- Email: [email protected]
Low-Dose Aspirin for the Prevention of Preeclampsia
Rx
Low-Dose Aspirin for the Prevention of Preeclampsia HEIDI COLLINS FANTASIA
P Photo © Joe_Potato / istockphoto.com
Preeclampsia is a systemic hypertensive disorder specific to pregnancy that involves multiple organ systems. It remains a significant cause of maternal morbidity and mortality in the United States and globally. Because the only resolution of preeclampsia is delivery of the placenta, the disease is also a leading causative factor in medically necessary preterm birth (Amaral, Wallace, Owens, & LaMarca, 2017). Because of
the potential adverse effects of preeclampsia for women and newborns, preventing preeclampsia, especially among women at greatest risk, is an important component of prenatal care.
Overview of Preeclampsia Preeclampsia is estimated to affect between 5% and 10% of pregnancies in the United States, with recurrence in up to 25% of subsequent
Abstract Preeclampsia is a hypertensive disorder specific to pregnancy that remains a significant cause of maternal and neonatal morbidity and mortality. Identification of women who are most at risk for preeclampsia is imprecise. Because of the potential negative health consequences of preeclampsia for women and newborns and the lack of effective screening mechanisms preventing preeclampsia is an important component of prenatal care. Researchers have documented that low-dose aspirin, taken daily after the first trimester, can decrease the development of preeclampsia and reduce the incidence of preterm birth and birth of small-for-gestational-age infants. This column includes an overview of low-dose aspirin in pregnancy and a review of current recommendations from leading national organizations. https://doi.org/ 10.1016/j.nwh.2017.12.002 Keywords aspirin | hypertension | preeclampsia | pregnancy
nwhjournal.org
© 2018, AWHONN
87
Rx
affect between 5% and 10% of pregnancies in the United States, with recurrence in up to 25% of subsequent pregnancies
Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an associate professor in the Zuckerberg College of Health Sciences, Susan and Alan Solomont School of Nursing, at the University of Massachusetts Lowell in Lowell, MA. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: Heidi_ [email protected].
88
pregnancies (Grotegut, 2016; Tolcher et al., 2017). Preeclampsia is recognized as a new onset of hypertension in the second half of pregnancy, often with blood pressure at greater than 140/90 mm Hg and co-occurring proteinuria. Multiorgan system complications can occur such as renal failure, elevated liver enzymes and low platelets (HELLP syndrome), edema, hemolysis, and progression to eclamptic seizures (Amaral et al., 2017). Risk factors for preeclampsia include pregnancy at the extremes of maternal age (adolescents and women older than 40 years of age), obesity, preexisting hypertension, diagnosis of preeclampsia in a previous pregnancy, diabetes or renal disease, nulliparity, multiple gestation, and preexisting autoimmune diseases such as antiphospholipid antibody syndrome and systemic lupus erythematosus (Grotegut, 2016). However, not all women with these risk factors develop preeclampsia, and the condition can occur in women who do not have any known
Nursing for Women’s Health
risk factors, which makes screening and prevention more challenging. Researchers have investigated different screening mechanisms to identify women at risk for preeclampsia, including maternal serum markers and first trimester ultrasonographic findings (including uterine artery Doppler flow and resistance), but these additional screening tests have not resulted in the accurate prediction of preeclampsia (Halscott, Ramsey, & Reddy, 2014). To date, an effective screening algorithm for the identification of women at risk for preeclampsia does not exist.
Pathophysiology of Preeclampsia The etiology and underlying pathophysiology of primary and recurrent preeclampsia are not completely understood. However, certain characteristics have been identified, and the placenta is involved in the development of the disease. Hallmarks of preeclampsia include placental ischemia, maternal immune activation, increased arterial resistance, decreased production of vasodilators, and maternal endothelial dysfunction. This causes decreased blood flow to major organs. These factors, combined with the maternal hypertension, often result in intrauterine fetal growth restriction (IUGR) and small-for-gestational-age infants (Amaral et al., 2017; Grotegut, 2016; Tolcher et al., 2017).
Volume 22
Issue 1
Photo © Pekic / istockphoto.com
Preeclampsia is estimated to
The pathophysiology of preeclampsia is not fully understood, and neither is the mechanism by which low-dose aspirin works to prevent preeclampsia. However, aspirin has anticoagulant and anti-inflammatory properties that contribute to the mechanism of action in preventing preeclampsia. When given at the beginning of the second trimester (<16 weeks gestation) low-dose aspirin works to inhibit platelet aggregation and promote vasodilation. This pharmacologic mechanism results in increased blood flow to the uterus and placenta (Mone, Mulcahy, McParland, & McAuliffe, 2017; Tolcher et al., 2017).
Safety of Low-Dose Aspirin in Pregnancy Low-dose aspirin is generally considered to be safe during pregnancy. There is no evidence that low-dose aspirin is associated with acute risks to the fetus, but data on long-term effects are lacking (American College of Obstetricians and Gynecologists [ACOG], 2013). Although the use of nonsteroidal anti-inflammatory drugs such as aspirin has been associated with increased maternal and neonatal bleeding risk and antenatal closure of the fetal ductus arteriosus, those adverse effects have not been observed in large, clinical trials of low-dose aspirin and
pregnancy, and the risk of overall harm is small (LeFevre, 2014). One reason may be the lower dose (81 mg) that is used for the prevention of preeclampsia. There is also no link between low-dose aspirin and fetal anomalies, and lowdose aspirin is typically initiated at the end of the first trimester, when organogenesis is complete (Henderson et al., 2014; Mone et al., 2017). Aspirin is excreted in breast milk (Bayer, n.d.), but low-dose aspirin is discontinued at childbirth, and women who have taken low-dose aspirin during pregnancy have no restrictions on initiation of breastfeeding.
Rx
Role of Low-Dose Aspirin
Current Recommendations In 2014, the U.S. Preventive Services Task Force (USPSTF) issued an update recommending the use of low-dose aspirin to prevent preeclampsia among women who are at risk of developing the disease (LeFevre, 2014). This is a Grade B recommendation, indicating that clinicians should offer this service to women (see Box 1). ACOG (2016) also supports this recommendation. According to ACOG, the use of low-dose aspirin, at a dosage of 81 mg per day, should be initiated between 12 and 28 weeks of gestation for the prevention of preeclampsia among women with significant risk factors that were identified by the USPSTF (see Box 2).
Box 1.
USPSTF Grade Definitions Grade
Definition
Implications for Practice
A
Recommended, high certainty of substantial benefit
Offer to women
B
Recommended, high certainty of moderate to substantial benefit
Offer to women
C
Recommend based on individual women’s characteristics and clinical judgment, benefit small
Offer to selected women based on individualized assessment
D
Do not recommend, moderate to high certainty of no benefit or harms outweigh benefits
Discourage
I
Insufficient evidence to assess benefits and harms; current evidence is poor, lacking, or conflicting
Discuss uncertainty of benefits and harms with women
Source: U.S. Preventive Services Task Force (2016).
February 2018
Nursing for Women’s Health
89
Rx
Box 2.
Summary of USPSTF Recommendations for Use of Low-Dose Aspirin in Pregnancy Risk Level
Risk Factors for Preeclampsia
USPSTF Recommendation
High risk
History of preeclampsia
Recommend low-dose aspirin if one or more factors present
Chronic hypertension Preexisting type 1 or type 2 diabetes Renal disease Multiple gestation Autoimmune disease Moderate risk
Consider low-dose aspirin if several factors present
Nulliparity BMI > 30 kg/m2 Age > 35 years Family history of preeclampsia Previous small-for-gestational-age or low-birth-weight infant African American race Low socioeconomic status 10 years since previous pregnancy
Low risk
No risk factors listed above Previous uncomplicated full-term birth
Do not recommend lowdose aspirin
Note. BMI = body mass index; USPSTF = U.S. Preventive Services Task Force. Source: LeFevre (2014).
Implications for Nursing Practice Researchers have documented that the use of low-dose aspirin among pregnant women at risk for preeclampsia has multiple benefits, including reduced risk of preeclampsia, preterm birth, and IUGR (Henderson, et al., 2014; LeFevre, 2014; Roberge et al., 2017; Rolnik et al., 2017). During clinical trials, researchers have used doses of aspirin ranging from 60 mg to 150 mg; however, there is no consensus on whether any one dose in that range is ideal. In the United States, low-dose aspirin is inexpensive and readily available without a prescription in a standard dose of 81 mg, which is why this is the
90
Nursing for Women’s Health
dose recommended by the USPSTF and ACOG (ACOG, 2016; LeFevre, 2014). There are no current recommendations for the use of low-dose aspirin for all women during pregnancy, and nurses should clarify this point when working with pregnant women. For women without any risk factors for preeclampsia, there is no benefit to daily low-dose aspirin therapy (see Box 2). However, for women at risk for preeclampsia, early identification is important. Although the current recommendation from ACOG and the USPSTF (ACOG, 2016; LeFevre, 2014) states that low-dose aspirin can be implemented at any time during the second trimester, other researchers have documented that low-dose aspirin appears to be less effective
Volume 22
Issue 1
A careful and thorough review of personal and family history will identify women who are most at risk for preeclampsia and for whom low-dose aspirin therapy would provide the most benefit at risk for preeclampsia and for whom low-dose aspirin therapy would provide the most benefit. Early identification of risk factors will allow time to discuss whether low-dose aspirin is an appropriate choice and if so, when to begin taking the medication. Additionally, it is not known if the use of low-dose aspirin during pregnancy has any protective effect on women’s cardiovascular health after the pregnancy has ended. Daily use of lowdose aspirin has been investigated as a pharmacologic therapy for the primary prevention of cardiovascular disease in women, but this recommendation is age dependent. According to the USPSTF, daily low-dose aspirin is not recommended for primary prevention of cardiovascular disease in women younger than 50 or older than 70 years. For women between the ages of 50 and 59 years who have a greater than 10% risk of developing cardiovascular disease in the next decade, it is a Grade B recommendation (see Box 1). For women between the ages of 60 and 69 years, the use of low-dose aspirin is a Grade C recommendation and should be an individualized decision because adverse events such as bleeding risk increase with age (Sarma & Scott, 2016). Although use of low-dose aspirin during pregnancy has not been associated with an increased risk for bleeding that can occur with the use of nonsteroidal anti-inflammatory drugs at greater doses (LeFevre, 2014), pregnant women should still be educated to report any side effects they think might be related to the low-dose aspirin. These could range from mild gastrointestinal events such dyspepsia to
February 2018
overt upper and lower gastrointestinal bleeding from ulceration. Additionally, aspirin has been associated with severe allergic reactions including hives, respiratory distress, and angioedema, even among women who report previously taking aspirin without incident (Bayer, n.d.).
Rx
for the prevention of preeclampsia if initiated after 16 weeks gestation (Roberge et al., 2017). A careful and thorough review of personal and family history will identify women who are most
Conclusion Preeclampsia is a significant cause of maternal and neonatal morbidity and mortality, and identification of women who are most at risk for developing the disease is imprecise. For women at risk, daily low-dose aspirin can reduce the incidence of preeclampsia and, therefore, decrease the risk for fetal IUGR and for medically necessary preterm birth. Early identification of women who would benefit most from low-dose aspirin will allow for the initiation of therapy at the beginning of the second trimester and potentially improve maternal and neonatal health outcomes. NWH
References Amaral, L. M., Wallace, K., Owens, M., & LaMarca, B. (2017). Pathophysiology and current clinical management of preeclampsia. Current Hypertension Reports, 19(8), 61. doi:10.1007/ s11906-017-0757-7 American College of Obstetricians and Gynecologists. (2013). Hypertension in pregnancy. Retrieved from https://www.acog.org/Resources -And-Publications/Task-Force-and-WorkGroup-Reports/Hypertension-in-Pregnancy American College of Obstetricians and Gynecologists. (2016). Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia: Updated Recommendations. Retrieved from https:// www.acog.org/About-ACOG/News-Room/ Practice-Advisories/Practice-Advisory-LowDose-Aspirin-and-Prevention-of-PreeclampsiaUpdated-Recommendations Bayer. (n.d.). Aspirin: Comprehensive prescribing information. Silver Spring, MD: U.S. Food and Drug Administration. Retrieved from https://www.fda.gov/ohrms/dockets/ac/03/ briefing/4012B1_03_Appd%201-Professional%20Labeling.pdf Grotegut, C. A. (2016). Prevention of preeclampsia. The Journal of Clinical Investigation, 126(12), 4396–4398. doi:10.1172/JCI91300 Halscott, T. L., Ramsey, P. S., & Reddy, U. M. (2014). First trimester screening cannot predict
Nursing for Women’s Health
91
Rx
adverse outcomes yet. Prenatal Diagnosis, 34(7), 668–676. doi:10.1002/pd.4407 Henderson, J. T., Whitlock, E. P., O’Connor, E., Senger, C. A., Thompson, J. H., & Rowland, M. G. (2014). Low-dose aspirin for the prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 112. AHRQ Publication No. 14-05207-EF-1. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www.ncbi .nlm.nih.gov/books/NBK196392/pdf/Bookshelf_NBK196392.pdf LeFevre, M. L. (2014). Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 161(11), 819–826. doi:10.7326/ M14-1884 Mone, F., Mulcahy, C., McParland, P., & McAuliffe, F. M. (2017). Should we recommend universal aspirin for all pregnant women? American Journal of Obstetrics and Gynecology, 216(2), 141.e1– 141.e5. doi:10.1016/j.ajog.2016.09.086 Roberge, S., Nicolaides, K., Demers, S., Hyett, J., Chaillet, N., & Bujold, E. (2017). The role of aspirin dose on the prevention of preeclampsia and fetal growth restriction: Systematic review and
meta-analysis. American Journal of Obstetrics and Gynecology, 216(2), 110–120. doi:10.1016/j. ajog.2016.09.076 Rolnik, D. L., Wright, D., Poon, L. C., O’Gorman, N., Syngelaki, A., de Paco Matallana, C., . . . Molina, F. S. (2017). Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. New England Journal of Medicine, 377, 613–622. doi:10.1056/NEJMoa1704559 Sarma, A., & Scott, N. S. (2016). Aspirin use in women: Current perspectives and future directions. Current Atherosclerosis Reports, 18(17), 1–8. doi:10.1007/s11883-016-0630-1 Tolcher, M. C., Chu, D. M., Hollier, L. M., Mastrobattista, J. M., Racusin, D. A., Ramin, S. M., . . . Aagaard, K. M. (2017). Impact of USPSTF recommendations for aspirin for prevention of recurrent preeclampsia. American Journal of Obstetrics and Gynecology, 217(3), 365.e1–365. e8. doi:10.1016/j.ajog.2017.04.035 U.S. Preventive Services Task Force. (2016). Grade definitions. Retrieved from https://www .uspreventiveservicestaskforce.org/Page/Name/ grade-definitions
It seems that barely a day goes by without a new drug being released—or perhaps recalled. How can you stay on top of it all? Read “Rx,” a clinical practice column appearing three times a year in Nursing for Women’s Health. It covers the latest developments in prescription and over-the-counter pharmacotherapeutics—everything from the HPV vaccine to over-the-counter weight loss drugs, all to help you provide optimum care to your patients and to answer their questions.
92
Nursing for Women’s Health
Volume 22
Issue 1
Low-Dose Aspirin for the Prevention of Preeclampsia HEIDI COLLINS FANTASIA
P Photo © Joe_Potato / istockphoto.com
Preeclampsia is a systemic hypertensive disorder specific to pregnancy that involves multiple organ systems. It remains a significant cause of maternal morbidity and mortality in the United States and globally. Because the only resolution of preeclampsia is delivery of the placenta, the disease is also a leading causative factor in medically necessary preterm birth (Amaral, Wallace, Owens, & LaMarca, 2017). Because of
the potential adverse effects of preeclampsia for women and newborns, preventing preeclampsia, especially among women at greatest risk, is an important component of prenatal care.
Overview of Preeclampsia Preeclampsia is estimated to affect between 5% and 10% of pregnancies in the United States, with recurrence in up to 25% of subsequent
Abstract Preeclampsia is a hypertensive disorder specific to pregnancy that remains a significant cause of maternal and neonatal morbidity and mortality. Identification of women who are most at risk for preeclampsia is imprecise. Because of the potential negative health consequences of preeclampsia for women and newborns and the lack of effective screening mechanisms preventing preeclampsia is an important component of prenatal care. Researchers have documented that low-dose aspirin, taken daily after the first trimester, can decrease the development of preeclampsia and reduce the incidence of preterm birth and birth of small-for-gestational-age infants. This column includes an overview of low-dose aspirin in pregnancy and a review of current recommendations from leading national organizations. https://doi.org/ 10.1016/j.nwh.2017.12.002 Keywords aspirin | hypertension | preeclampsia | pregnancy
nwhjournal.org
© 2018, AWHONN
87
Rx
affect between 5% and 10% of pregnancies in the United States, with recurrence in up to 25% of subsequent pregnancies
Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an associate professor in the Zuckerberg College of Health Sciences, Susan and Alan Solomont School of Nursing, at the University of Massachusetts Lowell in Lowell, MA. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: Heidi_ [email protected].
88
pregnancies (Grotegut, 2016; Tolcher et al., 2017). Preeclampsia is recognized as a new onset of hypertension in the second half of pregnancy, often with blood pressure at greater than 140/90 mm Hg and co-occurring proteinuria. Multiorgan system complications can occur such as renal failure, elevated liver enzymes and low platelets (HELLP syndrome), edema, hemolysis, and progression to eclamptic seizures (Amaral et al., 2017). Risk factors for preeclampsia include pregnancy at the extremes of maternal age (adolescents and women older than 40 years of age), obesity, preexisting hypertension, diagnosis of preeclampsia in a previous pregnancy, diabetes or renal disease, nulliparity, multiple gestation, and preexisting autoimmune diseases such as antiphospholipid antibody syndrome and systemic lupus erythematosus (Grotegut, 2016). However, not all women with these risk factors develop preeclampsia, and the condition can occur in women who do not have any known
Nursing for Women’s Health
risk factors, which makes screening and prevention more challenging. Researchers have investigated different screening mechanisms to identify women at risk for preeclampsia, including maternal serum markers and first trimester ultrasonographic findings (including uterine artery Doppler flow and resistance), but these additional screening tests have not resulted in the accurate prediction of preeclampsia (Halscott, Ramsey, & Reddy, 2014). To date, an effective screening algorithm for the identification of women at risk for preeclampsia does not exist.
Pathophysiology of Preeclampsia The etiology and underlying pathophysiology of primary and recurrent preeclampsia are not completely understood. However, certain characteristics have been identified, and the placenta is involved in the development of the disease. Hallmarks of preeclampsia include placental ischemia, maternal immune activation, increased arterial resistance, decreased production of vasodilators, and maternal endothelial dysfunction. This causes decreased blood flow to major organs. These factors, combined with the maternal hypertension, often result in intrauterine fetal growth restriction (IUGR) and small-for-gestational-age infants (Amaral et al., 2017; Grotegut, 2016; Tolcher et al., 2017).
Volume 22
Issue 1
Photo © Pekic / istockphoto.com
Preeclampsia is estimated to
The pathophysiology of preeclampsia is not fully understood, and neither is the mechanism by which low-dose aspirin works to prevent preeclampsia. However, aspirin has anticoagulant and anti-inflammatory properties that contribute to the mechanism of action in preventing preeclampsia. When given at the beginning of the second trimester (<16 weeks gestation) low-dose aspirin works to inhibit platelet aggregation and promote vasodilation. This pharmacologic mechanism results in increased blood flow to the uterus and placenta (Mone, Mulcahy, McParland, & McAuliffe, 2017; Tolcher et al., 2017).
Safety of Low-Dose Aspirin in Pregnancy Low-dose aspirin is generally considered to be safe during pregnancy. There is no evidence that low-dose aspirin is associated with acute risks to the fetus, but data on long-term effects are lacking (American College of Obstetricians and Gynecologists [ACOG], 2013). Although the use of nonsteroidal anti-inflammatory drugs such as aspirin has been associated with increased maternal and neonatal bleeding risk and antenatal closure of the fetal ductus arteriosus, those adverse effects have not been observed in large, clinical trials of low-dose aspirin and
pregnancy, and the risk of overall harm is small (LeFevre, 2014). One reason may be the lower dose (81 mg) that is used for the prevention of preeclampsia. There is also no link between low-dose aspirin and fetal anomalies, and lowdose aspirin is typically initiated at the end of the first trimester, when organogenesis is complete (Henderson et al., 2014; Mone et al., 2017). Aspirin is excreted in breast milk (Bayer, n.d.), but low-dose aspirin is discontinued at childbirth, and women who have taken low-dose aspirin during pregnancy have no restrictions on initiation of breastfeeding.
Rx
Role of Low-Dose Aspirin
Current Recommendations In 2014, the U.S. Preventive Services Task Force (USPSTF) issued an update recommending the use of low-dose aspirin to prevent preeclampsia among women who are at risk of developing the disease (LeFevre, 2014). This is a Grade B recommendation, indicating that clinicians should offer this service to women (see Box 1). ACOG (2016) also supports this recommendation. According to ACOG, the use of low-dose aspirin, at a dosage of 81 mg per day, should be initiated between 12 and 28 weeks of gestation for the prevention of preeclampsia among women with significant risk factors that were identified by the USPSTF (see Box 2).
Box 1.
USPSTF Grade Definitions Grade
Definition
Implications for Practice
A
Recommended, high certainty of substantial benefit
Offer to women
B
Recommended, high certainty of moderate to substantial benefit
Offer to women
C
Recommend based on individual women’s characteristics and clinical judgment, benefit small
Offer to selected women based on individualized assessment
D
Do not recommend, moderate to high certainty of no benefit or harms outweigh benefits
Discourage
I
Insufficient evidence to assess benefits and harms; current evidence is poor, lacking, or conflicting
Discuss uncertainty of benefits and harms with women
Source: U.S. Preventive Services Task Force (2016).
February 2018
Nursing for Women’s Health
89
Rx
Box 2.
Summary of USPSTF Recommendations for Use of Low-Dose Aspirin in Pregnancy Risk Level
Risk Factors for Preeclampsia
USPSTF Recommendation
High risk
History of preeclampsia
Recommend low-dose aspirin if one or more factors present
Chronic hypertension Preexisting type 1 or type 2 diabetes Renal disease Multiple gestation Autoimmune disease Moderate risk
Consider low-dose aspirin if several factors present
Nulliparity BMI > 30 kg/m2 Age > 35 years Family history of preeclampsia Previous small-for-gestational-age or low-birth-weight infant African American race Low socioeconomic status 10 years since previous pregnancy
Low risk
No risk factors listed above Previous uncomplicated full-term birth
Do not recommend lowdose aspirin
Note. BMI = body mass index; USPSTF = U.S. Preventive Services Task Force. Source: LeFevre (2014).
Implications for Nursing Practice Researchers have documented that the use of low-dose aspirin among pregnant women at risk for preeclampsia has multiple benefits, including reduced risk of preeclampsia, preterm birth, and IUGR (Henderson, et al., 2014; LeFevre, 2014; Roberge et al., 2017; Rolnik et al., 2017). During clinical trials, researchers have used doses of aspirin ranging from 60 mg to 150 mg; however, there is no consensus on whether any one dose in that range is ideal. In the United States, low-dose aspirin is inexpensive and readily available without a prescription in a standard dose of 81 mg, which is why this is the
90
Nursing for Women’s Health
dose recommended by the USPSTF and ACOG (ACOG, 2016; LeFevre, 2014). There are no current recommendations for the use of low-dose aspirin for all women during pregnancy, and nurses should clarify this point when working with pregnant women. For women without any risk factors for preeclampsia, there is no benefit to daily low-dose aspirin therapy (see Box 2). However, for women at risk for preeclampsia, early identification is important. Although the current recommendation from ACOG and the USPSTF (ACOG, 2016; LeFevre, 2014) states that low-dose aspirin can be implemented at any time during the second trimester, other researchers have documented that low-dose aspirin appears to be less effective
Volume 22
Issue 1
A careful and thorough review of personal and family history will identify women who are most at risk for preeclampsia and for whom low-dose aspirin therapy would provide the most benefit at risk for preeclampsia and for whom low-dose aspirin therapy would provide the most benefit. Early identification of risk factors will allow time to discuss whether low-dose aspirin is an appropriate choice and if so, when to begin taking the medication. Additionally, it is not known if the use of low-dose aspirin during pregnancy has any protective effect on women’s cardiovascular health after the pregnancy has ended. Daily use of lowdose aspirin has been investigated as a pharmacologic therapy for the primary prevention of cardiovascular disease in women, but this recommendation is age dependent. According to the USPSTF, daily low-dose aspirin is not recommended for primary prevention of cardiovascular disease in women younger than 50 or older than 70 years. For women between the ages of 50 and 59 years who have a greater than 10% risk of developing cardiovascular disease in the next decade, it is a Grade B recommendation (see Box 1). For women between the ages of 60 and 69 years, the use of low-dose aspirin is a Grade C recommendation and should be an individualized decision because adverse events such as bleeding risk increase with age (Sarma & Scott, 2016). Although use of low-dose aspirin during pregnancy has not been associated with an increased risk for bleeding that can occur with the use of nonsteroidal anti-inflammatory drugs at greater doses (LeFevre, 2014), pregnant women should still be educated to report any side effects they think might be related to the low-dose aspirin. These could range from mild gastrointestinal events such dyspepsia to
February 2018
overt upper and lower gastrointestinal bleeding from ulceration. Additionally, aspirin has been associated with severe allergic reactions including hives, respiratory distress, and angioedema, even among women who report previously taking aspirin without incident (Bayer, n.d.).
Rx
for the prevention of preeclampsia if initiated after 16 weeks gestation (Roberge et al., 2017). A careful and thorough review of personal and family history will identify women who are most
Conclusion Preeclampsia is a significant cause of maternal and neonatal morbidity and mortality, and identification of women who are most at risk for developing the disease is imprecise. For women at risk, daily low-dose aspirin can reduce the incidence of preeclampsia and, therefore, decrease the risk for fetal IUGR and for medically necessary preterm birth. Early identification of women who would benefit most from low-dose aspirin will allow for the initiation of therapy at the beginning of the second trimester and potentially improve maternal and neonatal health outcomes. NWH
References Amaral, L. M., Wallace, K., Owens, M., & LaMarca, B. (2017). Pathophysiology and current clinical management of preeclampsia. Current Hypertension Reports, 19(8), 61. doi:10.1007/ s11906-017-0757-7 American College of Obstetricians and Gynecologists. (2013). Hypertension in pregnancy. Retrieved from https://www.acog.org/Resources -And-Publications/Task-Force-and-WorkGroup-Reports/Hypertension-in-Pregnancy American College of Obstetricians and Gynecologists. (2016). Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia: Updated Recommendations. Retrieved from https:// www.acog.org/About-ACOG/News-Room/ Practice-Advisories/Practice-Advisory-LowDose-Aspirin-and-Prevention-of-PreeclampsiaUpdated-Recommendations Bayer. (n.d.). Aspirin: Comprehensive prescribing information. Silver Spring, MD: U.S. Food and Drug Administration. Retrieved from https://www.fda.gov/ohrms/dockets/ac/03/ briefing/4012B1_03_Appd%201-Professional%20Labeling.pdf Grotegut, C. A. (2016). Prevention of preeclampsia. The Journal of Clinical Investigation, 126(12), 4396–4398. doi:10.1172/JCI91300 Halscott, T. L., Ramsey, P. S., & Reddy, U. M. (2014). First trimester screening cannot predict
Nursing for Women’s Health
91
Rx
adverse outcomes yet. Prenatal Diagnosis, 34(7), 668–676. doi:10.1002/pd.4407 Henderson, J. T., Whitlock, E. P., O’Connor, E., Senger, C. A., Thompson, J. H., & Rowland, M. G. (2014). Low-dose aspirin for the prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 112. AHRQ Publication No. 14-05207-EF-1. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www.ncbi .nlm.nih.gov/books/NBK196392/pdf/Bookshelf_NBK196392.pdf LeFevre, M. L. (2014). Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 161(11), 819–826. doi:10.7326/ M14-1884 Mone, F., Mulcahy, C., McParland, P., & McAuliffe, F. M. (2017). Should we recommend universal aspirin for all pregnant women? American Journal of Obstetrics and Gynecology, 216(2), 141.e1– 141.e5. doi:10.1016/j.ajog.2016.09.086 Roberge, S., Nicolaides, K., Demers, S., Hyett, J., Chaillet, N., & Bujold, E. (2017). The role of aspirin dose on the prevention of preeclampsia and fetal growth restriction: Systematic review and
meta-analysis. American Journal of Obstetrics and Gynecology, 216(2), 110–120. doi:10.1016/j. ajog.2016.09.076 Rolnik, D. L., Wright, D., Poon, L. C., O’Gorman, N., Syngelaki, A., de Paco Matallana, C., . . . Molina, F. S. (2017). Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. New England Journal of Medicine, 377, 613–622. doi:10.1056/NEJMoa1704559 Sarma, A., & Scott, N. S. (2016). Aspirin use in women: Current perspectives and future directions. Current Atherosclerosis Reports, 18(17), 1–8. doi:10.1007/s11883-016-0630-1 Tolcher, M. C., Chu, D. M., Hollier, L. M., Mastrobattista, J. M., Racusin, D. A., Ramin, S. M., . . . Aagaard, K. M. (2017). Impact of USPSTF recommendations for aspirin for prevention of recurrent preeclampsia. American Journal of Obstetrics and Gynecology, 217(3), 365.e1–365. e8. doi:10.1016/j.ajog.2017.04.035 U.S. Preventive Services Task Force. (2016). Grade definitions. Retrieved from https://www .uspreventiveservicestaskforce.org/Page/Name/ grade-definitions
It seems that barely a day goes by without a new drug being released—or perhaps recalled. How can you stay on top of it all? Read “Rx,” a clinical practice column appearing three times a year in Nursing for Women’s Health. It covers the latest developments in prescription and over-the-counter pharmacotherapeutics—everything from the HPV vaccine to over-the-counter weight loss drugs, all to help you provide optimum care to your patients and to answer their questions.
92
Nursing for Women’s Health
Volume 22
Issue 1