Pregnancy

Aspirin to prevent complications in pregnancy

Pre-eclampsia is a complication of pregnancy that features both high blood pressure and protein in the urine. This is usually mild but, in some cases, (0.5%) it can develop into a life-threatening condition (eclampsia) for both the baby and the mother1. It affects around 8% of pregnancies globally and is an important cause of maternal and neonatal ill health and death2. Symptoms of pre-eclampsia include; headache, visual changes e.g. blurred or flashing vision, severe pain below the ribs, vomiting and a sudden onset swelling of the hands, face or feet2.

Aspirin is currently the only drug with evidence for use in pre-eclampsia prevention and is recommended by professional groups3.  International guidelines from the international Federation of Gynecology and Obstetrics4 recommend that women identified as high risk of pre-eclampsia during first trimester screening should be given aspirin prophylaxis (150mg at night from 11-14 weeks gestation until delivery or the diagnosis of pre-eclampsia). They do not advocate a policy of low-dose aspirin for all pregnant women4. A recent Cochrane review concluded that low dose aspirin does slightly reduce the risk of pre-eclampsia and its complications but that further research is required to identify those most likely to benefit5. The U.S. Preventative services Task Force (USPSTF) recommends (Grade B) low-dose aspirin (81 mg per day) after 12 weeks gestation as a preventative medication in women at high risk of pre-eclampsia6. NICE 2  recommends that women who are at high risk of pre-eclampsia take 75-150mg of aspirin daily from 12 weeks until the birth of the baby. They define women at high risk as those with; hypertension during a previous pregnancy, chronic kidney disease, an auto immune disease (e.g. systemic lupus erythematosus or antiphospholipid syndrome), diabetes (type 1 or 2) and/or chronic hypertension. In addition, they advise women with more than one moderate risk factor for pre-eclampsia to take low-dose aspirin from 12 weeks until birth. Moderate risk factors for pre-eclampsia are; first pregnancy, age 40 or above, a pregnancy interval of more than 10 years, obesity, family history of pre-eclampsia and a multiple foetus pregnancy.

References/Biography

  1. Royal College of Obstetricians and Gynaecologists Pre-eclampsia 08082012 accessed 22/05/2020 @ https://www.rcog.org.uk/en/patients/patient-leaflets-preeclampsia/.
  2. NICE NG133 Hypertension in pregnancy: diagnosis and management. 2019 @ https://www.nice.org.uk/guidance/ng133/chapter/Recommendations
  3. Ma’ayeh M, Rood KM, Kniss D et al. Novel Interventions for the prevention of preeclampsia. Current Hypertension Reports. 2020; Volume 22, 17
  4. Poon LC, Shennan A, Hyett JA et al The International federation of gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention. Int J Gynecol Obstet 2019; 145 (Suppl.1) 1-33. @ https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/ijgo.12802
  5. Duley L, Meher S and Hunter KE et al. Antiplatelet agents for preventing pre-eclampsia and its complications Cochrane Database of Systematic Reviews Oct 2019 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004659.pub3/full
  6. USPSTF Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: preventative medication. 2014 (currently being updated) available @ https://www.uspreventativeservicestaskforce.org/uspstf/recommendations/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortlality-from-preeclampsia-preventative-medication

Low-dose aspirin for the prevention of pre-eclampsia

In an editorial to the Drug and Therapeutics Bulletin, Joanna Girling, Consultant in Obstetrics and Gynaecology, in London, calls for a national patient group direction (PGD) to allow all community pharmacists to supply low-dose aspirin to pregnant women who have been advised by their midwives to take it due their risk of pre-eclampsia.  She believes this will increase the uptake of this medicine which is recommended in national guidelines, is low-cost and has the potential to save lives.

Girling explores the issues for women deemed to be at risk of pre-eclampsia in obtain low-dose aspirin and the reasons why the uptake is only around 50% in eligible pregnant women. Firstly, despite being able to recommend it most maternity units do not have a policy or PGD to allow midwives to supply low-dose aspirin. Instead midwives usually need to advise women to see their GP and ask them to prescribe it. Community pharmacists cannot legally sell aspirin for pre-eclampsia because it does not have a UK marketing license for this indication. In addition, some women may have safety concerns but signposting them to https://medicinesinpregnancy.org/Medicine–pregnancy/Aspirin/ can offer reassuring advice.

Joanna Girling states:

“There is well-established high-quality evidence that low-dose aspirin is effective in reducing pre-eclampsia (as well as reducing the risk of preterm birth, fetal growth restrictions and still birth) in women at risk of this condition and that it is safe for mother and baby.”

For further information please see;

Girling J. Low-dose aspirin for prevention of pre-eclampsia: when over the counter just isn’t. Drug and Therapeutics Bulletin April 2020 @ https://dtb.bmj.com/content/early/2020/04/23/dtb.2020.000003