using a conservative approach, application of the FMF algorithm achieved clinical benefit and an economic cost saving.
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Affiliation(s)
- Diane Nzelu
- Fetal Medicine Unit, University College London Hospital, Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Tom Palmer
- Institute for Global Health, University College London, London, UK
| | - Daniel Stott
- Fetal Medicine Unit, University College London Hospital, Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Pranav Pandya
- Fetal Medicine Unit, University College London Hospital, Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Raffaele Napolitano
- Fetal Medicine Unit, University College London Hospital, Elizabeth Garrett Anderson Institute for Women's Health, London, UK
- University College London, London, UK
| | - Davide Casagrandi
- Fetal Medicine Unit, University College London Hospital, Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Christina Ammari
- Fetal Medicine Unit, University College London Hospital, Elizabeth Garrett Anderson Institute for Women's Health, London, UK
| | - Sara Hillman
- Fetal Medicine Unit, University College London Hospital, Elizabeth Garrett Anderson Institute for Women's Health, London, UK
- University College London, London, UK
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Souter V, Painter I, Sitcov K, Khalil A. Propensity score analysis of low-dose aspirin and bleeding complications in pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:81-87. [PMID: 37674400 DOI: 10.1002/uog.27472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE Low-dose aspirin (LDA) has been shown to reduce the risk of preterm pre-eclampsia and it has been suggested that it should be recommended for all pregnancies. However, some studies have reported an association between LDA and an increased risk of bleeding complications in pregnancy. Our aim was to evaluate the risk of placental abruption and postpartum hemorrhage (PPH) in patients for whom their healthcare provider had recommended prophylactic aspirin. METHODS This multicenter cohort study included 72 598 singleton births at 19 hospitals in the USA, between January 2019 and December 2021. Pregnancies complicated by placenta previa/accreta, birth occurring at less than 24 weeks' gestation, multiple pregnancy or those with data missing for aspirin recommendation were excluded. Propensity scores were calculated using 20 features spanning sociodemographic factors, medical history, year and hospital providing care. The association between LDA recommendation and placental abruption or PPH was estimated by inverse-probability treatment weighting using the propensity scores. RESULTS We included 71 627 pregnancies in the final analysis. Aspirin was recommended to 6677 (9.3%) and was more likely to be recommended for pregnant individuals who were 35 years or older (P < 0.001), had a body mass index of 30 kg/m2 or higher (P < 0.001), had prepregnancy hypertension (P < 0.001) and who had a Cesarean delivery (P < 0.001). Overall, 1.7% of the study cohort (1205 pregnancies) developed preterm pre-eclampsia: 1.3% in the no-aspirin and 5.8% in the aspirin group. After inverse-probability weighting with propensity scores, aspirin was associated with increased risk of placental abruption (adjusted odds ratio (aOR), 1.44 (95% CI, 1.04-2.00)) and PPH (aOR, 1.21 (95% CI, 1.05-1.39)). The aOR translated to a number needed to harm with LDA of 79 (95% CI, 43-330) for PPH and 287 (95% CI, 127-3151) for placental abruption. CONCLUSIONS LDA recommendation in pregnancy was associated with increased risk for placental abruption and for PPH. Our results support the need for more research into aspirin use and bleeding complications in pregnancy before recommending it beyond the highest-risk pregnancies. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Souter
- Foundation for Health Care Quality, Seattle, WA, USA
| | - I Painter
- Foundation for Health Care Quality, Seattle, WA, USA
| | - K Sitcov
- Foundation for Health Care Quality, Seattle, WA, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Jones Pullins M, Boggess K, Porter TF. Aspirin in Pregnancy. Obstet Gynecol 2023; 142:1333-1340. [PMID: 37917941 DOI: 10.1097/aog.0000000000005429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/31/2023] [Indexed: 11/04/2023]
Abstract
Preeclampsia is associated with significant perinatal morbidity and mortality. Aspirin has been long purported and extensively studied for prevention of preeclampsia. For this reason, the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine recommend its use in pregnancy for preeclampsia prevention in those at high risk. Yet, much controversy exists regarding optimal use in pregnancy with guidelines across global organizations varying. In this narrative review, we summarize the published literature related to the safety, optimal dose, and timing and duration of use of aspirin, as well as other indications for which aspirin has been studied in pregnancy.
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Affiliation(s)
- Maura Jones Pullins
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and the Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, Utah
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Ayyash M, Goyert G, Pitts D, Khangura R, Garcia R, Jacobsen G, Shaman M. Provider adherence to aspirin prophylaxis prescription guidelines for preeclampsia. Pregnancy Hypertens 2023; 34:1-4. [PMID: 37696232 DOI: 10.1016/j.preghy.2023.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/02/2023] [Accepted: 09/05/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To evaluate provider adherence to aspirin prophylaxis prescription guidelines for patients at risk. STUDY DESIGN A retrospective chart review was performed at Henry Ford Health (HFH) between October 2015 and December 2020. In October 2015, low-dose aspirin was recommended for women who met high risk criteria for preeclampsia at HFH; in February 2019, aspirin recommendation expanded to include women who met either moderate or high-risk criteria. A total of 46,016 pregnancies occurred between Oct 2015 and Dec 2020 of which 15,167 (33.0%) met high and moderate risk criteria. RESULTS From the population at risk, 1,255 (8.3%) had a history of preeclampsia, 2,534 (16.7%) had a history of chronic hypertension, 1,418 (9.3%) had a history of diabetes, 7,470 (49.3%) were nulliparous, 4,038 (26.6%) were 35 years of age or older, 6,395 (42.2%) had a body mass index greater than 30 kg/m2, and 8,174 (54.5%) were African Americans. Only 630 out of 3,584 (17.6%) of women meeting the high-risk criteria for preeclampsia between Oct 2015 and Jan 2019 received low-dose aspirin and only 891 out of 5,874 (15.2%) of women meeting the high or moderate risk criteria for preeclampsia between Feb 2019 and Dec 2020 received low-dose aspirin prophylaxis. CONCLUSION Adherence to aspirin prophylaxis guidelines was low. Most urban healthcare systems serve diverse, high-risk populations with multiple comorbidities rendering many women at risk for preeclampsia. Educational efforts to improve provider knowledge regarding this important preventative measure are indicated. Recommendation for implementing universal aspirin in such high-risk populations should also be considered.
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Affiliation(s)
- Mariam Ayyash
- Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States.
| | - Gregory Goyert
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
| | - D'Angela Pitts
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
| | - Raminder Khangura
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
| | - Robyn Garcia
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
| | - Gordon Jacobsen
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, United States
| | - Majid Shaman
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
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Horgan R, Hage Diab Y, Waller J, Abuhamad A, Saade G. Low-dose aspirin therapy for the prevention of preeclampsia: time to reconsider our recommendations? Am J Obstet Gynecol 2023; 229:410-418. [PMID: 37120049 DOI: 10.1016/j.ajog.2023.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
The American College of Obstetricians and Gynecologists recommends initiation of 81 mg of aspirin daily for women at risk of preeclampsia between 12 and 28 weeks' gestation, optimally before 16 weeks, with continuation until delivery. The World Health Organization recommends that 75 mg of aspirin should be initiated before 20 weeks of gestation for women at high risk of preeclampsia. Both the Royal College of Obstetricians and Gynaecologists and the National Institute of Health and Care Excellence quality statement on "Antenatal Assessment of Pre-eclampsia Risk" request that healthcare providers prescribe low-dose aspirin to pregnant women at increased risk of preeclampsia daily from 12 weeks of gestation. The Royal College of Obstetricians and Gynaecologists recommends 150 mg of aspirin daily, and the National Institute of Health and Care Excellence guidelines suggest risk stratification with a dosage of 75 mg for those at moderate risk of preeclampsia and 150 mg for those at high risk of preeclampsia. The International Federation of Gynecology and Obstetrics initiative on preeclampsia recommends 150 mg of aspirin to be initiated at 11 to 14+6 week's gestation and also proposes that 2 tablets of 81 mg is an acceptable alternative. Review of the available evidence suggests that both the dosage and timing of aspirin initiation is key to its effectiveness at reducing the risk of preeclampsia. Doses of >100 mg of aspirin daily initiated before 16 weeks' gestation seem to be most effective at reducing the risk of preeclampsia and thus dosages recommended by most major societies and organizations may not be effective. Randomized control trials examining 81 mg vs 162 mg of aspirin daily for the prevention of preeclampsia are required to assess the safety and efficacy of aspirin dosages available in the United States.
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Affiliation(s)
- Rebecca Horgan
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA.
| | - Yara Hage Diab
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Jerri Waller
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Alfred Abuhamad
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - George Saade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX
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White KJ, Son M, Lundsberg LS, Culhane JF, Partridge C, Reddy UM, Merriam AA. Low-Dose Aspirin during Pregnancy and Postpartum Bleeding. Am J Perinatol 2023; 40:1390-1397. [PMID: 37211010 DOI: 10.1055/a-2096-5199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE This study aimed to investigate whether aspirin 81 mg daily for preeclampsia prevention is associated with increased risk of postpartum blood loss at the time of delivery. STUDY DESIGN This is a retrospective cohort study performed at a tertiary hospital from January 2018 to April 2021. Data were extracted from the electronic medical record. Patients prescribed low-dose aspirin (LDA) were compared with patients who were not. The primary outcome was a composite of postpartum blood loss, defined as: estimated blood loss (EBL) >1,000 mL, documentation of International Classification of Diseases-9/-10 codes for postpartum hemorrhage (PPH), or red blood cell (RBC) transfusion. Bivariate analysis, and unadjusted and adjusted logistic regression modeling were performed. RESULTS Among 16,980 deliveries, 1,922 (11.3%) were prescribed LDA. Patients prescribed LDA were more likely to be >35 years old, nulliparous, obese, taking other anticoagulants, or have diagnoses of diabetes, systemic lupus erythematosus, fibroids, or hypertensive disease of pregnancy. After adjusting for potential confounders, the significant association between LDA use and the composite did not persist (adjusted odds ratio [aOR]: 1.1, 95% confidence interval [CI]: 1.0-1.3) nor did the association between EBL > 1,000 mL (aOR: 1.0, 95% CI: 0.9-1.3) and RBC transfusion (aOR: 1.3, 95% CI: 0.9-1.7). The association between LDA and PPH remained significant (aOR: 1.3, 95% CI: 1.1-1.6). Patients who discontinued LDA <7 days prior to delivery had an increased risk of the postpartum blood loss composite compared discontinuation ≥7 days (15.0 vs. 9.3%; p = 0.03). CONCLUSION There may be an association between LDA use and increased risk of postpartum bleeding. This suggests that use of LDA outside the recommended guidelines should be cautioned and further investigation is needed to determine its ideal dosing and timing of discontinuation. KEY POINTS · There may be an association with LDA and an increased risk of postpartum bleeding.. · Patients who discontinued LDA less than 7 days prior to delivery had an increased rate of postpartum bleeding.. · Additional research is need to determine optimal LDA dose and timing of discontinuation..
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Affiliation(s)
- Kelsey J White
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Moeun Son
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer F Culhane
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Caitlin Partridge
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Audrey A Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
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Cardoso MIMP, Rezende KBDC, Da Matta FG, Saunders C, Cardoso FFO, Costa Junior IB, Gama LB, Amim J, Bornia RG. The prevalence and perinatal repercussions of preeclampsia after the implementation of a prophylaxis protocol with aspirin. Pregnancy Hypertens 2023; 33:17-21. [PMID: 37327650 DOI: 10.1016/j.preghy.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 06/01/2023] [Accepted: 06/09/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES To evaluate the prevalence and perinatal repercussions of preeclampsia (PE) after the implementation of a prophylaxis protocol with aspirin in singleton pregnancy at Maternity School of Federal University of Rio de Janeiro, Rio de Janeiro, Brazil (2015-2106). METHODOLOGY PE prevalence according to gestational age (GA) and the prevalence ratio (PR) between PE and prematurity, small for gestational age (SGA), and fetal death were calculated in patients assisted during 2015 and 2016. RESULTS PE occurred in 373(10.75%) of 3468 investigated cases, where PE < 37 weeks was of 2.79% and PE greater than 37 weeks was of 7.95%. A total of 413 (11.9%) prematurity cases, 320 SGA (9.22%), and 50 fetal deaths (1.44%) occurred. In the PE group, 97 premature newborns (PR 0.90) and 51 SGA (PR 1.16) were born, and two fetal deaths occurred (PR 7.46). Concerning PE < 37 weeks, 27 SGA cases (PR 1.42) and two fetal deaths (PR 2.62) were observed. Regarding PE greater than 37 weeks, 24 SGA (PR 1.09) were born, and no fetal deaths were observed. Our findings were compared to previously published results. CONCLUSIONS PE was significantly associated with SGA newborns, especially premature PE. Prescribing aspirin for PE prophylaxis based only on clinical risk factors in a real-life scenario does not appear to be effective but resulted in a PE screening and prophylaxis protocol review and update at ME/UFRJ.
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Affiliation(s)
- Maria Isabel M P Cardoso
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Professional Master Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Karina B de C Rezende
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Clinical Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Fabio G Da Matta
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Professional Master Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Pedro Ernesto University Hospital, Rio de Janeiro State University, Brazil
| | - Cláudia Saunders
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Professional Master Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fernanda F O Cardoso
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Pedro Ernesto University Hospital, Rio de Janeiro State University, Brazil
| | - Ivo B Costa Junior
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luiza B Gama
- Professional Master Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Joffre Amim
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Professional Master Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rita G Bornia
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Professional Master Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Tousty P, Fraszczyk-Tousty M, Dzidek S, Jasiak-Jóźwik H, Michalczyk K, Kwiatkowska E, Cymbaluk-Płoska A, Torbé A, Kwiatkowski S. Low-Dose Aspirin after ASPRE-More Questions Than Answers? Current International Approach after PE Screening in the First Trimester. Biomedicines 2023; 11:1495. [PMID: 37371598 DOI: 10.3390/biomedicines11061495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
Preeclampsia (PE) is a multi-factorial disorder of pregnancy, and it continues to be one of the leading causes of fetal and maternal morbidity and mortality worldwide. Aspirin is universally recommended for high-risk women to reduce preeclampsia risk. The purpose of this review is to summarize the recommendations of various scientific societies on predicting preeclampsia and their indications for the inclusion of acetylsalicylic acid (ASA) prophylaxis. Fourteen guidelines were compared. The recommended dose, screening method, and gestational age at the start of the test vary depending on the recommendation. The societies are inclined to recommend using increasingly higher doses (>75 mg) of ASA, with many encouraging doses from 100 mg upward. Most societies indicate that the optimal time for implementing aspirin is prior to 16 weeks' gestation. Following the publication of the Aspirin for Evidence-Based Preeclampsia Prevention (ASPRE) trial results and other papers evaluating the Fetal Medicine Foundation (FMF) screening model, a large number of societies have changed their recommendations from those based on risk factors alone to the ones based on the risk assessment proposed by the FMF. This allows for the detection of a high-risk pregnancy population in whom aspirin will be remarkably effective in preventing preterm PE, thereby decreasing maternal and fetal morbidity.
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Affiliation(s)
- Piotr Tousty
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Magda Fraszczyk-Tousty
- Department of Neonatology and Neonatal Intensive Care, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Sylwia Dzidek
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Hanna Jasiak-Jóźwik
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Kaja Michalczyk
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Ewa Kwiatkowska
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Aneta Cymbaluk-Płoska
- Department of Reconstructive Surgery and Gynecological Oncology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Andrzej Torbé
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Sebastian Kwiatkowski
- Department of Gynecology and Obstetrics, Pomeranian Medical University, 70-111 Szczecin, Poland
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Balint O, Secosan C, Pirtea L. Assessment of CA-125 First-Trimester Values as a Potential Screening Marker for Pre-Eclampsia. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050891. [PMID: 37241123 DOI: 10.3390/medicina59050891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/19/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
Background: Pre-eclampsia is a major public health issue. Current screening methods are based on maternal characteristics and medical history, but complex predictive models combining different clinical and biochemical markers have been proposed. However, although their accuracy is high, the implementation of these models in clinical practice is not always feasible, especially in low- and middle-resource settings. CA-125 is a tumoral marker, accessible and cheap, with proven potential as a severity marker in the third trimester of pregnancy in pre-eclamptic women. Assessment of its use as a first-trimester marker is necessary. Methods: This observational study involved fifty pregnant women between 11 and 14 weeks of pregnancy. Clinical and biochemical markers (PAPP-A), known for their value in pre-eclampsia screening, were recorded for every patient as well as first-trimester value of CA-125 and third-trimester data regarding blood pressure and pregnancy outcome. Results: No statistical correlation between CA-125 and first-trimester markers was observed except with PAPP-A, with which it exhibited a positive correlation. Additionally, no correlation was made between it and third-trimester blood pressure or pregnancy outcomes. Conclusions: CA-125 first-trimester values do not represent a valuable marker for pre-eclampsia screening. Further research on identifying an accessible and cheap marker to improve pre-eclampsia screening in low- and middle-income settings is needed.
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Affiliation(s)
- Oana Balint
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy "Victor Babes", 300041 Timișoara, Romania
| | - Cristina Secosan
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy "Victor Babes", 300041 Timișoara, Romania
| | - Laurentiu Pirtea
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy "Victor Babes", 300041 Timișoara, Romania
- Emergency Clinical City Hospital Timișoara, Obstetrics-Gynecology Clinic, 300231 Timișoara, Romania
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Li W, Kim CS, Howell EA, Janevic T, Liu B, Shi L, Li Y. Economic Evaluation of Prenatal and Postpartum Care in Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:2062-2080. [PMID: 35989155 PMCID: PMC9669139 DOI: 10.1016/j.jval.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES This study aimed to summarize evidence on the economic outcomes of prenatal and postpartum interventions for the management of gestational diabetes mellitus and hypertensive disorders of pregnancy (HDP), assess the quality of each study, and identify research gaps that may inform future research. METHODS Electronic databases including PubMed/MEDLINE, Embase, the Cochrane Library, and Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to October 1, 2021. Selected studies were included in narrative synthesis and extracted data were presented in narrative and tabular forms. The quality of each study was assessed using the Consolidated Health Economic Evaluation Reporting Standards and Consensus on Health Economic Criteria list. RESULTS Among the 22 studies identified through the systematic review, 19 reported favorable cost-effectiveness of the intervention. For prenatal management of HDP, home blood pressure monitoring was found to be cost-effective compared with in-person visits in improving maternal and neonatal outcomes. For postpartum care, regular screening for hypertension or metabolic syndrome followed by subsequent treatment was found to be cost-effective compared with no screening in women with a history of gestational diabetes mellitus or HDP. CONCLUSIONS Existing economic evaluation studies showed that prenatal home blood pressure monitoring and postpartum screening for hypertension or metabolic syndrome were cost-effective. Nevertheless, limitations in the approach of the current economic evaluations may dampen the quality of the evidence and warrant further investigation.
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Affiliation(s)
- Weixin Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; The Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chi-Son Kim
- Department of Obstetrics and Gynecology, Stamford Hospital, Stamford, CT, USA
| | - Elizabeth A Howell
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Teresa Janevic
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Blavatnik Family Women's Health Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lizheng Shi
- Department of Global Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Yan Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Blavatnik Family Women's Health Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Louis JM, Parchem J, Vaught A, Tesfalul M, Kendle A, Tsigas E. Preeclampsia: a report and recommendations of the workshop of the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2022.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Diguisto C, Le Gouge A, Marchand MS, Megier P, Ville Y, Haddad G, Winer N, Arthuis C, Doret M, Debarge VH, Flandrin A, Delmas HL, Gallot D, Mares P, Vayssiere C, Sentilhes L, Cheve MT, Paumier A, Durin L, Schaub B, Equy V, Giraudeau B, Perrotin F. Low-dose aspirin to prevent preeclampsia and growth restriction in nulliparous women identified by uterine artery Doppler as at high risk of preeclampsia: A double blinded randomized placebo-controlled trial. PLoS One 2022; 17:e0275129. [PMID: 36260615 PMCID: PMC9581352 DOI: 10.1371/journal.pone.0275129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/08/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This trial evaluates whether daily low-dose aspirin initiated before 16 weeks of gestation can reduce preeclampsia and fetal growth restriction in nulliparous women identified by first-trimester uterine artery Dopplers as at high risk of preeclampsia. METHODS This randomized, blinded, placebo-controlled, parallel-group trial took place in 17 French obstetric departments providing antenatal care. Pregnant nulliparous women aged ≥ 18 years with a singleton pregnancy at a gestational age < 16 weeks of gestation with a lowest pulsatility index ≥ 1.7 or a bilateral protodiastolic notching for both uterine arteries on an ultrasound performed between 11+0 and 13+6 weeks by a certified sonographer were randomized at a 1:1 ratio to 160 mg of low-dose aspirin or to placebo to be taken daily from inclusion to their 34th week of gestation. The main outcome was preeclampsia or a birthweight ≤ 5th percentile. Other outcomes included preeclampsia, severe preeclampsia, preterm preeclampsia, preterm delivery before 34 weeks, mode of delivery, type of anesthesia, birthweight ≤ 5th percentile and perinatal death. RESULTS The trial was interrupted due to recruiting difficulties. Between June 2012 and June 2016, 1104 women were randomized, two withdrew consent, and two had terminations of pregnancies. Preeclampsia or a birthweight ≤ 5th percentile occurred in 88 (16.0%) women in the low-dose aspirin group and in 79 (14.4%) in the placebo group (proportion difference 1.6 [-2.6; 5.9] p = 0.45). The two groups did not differ significantly for the secondary outcomes. CONCLUSION Low-dose aspirin was not associated with a lower rate of either preeclampsia or birthweight ≤ 5th percentile in women identified by their first-trimester uterine artery Doppler as at high risk of preeclampsia. TRIAL REGISTRATION (NCT0172946).
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Affiliation(s)
- Caroline Diguisto
- Pôle de Gynécologie Obstétrique, Médecine Fœtale, Médecine et Biologie de la Reproduction, Centre Olympe de Gouges, CHRU de Tours, Tours, France
- Université de Tours, Tours, France
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE,F, Paris, France
| | | | | | - Pascal Megier
- Department of Gynaecology and Obstetrics, Centre Hospitalier Régional d’Orléans, Orleans, France
| | - Yves Ville
- Centre de Dépistage PRIMA FACIE Université de Paris, Paris, France
- Maternité, AP-HP, Hôpital Necker, Paris, France
| | - Georges Haddad
- Cabinet Mosaïque Santé, La Chaussée Saint Victor, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology, University Hospital of Nantes, Nantes, NUN, INRAE, UMR 1280, PhAN, Université de Nantes, Nantes, France
| | - Chloé Arthuis
- Department of Obstetrics and Gynecology, University Hospital of Nantes, Nantes, NUN, INRAE, UMR 1280, PhAN, Université de Nantes, Nantes, France
| | - Muriel Doret
- Service de Gynécologie-Obstétrique, HFME, Hospices Civils de Lyon, Lyon, France
| | - Veronique Houfflin Debarge
- Department of Obstetrics, CHU Lille, Univ. Lille, ULR 2694—METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Anaig Flandrin
- Service de Gynécologie-Obstétrique, Hôpital Arnaud de Villeneuve, CHRU de Montpellier, Montpellier, France
| | - Hélène Laurichesse Delmas
- Service de Gynécologie-Obstétrique, Hôpital d’Estaing, CHU de Clermont-Ferrand, Maternité Clermont Ferrand, Clermont-Ferrand, France
| | - Denis Gallot
- Service de Gynécologie-Obstétrique, Hôpital d’Estaing, CHU de Clermont-Ferrand, Maternité Clermont Ferrand, Clermont-Ferrand, France
| | - Pierre Mares
- Département de Gynécologie Obstétrique, Centre Hospitalo-Universitaire Caremeau, Nîmes, France
- École de Maïeutique, Université de Montpellier, Site de Nîmes, Nîmes, France
| | - Christophe Vayssiere
- Department of Obstetrics and Gynaecology, Paule de Viguier Hospital, Toulouse University Hospital Center, Toulouse, France
- Centre for Epidemiology and Population Health Research, Team SPHERE, Toulouse III University, Toulouse, France
| | - Loïc Sentilhes
- Service de Gynécologie-Obstétrique, Groupe Hospitalier Pellegrin, CHRU de Bordeaux, Talence, France
| | | | - Anne Paumier
- Service de Gynécologie-Obstétrique, Polyclinique de l’Atlantique, Saint-Herblain, France
| | - Luc Durin
- Service de Gynécologie-Obstétrique, Polyclinique du Parc, Caen, France
| | - Bruno Schaub
- Service de Gynécologie-Obstétrique, Maison de la Femme, de la Mère et de l’Enfant, CHU Martinique, Fort-de-France, Martinique, France
| | - Veronique Equy
- Service de Gynécologie-Obstétrique, Hôpital Couple Enfant, CHRU de Grenoble, La Tronche, France
| | - Bruno Giraudeau
- Université de Tours, Tours, France
- INSERM CIC1415, CHRU de Tours, Tours, France
| | - Franck Perrotin
- Pôle de Gynécologie Obstétrique, Médecine Fœtale, Médecine et Biologie de la Reproduction, Centre Olympe de Gouges, CHRU de Tours, Tours, France
- Université de Tours, Tours, France
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Standardizing Screening for Preeclampsia Risk Factors to Improve Prescribing of Low-Dose Aspirin. J Healthc Qual 2022; 44:324-330. [PMID: 36041069 DOI: 10.1097/jhq.0000000000000362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Preeclampsia is a serious health condition and leading cause of perinatal and neonatal morbidity and mortality. Research supports the use of low-dose aspirin therapy to prevent preeclampsia in high-risk pregnant people. This quality improvement project outlines the implementation of a preeclampsia risk screen in the electronic health record to ensure standardized screening for, and provision of, low-dose aspirin therapy consistent with professional guidelines. Two thousand three hundred seventy-one patients were seen between March and November 2020 at 13 OB/GYN and family practice offices at a large health system in our state. Provider screening and prescribing rates were evaluated at the first prenatal visit, and at 3-month intervals using an analytics dashboard built in the EHR. In the first 3 months after rollout visits at all offices in our system (March to May 2020), the average screening rate during first prenatal visits at all offices was 74.2% (n = 561), 41% (n = 230) had a positive screen, and 81.3% (n = 187) of those who screened high risk were prescribed aspirin as recommended. At 9 months after rollout, the screening rate during first prenatal visits at all offices improved to 95.6% (n = 782), 39.6% (n = 310) of those screened, screened positive, and 97.1% (n = 301) were prescribed low-dose aspirin therapy appropriately.
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Mewes JC, Lindenberg M, Vrijhoef HJM. Cost-effectiveness analysis of implementing screening on preterm pre-eclampsia at first trimester of pregnancy in Germany and Switzerland. PLoS One 2022; 17:e0270490. [PMID: 35763507 PMCID: PMC9239465 DOI: 10.1371/journal.pone.0270490] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 06/10/2022] [Indexed: 11/19/2022] Open
Abstract
Objective
To assess the cost-effectiveness of preterm preeclampsia (PE) screening versus routine screening based on maternal characteristics in Germany and Switzerland.
Methods
A health economic model was used to analyse the cost-effectiveness of PE screening versus routine screening based on maternal characteristics. The analysis was conducted from the healthcare perspective with a time horizon of one year from the start of pregnancy. The main outcome measures were incremental health care costs and incremental costs per PE case averted.
Results
The incremental health care costs for PE screening versus routine screening per woman were €14 in Germany, and -CHF42 in Switzerland, the latter representing cost savings. In Germany, the incremental costs per PE case averted were €3,795. In Switzerland, PE screening was dominant. The most influential parameter in the one-way sensitivity analysis was the cost of PE screening (Germany) and the probability of preterm PE in routine screening (Switzerland). In Germany, at a willingness-to-pay for one PE case avoided of €4,200, PE screening had a probability of more than 50% of being cost-effective compared to routine screening. In Switzerland, at a willingness-to-pay of CHF0, PE screening had a 78% probability of being the most cost-effective screening strategy.
Conclusion
For Switzerland, PE screening is expected to be cost saving in comparison to routine screening. For Germany, the additional health care costs per woman were expected to be €14. Future cost-effectiveness studies should be conducted with a longer time horizon.
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Affiliation(s)
| | | | - Hubertus J. M. Vrijhoef
- Panaxea b.v., Amsterdam, North Holland, The Netherlands
- Maastricht University Medical Center, Limburg, The Netherlands
- * E-mail:
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Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, von Dadelszen P, Helewa M, Rey E. Directive clinique n o 426 : Troubles hypertensifs de la grossesse : Diagnostic, prédiction, prévention et prise en charge. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:572-597.e1. [PMID: 35577427 DOI: 10.1016/j.jogc.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIF La présente directive a été élaborée par des fournisseurs de soins de maternité en obstétrique et en médecine interne. Elle aborde le diagnostic, l'évaluation et la prise en charge des troubles hypertensifs de la grossesse, la prédiction et la prévention de la prééclampsie ainsi que les soins post-partum des femmes avec antécédent de trouble hypertensif de la grossesse. POPULATION CIBLE Femmes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en œuvre des recommandations de la présente directive devrait réduire l'incidence des troubles hypertensifs de la grossesse, en particulier la prééclampsie, et des issues défavorables associées. DONNéES PROBANTES: La revue exhaustive de la littérature a été mise à jour en tenant compte des nouvelles données probantes jusqu'en décembre 2020 et en suivant la même méthodologie que pour la précédente directive de la Société des obstétriciens et gynécologues du Canada (SOGC) sur les troubles hypertensifs de la grossesse. La recherche s'est limitée aux articles publiés en anglais ou en français. Les recommandations relatives aux traitements s'appuient d'abord sur les essais cliniques randomisés et les revues systématiques (lorsque disponibles), ainsi que sur l'évaluation des résultats cliniques substantiels chez les mères et les bébés. MéTHODES DE VALIDATION: Les auteurs se sont entendus sur le contenu et les recommandations par consensus et ont répondu à l'examen par les pairs du comité de médecine fœto-maternelle de la SOGC. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE) et se sont gardé l'option de désigner certaines recommandations par la mention « bonne pratique ». Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. PROFESSIONNELS CIBLES Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières et anesthésistes) qui prodiguent des soins aux femmes avant, pendant ou après la grossesse. RECOMMANDATIONS
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Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, von Dadelszen P, Helewa M, Rey E. Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:547-571.e1. [PMID: 35577426 DOI: 10.1016/j.jogc.2022.03.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP. TARGET POPULATION Pregnant women. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes. EVIDENCE A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies. VALIDATION METHODS The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication. INTENDED USERS All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy. RECOMMENDATIONS
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Zakiyah N, Tuytten R, Baker PN, Kenny LC, Postma MJ, van Asselt ADI. Early cost-effectiveness analysis of screening for preeclampsia in nulliparous women: A modelling approach in European high-income settings. PLoS One 2022; 17:e0267313. [PMID: 35446907 PMCID: PMC9022877 DOI: 10.1371/journal.pone.0267313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background Preeclampsia causes substantial maternal and perinatal morbidity and mortality and significant societal economic impact. Effective screening would facilitate timely and appropriate prevention and management of preeclampsia. Objectives To develop an early cost-effectiveness analysis to assess both costs and health outcomes of a new screening test for preeclampsia from a healthcare payer perspective, in the United Kingdom (UK), Ireland, the Netherlands and Sweden. Methods A decision tree over a 9-month time horizon was developed to explore the cost-effectiveness of the new screening test for preeclampsia compared to the current screening strategy. The new test strategy is being developed so that it can stratify healthy low risk nulliparous women early in pregnancy to either a high-risk group with a risk of 1 in 6 or more of developing preeclampsia, or a low-risk group with a risk of 1 in 100 or less. The model simulated 25 plausible scenarios in a hypothetical cohort of 100,000 pregnant women, in which the sensitivity and specificity of the new test were varied to set a benchmark for the minimum test performance that is needed for the test to become cost-effective. The input parameters and costs were mainly derived from published literature. The main outcome was incremental costs per preeclampsia case averted, expressed as an incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty. Results Base case results showed that the new test strategy would be more effective and less costly compared to the current situation in the UK. In the Netherlands, the majority of scenarios would be cost-effective from a threshold of €50,000 per preeclampsia case averted, while in Ireland and Sweden, the vast majority of scenarios would be considered cost-effective only when a threshold of €100,000 was used. In the best case analyses, ICERs were more favourable in all four participating countries. Aspirin effectiveness, prevalence of preeclampsia, accuracy of the new screening test and cost of regular antenatal care were identified as driving factors for the cost-effectiveness of screening for preeclampsia. Conclusion The results indicate that the new screening test for preeclampsia has potential to be cost-effective. Further studies based on proven accuracy of the test will confirm whether the new screening test is a cost-effective additional option to the current situation.
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Affiliation(s)
- Neily Zakiyah
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- * E-mail:
| | - Robin Tuytten
- Research & Development, Metabolomic Diagnostics, Little Island, Ireland
| | - Philip N. Baker
- College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Louise C. Kenny
- Department of Women’s and Children’s Health, the Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Maarten J. Postma
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- Unit of Global Health, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Antoinette D. I. van Asselt
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Unit of Global Health, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Effectiveness of Different Algorithms and Cut-off Value in Preeclampsia First Trimester Screening. J Pregnancy 2022; 2022:6414857. [PMID: 35433048 PMCID: PMC9012645 DOI: 10.1155/2022/6414857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 11/17/2022] Open
Abstract
Results For the cut-off point >1 : 150, 86 women at an increased risk of eo-PE using algorithm 1 were identified. Of these 86 patients, 83 (96%) were identified using algorithm 2, 62 (72%) using algorithm 3, and 60 (69%) using algorithm 4. In addition, it was demonstrated that between 21% and 29% of women at a low risk of eo-PE could be given acetylsalicylic acid if a screening test was used that did not account for PlGF. Conclusions In order to provide the highest level of health care to pregnant women, it is extremely important that full screening for eo-PE should be ensured. The cheapest algorithm based only on MAP and UtPI resulted in our patients being unnecessarily exposed to complications.
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Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, Kenny LC, McCarthy F, Myers J, Poon LC, Rana S, Saito S, Staff AC, Tsigas E, von Dadelszen P. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2022; 27:148-169. [DOI: 10.1016/j.preghy.2021.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
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Wright D, Wright A, Tan MY, Nicolaides KH. When to give aspirin to prevent preeclampsia: application of Bayesian decision theory. Am J Obstet Gynecol 2022; 226:S1120-S1125. [PMID: 35177216 DOI: 10.1016/j.ajog.2021.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/17/2021] [Accepted: 10/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is good evidence that first-trimester assessment of the risk for preterm preeclampsia and treatment of the high-risk group with aspirin reduces the incidence of preterm preeclampsia. Furthermore, there is evidence that aspirin is associated with an increased risk of maternal and neonatal hemorrhagic complications. Against this background, there are ongoing debates whether aspirin should be recommended for all women or to a subpopulation of women predicted to be at increased risk of developing preeclampsia. Moreover, if a strategy of the prediction and prevention of preterm preeclampsia is to be used, what method should be used for the prediction, and what risk cutoff should be used to decide on who to treat? OBJECTIVE This study aimed to compare the policies of universal treatment, stratified treatment, and no treatment with aspirin. STUDY DESIGN Decisions about aspirin prophylaxis were considered from the perspective of the Bayesian decision theory. Using this approach, the treatment policies were evaluated for risks of preterm preeclampsia, effects of aspirin, and trade-offs between the harms and benefits of the treatment. Evidence on the risk of preterm preeclampsia was taken from the Screening programme for pre-eclampsia study, which was a first-trimester screening study for the prediction of preeclampsia. Evidence of the effect of aspirin was taken from the Aspirin for Evidence-Based Preeclampsia Prevention trial, which was a trial of aspirin vs placebo in the prevention of preterm preeclampsia. The trade-off between the benefits and harms of aspirin was specified by addressing the question, "What is the maximum number of women that should be treated to prevent 1 case of preterm preeclampsia?" The number can be considered as an exchange rate between the harms and benefits of using aspirin to prevent preterm PE. Given the uncertainty about the harms associated with aspirin, the treatment policies were compared across a wide range of exchange rates. RESULTS For exchange rates between 10 and 1000 women treated with aspirin to prevent 1 case of preterm preeclampsia, the net benefit achieved from the risk assessment and targeted treatment of women at high risk of preterm preeclampsia was higher than that from women with no treatment or women with universal treatment with aspirin. CONCLUSION Universal treatment with aspirin should be avoided. Risk-based screening should be used, and the cutoff for taking aspirin should be determined from the consideration of the trade-off between the benefits and harms and detection, false-positive, and screen-positive rates.
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Affiliation(s)
- David Wright
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
| | - Alan Wright
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
| | - Min Yi Tan
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Kypros H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom.
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Toward personalized management of chronic hypertension in pregnancy. Am J Obstet Gynecol 2022; 226:S1196-S1210. [PMID: 32687817 PMCID: PMC7367795 DOI: 10.1016/j.ajog.2020.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/27/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022]
Abstract
Chronic hypertension complicates 1% to 2% of pregnancies, and it is increasingly common. Women with chronic hypertension are an easily recognized group who are in touch with a wide variety of healthcare providers before, during, and after pregnancy, mandating that chronic hypertension in pregnancy be within the scope of many practitioners. We reviewed recent data on management to inform current care and future research. This study is a narrative review of published literature. Compared with normotensive women, women with chronic hypertension are at an increased risk of maternal and perinatal complications. Women with chronic hypertension who wish to be involved in their care can do by measuring blood pressure at home. Accurate devices for home blood pressure monitoring are now readily available. The diagnostic criteria for superimposed preeclampsia remain problematic because most guidelines continue to include deteriorating blood pressure control in the definition. It has not been established how angiogenic markers may aid in confirmation of the diagnosis of superimposed preeclampsia when suspected, over and above information provided by routinely available clinical data and laboratory results. Although chronic hypertension is a strong risk factor for preeclampsia, and aspirin decreases preeclampsia risk, the effectiveness specifically among women with chronic hypertension has been questioned. It is unclear whether calcium has an independent effect in preeclampsia prevention in such women. Treating hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes, but a reduction in preeclampsia or serious maternal complications has not been observed; however, the lack of evidence for the latter is possibly owing to few events. In addition, treating chronic hypertension neither reduces nor increases fetal or newborn death or morbidity, regardless of the gestational age at which the antihypertensive treatment is started. Antihypertensive agents are not teratogenic, but there may be an increase in malformations associated with chronic hypertension itself. At present, blood pressure treatment targets used in clinics are the same as those used at home, although blood pressure values tend to be inconsistently lower at home among women with hypertension. Although starting all women on the same antihypertensive medication is usually effective in reducing blood pressure, it remains unclear whether there is an optimal agent for such an approach or how best to use combinations of antihypertensive medications. An alternative approach is to individualize care, using maternal characteristics and blood pressure features beyond blood pressure level (eg, variability) that are of prognostic value. Outcomes may be improved by timed birth between 38 0/7 and 39 6/7 weeks' gestation based on observational literature; of note, confirmatory trial evidence is pending. Postnatal care is facilitated by the acceptability of most antihypertensives (including angiotensin-converting enzymes inhibitors) for use in breastfeeding. The evidence base to guide the care of pregnant women with chronic hypertension is growing and aligning with international guidelines. Addressing outstanding research questions would inform personalized care of chronic hypertension in pregnancy.
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Pre-eclampsia diagnosis and management. Best Pract Res Clin Anaesthesiol 2022; 36:107-121. [DOI: 10.1016/j.bpa.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
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Rolnik DL, Nicolaides KH, Poon LC. Prevention of preeclampsia with aspirin. Am J Obstet Gynecol 2022; 226:S1108-S1119. [PMID: 32835720 DOI: 10.1016/j.ajog.2020.08.045] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 01/02/2023]
Abstract
Preeclampsia is defined as hypertension arising after 20 weeks of gestational age with proteinuria or other signs of end-organ damage and is an important cause of maternal and perinatal morbidity and mortality, particularly when of early onset. Although a significant amount of research has been dedicated in identifying preventive measures for preeclampsia, the incidence of the condition has been relatively unchanged in the last decades. This could be attributed to the fact that the underlying pathophysiology of preeclampsia is not entirely understood. There is increasing evidence suggesting that suboptimal trophoblastic invasion leads to an imbalance of angiogenic and antiangiogenic proteins, ultimately causing widespread inflammation and endothelial damage, increased platelet aggregation, and thrombotic events with placental infarcts. Aspirin at doses below 300 mg selectively and irreversibly inactivates the cyclooxygenase-1 enzyme, suppressing the production of prostaglandins and thromboxane and inhibiting inflammation and platelet aggregation. Such an effect has led to the hypothesis that aspirin could be useful for preventing preeclampsia. The first possible link between the use of aspirin and the prevention of preeclampsia was suggested by a case report published in 1978, followed by the first randomized controlled trial published in 1985. Since then, numerous randomized trials have been published, reporting the safety of the use of aspirin in pregnancy and the inconsistent effects of aspirin on the rates of preeclampsia. These inconsistencies, however, can be largely explained by a high degree of heterogeneity regarding the selection of trial participants, baseline risk of the included women, dosage of aspirin, gestational age of prophylaxis initiation, and preeclampsia definition. An individual patient data meta-analysis has indicated a modest 10% reduction in preeclampsia rates with the use of aspirin, but later meta-analyses of aggregate data have revealed a dose-response effect of aspirin on preeclampsia rates, which is maximized when the medication is initiated before 16 weeks of gestational age. Recently, the Aspirin for Evidence-Based Preeclampsia Prevention trial has revealed that aspirin at a daily dosage of 150 mg, initiated before 16 weeks of gestational age, and given at night to a high-risk population, identified by a combined first trimester screening test, reduces the incidence of preterm preeclampsia by 62%. A secondary analysis of the Aspirin for Evidence-Based Preeclampsia Prevention trial data also indicated a reduction in the length of stay in the neonatal intensive care unit by 68% compared with placebo, mainly because of a reduction in births before 32 weeks of gestational age with preeclampsia. The beneficial effect of aspirin has been found to be similar in subgroups according to different maternal characteristics, except for the presence of chronic hypertension, where no beneficial effect is evident. In addition, the effect size of aspirin has been found to be more pronounced in women with good compliance to treatment. In general, randomized trials are underpowered to investigate the treatment effect of aspirin on the rates of other placental-associated adverse outcomes such as fetal growth restriction and stillbirth. This article summarizes the evidence around aspirin for the prevention of preeclampsia and its complications.
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Wheeler SM, Myers SO, Swamy GK, Myers ER. Estimated Prevalence of Risk Factors for Preeclampsia Among Individuals Giving Birth in the US in 2019. JAMA Netw Open 2022; 5:e2142343. [PMID: 34982156 PMCID: PMC8728614 DOI: 10.1001/jamanetworkopen.2021.42343] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Low-dose aspirin (LDA) is one of the few evidence-based interventions for preventing preeclampsia, which is a leading cause of maternal or fetal morbidity and mortality. Current guidelines recommend LDA based on the presence of risk factors for preeclampsia, but the population-based prevalence of these factors is unknown. OBJECTIVE To estimate population-level prevalence of preeclampsia risk factors used in prophylactic LDA guidelines for pregnant patients and the association of these risk factors with reported rates of pregnancy-related hypertension. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using National Center for Health Statistics birth certificate data to describe the frequency of pregnant individuals with moderate to high-risk factors for preeclampsia and pregnancy-related hypertension rates. The study used all birth records in the United States for the 2019 calendar year. EXPOSURES Documentation of preeclampsia risk factors: multifetal gestation, pregestational diabetes, chronic hypertension (high-risk factors) and nulliparity, a body mass index greater than 30, African American race, a maternal age 35 years or older, an interval of more than 10-years since last birth, and having low socioeconomic status (moderate risk factors). MAIN OUTCOMES AND MEASURES Prevalence of each risk factor alone and in combinations leading to a recommendation for LDA; incidence of pregnancy-related hypertension by risk factor and combinations of risk factors. RESULTS There were 3 695 019 pregnancies in 2019, including 528 778 with no risk factors, 169 540 with 1 or more high-risk factors, and 2 996 701 with 1 or more moderate-risk factors. The mean (SD) of the cohort was 29.1 (5.8) years. Multifetal gestation was the most common high-risk factor and found in 123 995 pregnancies (3.4%), and low socioeconomic status was the most common moderate-risk factor and present in 1 732 729 pregnancies (46.9%). Based on 2021 criteria (a single high- or moderate-risk factors for preeclampsia), 3 166 241 pregnant patients (85.7%) were eligible for LDA. The incidence of pregnancy-related hypertension increased with the number of moderate-risk factors. The 2021 guidelines suggest considering or recommend LDA in 92.3% of pregnancies diagnosed with pregnancy-related hypertension. CONCLUSIONS AND RELEVANCE These data support the recently published guidelines and suggest further simplified guidelines recommending LDA to patients with any single moderate-risk factors.
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Affiliation(s)
- Sarahn M. Wheeler
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | | | - Geeta K. Swamy
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Evan R. Myers
- Division of Women’s Community and Population Health, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina
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Florio KL, Grodzinsky A. Cardiovascular Indexes in the Era of Preeclampsia: Prevention or Long-Term Outcome Prediction? J Am Coll Cardiol 2022; 79:63-65. [PMID: 34991790 DOI: 10.1016/j.jacc.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Karen L Florio
- Saint Luke's Hospital of Kansas City, Women's and Children's Division, Kansas City, Missouri, USA; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA.
| | - Anna Grodzinsky
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA; Mid-America Heart Institute of Saint Luke's Hospital, Kansas City, Missouri, USA
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Combs CA, Zhou MK, Pandipati S, Rosario MAD. Prevalence of Preeclampsia Risk Factors: Implications for Low-Dose Aspirin Prophylaxis. Am J Obstet Gynecol MFM 2021; 4:100547. [PMID: 34871780 DOI: 10.1016/j.ajogmf.2021.100547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/30/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Affiliation(s)
- C Andrew Combs
- Obstetrix Medical Group, Campbell, California; The Mednax Center for Research, Education, Quality, and Safety, Sunrise, Florida.
| | | | | | - Ms Amber Del Rosario
- Obstetrix Medical Group, Campbell, California; University of California Santa Cruz, Santa Cruz, California
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Park F, Deeming S, Bennett N, Hyett J. Cost-effectiveness analysis of a model of first-trimester prediction and prevention of preterm pre-eclampsia compared with usual care. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:688-697. [PMID: 32851709 DOI: 10.1002/uog.22193] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/09/2020] [Accepted: 08/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Pre-eclampsia (PE) causes substantial maternal and neonatal mortality and morbidity. In addition to the personal impact on women, children and their families, PE has a significant economic impact on our society. Recent research suggests that a first-trimester multivariate model is highly predictive of preterm (< 37 weeks' gestation) PE and can be combined successfully with targeted prophylaxis (low-dose aspirin), resulting in an 80% reduction in prevalence of disease. The aim of this study was to examine the potential health outcomes and cost implications following introduction of first-trimester prediction and prevention of preterm PE within a public healthcare setting, compared with usual care, and to conduct a cost-effectiveness analysis to inform health-service decisions regarding implementation of such a program. METHODS A decision-analytic model was used to compare usual care with the proposed first-trimester screening intervention within the obstetric population (n = 6822) attending two public hospitals within a metropolitan district health service in New South Wales, Australia, between January 2015 and December 2016. The model, applied from early pregnancy, included exposure to a variety of healthcare professionals and addressed type of risk assessment (usual care or first-trimester screening) and use of (compliance with) low-dose aspirin prescribed prophylactically for prevention of PE. All pathways culminated in six possible health outcomes, ranging from no PE to maternal death. Results were presented as the number of cases of PE gained/avoided and the incremental increase/decrease in economic costs arising from the intervention compared with usual care. Significant assumptions were tested in sensitivity/uncertainty analyses. RESULTS The intervention produced, across all gestational ages, 31 fewer cases of PE and reduced aggregate economic health-service costs by 1 431 186 Australian dollars over the 2-year period. None of the tested iterations of uncertainty analyses reported additional cases of PE or higher economic costs. The new intervention based on first-trimester screening dominated usual care. CONCLUSION This cost-effectiveness analysis demonstrated a reduction in prevalence of preterm PE and substantial cost savings associated with a population-based program of first-trimester prediction and prevention of PE, and supports implementation of such a policy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F Park
- Department of Maternal Fetal Medicine, John Hunter Hospital, Newcastle, Australia
| | - S Deeming
- Health Research Economics, Hunter Medical Research Institute, Newcastle, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
| | - N Bennett
- Department of Maternal Fetal Medicine, John Hunter Hospital, Newcastle, Australia
| | - J Hyett
- Sydney Institute for Women, Children and their Families, Royal Prince Alfred Hospital, Sydney, Australia
- Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine, University of Sydney, Sydney, Australia
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Hu J, Gao J, Liu J, Meng H, Hao N, Song Y, Ma L, Luo W, Sun J, Gao W, Meng W, Sun Y. Prospective evaluation of first-trimester screening strategy for preterm pre-eclampsia and its clinical applicability in China. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:529-539. [PMID: 33817865 DOI: 10.1002/uog.23645] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/05/2021] [Accepted: 03/25/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To evaluate, in a Chinese population, the performance of a screening strategy for preterm pre-eclampsia (PE) using The Fetal Medicine Foundation (FMF)'s competing-risks model and to explore its clinical applicability in mainland China. METHODS This was a prospective, multicenter, observational cohort study including 10 899 women with singleton pregnancy who sought prenatal care at one of 13 hospitals, located in seven cities in mainland China, between 1 December 2017 and 30 December 2019. Mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and maternal serum levels of placental growth factor (PlGF) and pregnancy-associated plasma protein-A (PAPP-A) at 11 + 0 to 13 + 6 weeks' gestation were measured and converted into multiples of the median using Chinese reference ranges. Individualized risk for preterm PE was calculated using the FMF algorithm. Prior risk was calculated based on maternal demographic characteristics and obstetric history. We evaluated the efficiency of the screening strategy using various combinations of biomarkers and analyzed its predictive performance for a composite of placenta-associated adverse pregnancy outcomes, including PE, placental abruption, small-for-gestational age (SGA) and preterm birth, at fixed false-positive rates for preterm PE. RESULTS We identified 312 pregnancies that developed PE, of which 117 cases were diagnosed as preterm PE (< 37 weeks' gestation). There were 386 pregnancies complicated by severe composite placenta-associated adverse outcome, including preterm PE, 146 cases of severe SGA (birth weight < 3rd percentile) neonate, 61 cases with placental abruption and 109 cases of early preterm birth < 34 gestational weeks. The triple-marker model containing biomarkers MAP, UtA-PI and PAPP-A achieved, at fixed false-positive rates of 10%, 15% and 20%, detection rates for preterm PE of 65.0%, 72.7% and 76.1%, respectively, and detection rates for severe composite placenta-associated adverse outcome of 34.7%, 41.7% and 46.4%, respectively. Replacing PAPP-A with PlGF or adding PlGF to the model did not improve the performance. Of women screening positive for preterm PE at a fixed 5% false-positive rate, an estimated 30% developed at least one placenta-associated adverse pregnancy outcome, including PE, placental abruption, SGA (birth weight < 10th percentile) and preterm birth < 37 weeks. CONCLUSIONS The FMF competing-risks model for preterm PE was found to be effective in screening a mainland Chinese population. Women who screened positive for preterm PE had increased risk for other placenta-associated pregnancy complications. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Hu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - J Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - J Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - H Meng
- Department of Ultrasonic Diagnosis, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - N Hao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Y Song
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - L Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - W Luo
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - J Sun
- Department of Obstetrics and Gynecology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - W Gao
- Department of Obstetrics and Gynecology, Beijing Daxing People's Hospital, Beijing, China
| | - W Meng
- Department of Obstetrics and Gynecology, Tongzhou Maternal and Child Health Hospital of Beijing, Beijing, China
| | - Y Sun
- Department of Obstetrics and Gynecology, Beijing Shunyi District Maternal and Child Health Hospital, Beijing, China
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Poon LC, Magee LA, Verlohren S, Shennan A, von Dadelszen P, Sheiner E, Hadar E, Visser G, Da Silva Costa F, Kapur A, McAuliffe F, Nazareth A, Tahlak M, Kihara AB, Divakar H, McIntyre HD, Berghella V, Yang H, Romero R, Nicolaides KH, Melamed N, Hod M. A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre-eclampsia: Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics). Int J Gynaecol Obstet 2021; 154 Suppl 1:3-31. [PMID: 34327714 PMCID: PMC9290930 DOI: 10.1002/ijgo.13763] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Laura A Magee
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Andrew Shennan
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology B, Soroka University Medical Center, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gerard Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - Fabricio Da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Anil Kapur
- World Diabetes Foundation, Bagsvaerd, Denmark
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Amala Nazareth
- Jumeira Prime Healthcare Group, Emirates Medical Association, Dubai, United Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and Children, Dubai Health Authority, Emirates Medical Association, Mohammed Bin Rashid University for Medica Sciences, Dubai, United Arab Emirates
| | - Anne B Kihara
- African Federation of Obstetricians and Gynaecologists, Khartoum, Sudan
| | | | - H David McIntyre
- University of Queensland Mater Clinical School, Brisbane, Queensland, Australia
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
| | | | - Nir Melamed
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Dubon Garcia A, Devlieger R, Redekop K, Vandeweyer K, Verlohren S, Poon LC. Cost-utility of a first-trimester screening strategy versus the standard of care for nulliparous women to prevent pre-term pre-eclampsia in Belgium. Pregnancy Hypertens 2021; 25:219-224. [PMID: 34271426 DOI: 10.1016/j.preghy.2021.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/09/2021] [Accepted: 06/28/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To assess the cost-effectiveness of the Fetal Medicine Foundation (FMF) combined first-trimester pre-eclampsia (PE) screening algorithm, coupled with low-dose aspirin treatment in high-risk patients, compared to the standard of care (SOC; screening based on maternal risk factors) for nulliparous pregnancies in Belgium. STUDY DESIGN A decision analytic model was used to estimate the costs and outcomes for patients screened using the SOC and for those using the FMF screening algorithm, from the Belgian payers' perspective. Where possible, the probabilities and associated costs at each decision point were calculated based on published literature and public databases. MAIN OUTCOME MEASURES Cost-effectiveness was assessed using an incremental cost-effectiveness ratio. One-way sensitivity analyses were performed to assess the impact of independent variations in each model parameter. A probabilistic sensitivity analysis was used to estimate the impact of the overall uncertainty of the model on the estimated cost-effectiveness. RESULTS Considering an estimated 51,309 pregnancies in nulliparous women in Belgium per year, the FMF screening algorithm resulted in fewer cases of pre-term PE compared with the SOC (479 versus 816 cases) and a cost saving of €28.67 per patient. The outcome in quality-adjusted life-years was similar for both screening approaches (FMF screening algorithm 1.8521 versus SOC 1.8518). The FMF screening algorithm was cost-saving and more effective in 99.4% of simulations. CONCLUSIONS The FMF screening algorithm coupled with early intervention using low-dose aspirin has the potential to prevent an additional 337 cases of pre-term PE per year compared with the current SOC in this population, along with a cost saving.
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Affiliation(s)
- Ana Dubon Garcia
- Roche Diagnostics Belgium NV/SA, Berkenlaan 8, 1831 Diegem, Belgium.
| | - Roland Devlieger
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Ken Redekop
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, The Netherlands.
| | | | - Stefan Verlohren
- Department of Obstetrics (S.V.), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Sha Tin, Hong Kong.
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Connect the Dots-July 2021. Obstet Gynecol 2021; 138:133-134. [PMID: 34259477 DOI: 10.1097/aog.0000000000004458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rolnik DL, Carvalho MHBD, Lobo GAR, Verlohren S, Poon L, Baschat A, Hyett J, Thilaganathan B, Bujold E, Costa FDS. Preeclampsia: Universal Screening or Universal Prevention for Low and Middle-Income Settings? REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:334-338. [PMID: 33979894 PMCID: PMC10183917 DOI: 10.1055/s-0041-1729953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Daniel Lorber Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | | | - Guilherme Antonio Rago Lobo
- Department of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Stefan Verlohren
- Department of Obstetrics, Charité Universitätsmedizin, Berlin, Germany
| | - Liona Poon
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
| | - Ahmet Baschat
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, The Johns Hopkins Hospital, Baltimore, United States
| | - Jon Hyett
- RPA Women's and Babies, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Emmanuel Bujold
- Department of Obstetrics and Gynaecology, Laval University, Quebec, Canada
| | - Fabricio da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Australia
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Abstract
PURPOSE OF REVIEW The use of low dose aspirin (LDA) has become routine in prenatal care for a variety of diagnoses, most importantly in women with a history of preeclampsia and associated poor pregnancy outcomes. Although LDA is currently indicated in patients considered to be at risk for development of preeclampsia, optimal dosing, timing of treatment initiation, and persons of benefit are under investigation. Several studies have also looked at LDA treatment and its effect on other maternal and fetal outcomes. This review summarizes the current guidelines for the use of LDA, incorporating the most recent research findings, and offers possible future implications of LDA treatment. RECENT FINDINGS Over 10 years ago, the American College of Obstetricians and Gynecologists, the World Health Organization, and the United States Preventive Service Task Force began publishing guidelines focused on the use of LDA in pregnancy. Since the release of these guidelines, several large studies have re-evaluated the use of LDA with a focus on initiation of treatment and dosing. The combined results of these studies suggest a decreased rate of preeclampsia at aspirin doses >100 mg when treatment is initiated prior to 16 weeks of gestation. SUMMARY Overall, early initiation of LDA has been shown to decrease the development of preeclampsia in patients considered at increased risk. Current literature suggests increasing the recommended dose to >100 mg to optimize these risk reductions. Although LDA use seems promising for other outcomes like preterm delivery and intrauterine growth restriction, further studies to strengthen recommendations are warranted.
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De Oliveira LG, Diniz ALD, Prado CADC, Cunha Filho EVD, Souza FLPD, Korkes HA, Ramos JG, Costa ML, Corrêa Junior MD, Sass N, Cavalli RDC, Martins-Costa SHDA, Peraçoli JC. Pre-eclampsia: Universal Screening or Universal Prevention for Low and Middle-Income Settings? REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:61-65. [PMID: 33513638 PMCID: PMC10183869 DOI: 10.1055/s-0040-1713803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
AbstractPre-eclampsia (PE) is a severe disorder that affects up to 8% of all pregnancies and represents an important cause of maternal and perinatal morbidity and mortality. The screening of the disease is a subject of studies, but the complexity and uncertainties regarding its etiology make this objective a difficult task. In addition, the costs related to screening protocols, the heterogeneity of the most affected populations and the lack of highly effective prevention methods reduce the potential of current available algorithms for screening. Thus, the National Specialized Commission of Hypertension in Pregnancy of the Brazilian Association of Gynecology and Obstetrics Federation (Febrasgo, in the Portuguese acronym) (NSC Hypertension in Pregnancy of the Febrasgo) considers that there are no screening algorithms to be implemented in the country to date and advocates that Aspirin and calcium should be widely used.
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Affiliation(s)
- Leandro Gustavo De Oliveira
- Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista “Júlio de Mesquita Filho,” Botucatu, SP, Brazil
| | - Angélica Lemos Debs Diniz
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil
| | - Caio Antônio de Campos Prado
- Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Edson Vieira Da Cunha Filho
- Gynecology and Obstetrics Training Center, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Henri Augusto Korkes
- Department of Obstetrics and Gynecology, Faculty of Medicine, Pontifícia Universidade Católica de São Paulo, Sorocaba, SP, Brazil
| | - José Geraldo Ramos
- Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Maria Laura Costa
- Department of Gynecology and Obstetrics, Faculty of Medical Sciences, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Mário Dias Corrêa Junior
- Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Nelson Sass
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Ricardo De Carvalho Cavalli
- Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | | | - José Carlos Peraçoli
- Department of Gynecology and Obstetrics, Botucatu Medical School, Universidade Estadual Paulista “Júlio de Mesquita Filho,” Botucatu, SP, Brazil
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Aspirin use during pregnancy and the risk of bleeding complications: a Swedish population-based cohort study. Am J Obstet Gynecol 2021; 224:95.e1-95.e12. [PMID: 32687818 DOI: 10.1016/j.ajog.2020.07.023] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 06/21/2020] [Accepted: 07/14/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Aspirin is offered to pregnant women to prevent preeclampsia, a severe obstetrical complication. Large studies of nonpregnant populations have consistently shown that aspirin prophylaxis increases the risk of hemorrhagic complications. However, there have not been any population-based studies investigating this in a pregnant population. OBJECTIVE This study aimed to investigate whether aspirin use during pregnancy is associated with an increased risk of bleeding complications. STUDY DESIGN We performed a register-based cohort study using the Swedish Pregnancy Register wherein we examined 313,624 women giving birth between January 2013 and July 2017. Logistic regression was used to assess the risk of antepartum, intrapartum, and postpartum hemorrhage. A propensity score and inverse probability treatment weighting was used to generate an odds ratio that corrects for differences in baseline characteristics. RESULTS Aspirin use was registered in 4088 (1.3%) women during pregnancy. Compared with women who did not take aspirin, aspirin use was not associated with bleeding complications during the antepartum period (adjusted odds ratio, 1.22; 95% confidence interval, 0.97-1.54). However, aspirin users had a higher incidence of intrapartum bleeding (2.9% aspirin users vs 1.5% nonusers; adjusted odds ratio, 1.63; 95% confidence interval, 1.30-2.05), postpartum hemorrhage (10.2% vs 7.8%; adjusted odds ratio, 1.23; 95% confidence interval, 1.08-1.39), and postpartum hematoma (0.4% vs 0.1%; adjusted odds ratio, 2.21; 95% confidence interval, 1.13-4.34). The risk of a neonatal intracranial hemorrhage was also increased (0.07% vs 0.01%; adjusted odds ratio, 9.66; 95% confidence interval, 1.88-49.48). After stratifying by mode of birth, a higher incidence of bleeding among aspirin users was present for those who had a vaginal birth but not those who had a cesarean delivery. CONCLUSION Using aspirin during pregnancy is associated with increased postpartum bleeding and postpartum hematoma. It may also be associated with neonatal intracranial hemorrhage. When offering aspirin during pregnancy, these risks need to be weighed against the potential benefits.
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Strategies for Prescribing Aspirin to Prevent Preeclampsia: A Cost-Effectiveness Analysis. Obstet Gynecol 2020; 135:217. [DOI: 10.1097/aog.0000000000003631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Response to Letter. Obstet Gynecol 2019; 135:217-218. [PMID: 31856105 DOI: 10.1097/aog.0000000000003632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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