Study Finds Preeclampsia Aspirin Prophylaxis Underused

Preeclampsia is a leading cause of morbidity and mortality in pregnancy, but a simple, cheap intervention could reduce the risk of preeclampsia—low-dose aspirin (LDASA) taken daily beginning at or before 16 weeks’ gestation, an intervention recommended by the U.S. Preventive Services Task Force in 2014. But almost a decade later, a prospective cohort study by University of Pittsburgh researchers found that LDASA was recommended for less than half of at-risk women, and a third of at-risk, pregnant women were never told of the value of LDASA.

Tamar Krishnamurti, PhD, of the Division of General Internal Medicine, University of Pittsburgh, and colleagues tracked the rate of prophylactic LDASA recommendations via a smart phone app (MyHealthyPregnancy) and review of medical records for 2,563 women (2,567 pregnancies) treated in a single center from Sept. 23, 2019 through Aug 31, 2020. The women were given information about the app on their first prenatal visit, and women in 1,015 pregnancies used the app to answer questions about LDASA use.

“In this cohort study, only 46.0% of prenatal care app users who met the criteria for highest preeclampsia risk reported receiving an LDASA recommendation from their practitioner, and medical records suggested that there may have been frequent miscommunication between patients and practitioners about LDASA use,” Krishnamurti et al wrote in JAMA Network Open. Of the 1,015 pregnancies in which women used the app, “124 (12.2%) met at least 1 criterion for highest risk of preeclampsia. In 57 (46.0%) of these pregnancies, the patient indicated that their practitioner recommended LDASA; after examination of the medical records, 90 pregnancies (72.6%) had evidence of an LDASA recommendation and 34 (27.4%) did not. Of the 90 pregnancies with a documented LDASA recommendation, 33 patients (36.7%) were unaware of it.”

Two preeclampsia high risk factors—a history of preeclampsia and chronic hypertension—were associated with increased likelihood that a healthcare provider would recommend LDASA. Of note, women who didn’t have an identifiable high risk factor, but who did have multiple moderate risk factors, were not likely to receive an LDASA recommendation.

“Use of certain risk factors incorrectly or not at all may have resulted from lack of information about whether the patient met the risk criteria (e.g., the patient’s annual household income) or a lack of time available to elicit certain maternal factors (e.g., family history) or may indicate that patients with specific risk criteria may also experience greater barriers to accessing preventive care. Underuse or inaccurate use of factors not only may lead to underestimates of overall preeclampsia risk but may also exacerbate disparities in preventive preeclampsia care, such as among those with low socioeconomic status,” Krishnamurti and colleagues wrote.

In an invited commentary published with the study, Adam K. Lewkowitz, MD, MPHS, and Dwight J. Rouse, MD, MSPH, of Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, Rhode Island, wrote, “Krishnamurti and colleagues are to be commended for their innovative approach to assessing potential impediments to LDASA implementation; their study findings could be used to increase understanding of both the prescription of and patient adherence to LDASA prophylaxis per USPSTF and ACOG clinical guidelines recommending screening for preeclampsia risk factors and LDASA prophylaxis for those at risk. First and foremost, prenatal care practitioners must successfully identify patients at risk for preeclampsia to recommend LDASA for all those who should receive it. As Krishnamurti and colleagues suggest, technology-based tools such as automatic reminders in the electronic medical record may facilitate appropriate identification. However, identification of eligible patients is only the first step; practitioners must then successfully communicate the importance of LDASA adherence to all women to whom this therapy is recommended. This could occur directly by practitioners or by using videos or other mobile health interventions, which have been shown to be associated with improved adherence to daily medication regimens.”

Lewkowitz and Rouse went on to suggest that a simpler approach would be to recommend universal LDASA for all pregnant women. BreakingMED asked Lewkowitz why this universal approach could not be initiated much the same way that folic acid supplementation to prevent neural tube damage was done.

“The main reason universal LDASA is not done is that it is not recommended by ACOG or SMFM (Society of Maternal Fetal Medicine),” Lewkowitz replied in an email. “And I think that’s because not all trials showed convincing evidence that it worked to reduce preeclampsia. Other things to consider are that 1) the number needed to treat is very high, so on an individual level it may be difficult for providers to notice a difference in their own practice and 2) unlike folic acid, which is a vitamin needed for normal non-pregnancy physiology, aspirin is a medication that treats inflammation by inhibiting prostaglandins. Some women or even OBs are wary about providing medications during pregnancy, even if there is a maternal benefit (as a [maternal-fetal medicine specialist], I often need to convince patients who were stable for years on their meds to resume them during pregnancy when they see me in a consult).”

The smart phone app was recommended to 3,484 women of whom 2,563 downloaded it, and four of the women used it for 2 pregnancies, thus the pregnancy total was 2,567. The average age of women who used the app was 30 and the majority were White (79.3%).

The authors noted several limitations for the study, including its reliance on self-reporting of LDASA use via the app—as a result, self-reported LDASA data were missing for 60.5% of the patients in the study, which may have introduced selection bias. It is also possible that not all of the communication—including recommendations—between providers and patients was documented in either the app or the medical record.

1. In a cohort study that examined use of a smart phone app to improve use of low-dose aspirin (LDASA) for preeclampsia prevention, there was no documented recommendation for LDASA in nearly 37% of at-risk women.

2. Be aware that the findings suggest a need for improved identification of women at risk for preeclampsia and communication about the value of LDASA for prevention.

Peggy Peck, Editor-in-Chief, BreakingMED™

Cat ID: 41

Topic ID: 83,41,730,6,41,192,916,925