Summary
JAMA Associate Editor Dr. Linda Brubaker interviews Dr. Erin Coy, a USPSTF member and professor at Oregon Health and Science University, about the updated Task Force recommendation on aspirin for preeclampsia prevention. This 2021 update reaffirms the 2014 recommendation for low-dose aspirin (81 mg daily) in pregnant persons at high risk for preeclampsia. The episode covers the epidemiology of preeclampsia (affects 4-5% of pregnancies), racial disparities with Black persons facing higher risk and worse outcomes, and the biologic rationale involving placental blood vessel formation. Low-dose aspirin provides roughly 15% reduction in preeclampsia risk and approximately 20% reduction in preterm birth, fetal growth restriction, and perinatal mortality. The risk stratification uses high-risk factors (prior preeclampsia, chronic hypertension, diabetes) and moderate factors including the newly added IVF history.
Key Points
- USPSTF reaffirmed 81 mg daily aspirin for pregnant persons with one high-risk factor or two or more moderate risk factors for preeclampsia
- Preeclampsia affects 4-5% of pregnancies; aspirin reduces this risk by approximately 15%
- Additional benefits include ~20% reduction in preterm birth, fetal growth restriction, and perinatal mortality
- Black persons have higher preeclampsia risk, more severe manifestations, and worse maternal/neonatal outcomes
- High-risk factors include prior preeclampsia, chronic hypertension, pre-existing diabetes, and kidney disease
- IVF was newly added as a moderate risk factor in this update
- Aspirin should start after 12 weeks of gestation (earlier is better) and continue until delivery; risks of low-dose aspirin in pregnancy are rare
Key Moments
How Aspirin Affects Placental Blood Vessel Formation
Dr. Coy explains the biologic rationale for aspirin in preeclampsia prevention, including how it affects thromboxane and prostacyclin balance in placental vasculature.
"aspirin affects some of the hormones that guide and interact with these blood vessels in the placenta. Some hormones, things that are called from boxing, for example, and these are not hormones that everybody's familiar with, but it affects the balance of them"
15% Preeclampsia Reduction Plus Multiple Secondary Benefits
Dr. Coy presents the magnitude of aspirin's benefits, including roughly 15% reduction in preeclampsia and about 20% reduction in preterm birth, fetal growth restriction, and perinatal mortality.
"there was about a 15% reduction in the risk of developing preeclampsia by just taking a low-dose aspirin daily. But importantly, in addition to the risk of preeclampsia being reduced, there was a reduction in the risk of preterm birth, a reduction in the risk of fetal growth restriction"
Risk Stratification for Aspirin in Pregnancy
Dr. Coy walks through the USPSTF risk categories, explaining that one high-risk factor or two moderate risk factors qualifies a patient for low-dose aspirin.
"a Black woman who was also above the age of 35, that'd be two moderate risk factors, and that person should be recommended to take low-dose aspirin for the prevention of preeclampsia"
