Prophylactic use of aspirin can considerably bring down the incidence of preterm SGA

Use of prophylactic aspirin in high-risk group identified by first trimester screening for preeclampsia would considerably lower the incidence of preterm and early SGA by about 20% and 40%, respectively report the results of a data analysis published July 2018 in ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) journal Ultrasound in Obstetrics and Gynecology.

The researchers analyzed the data from two multicentric trials: Screening program for pre-eclampsia (SPREE) study and the Aspirin for Evidence-Based Preeclampsia Prevention trial (ASPRE). SPREE is a prospective multicenter cohort study that screened women for PE during 11-13 weeks by measuring Mean arterial pressure (MAP), Uterine artery pulsatility index (UtA‐PI), Serum placental growth factor (PlGF), and Serum pregnancy‐associated plasma protein‐A (PAPP‐A).

ASPRE trial examined the prophylactic effect of low-dose aspirin started at 11-14 weeks for prevention of PE in women at increased risk for preterm PE.  The results demonstrated that aspirin reduces the incidence of early-PE by 89% and pre-term PE by 62% but does not much reduce the incidence of term PE.

The combined use of maternal factors mean arterial pressure, uterine artery pulsatility index and serum placental growth factor for the screening for preterm preeclampsia identifies a high proportion of patients who will develop small for gestational age (SGA) babies.

Screening in SPREE trial identified 46% of SGA <10th Percentile neonate born before 37 weeks and 56% of those born before 32 weeks with a screen positive rate of 12.2%. Analysis of data from ASPRE trial showed that aspirin reduced the rate of SGA <10th Percentile by 40% in babies born at or before 37 weeks and by 73% in babies born before 32 weeks.

The decrease in the incidence of SGA infants was mainly due to a substantial decrease in the incidence of PE to the amount of 90% in babies born before 32 weeks and 70% in babies born at or before 37 weeks.

Hence, the authors concluded that first-trimester screening of PE identifies a high proportion of patients with who will develop preterm-SGA as the pregnancy progresses further and the prophylactic use of aspirin can prevent that.

Here is a Video abstract of the above study

Abstract

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What should midlife women know about preventive cardiology?

We are all aware that sex and gender differences are important in the diagnosis and management of cardiovascular diseases. A woman’s risk of a cardiac event and stroke sharply increases after the onset of menopause. Here is an informative video regarding preventing and managing the increased risk of a cardiac event after menopause.

Dr. Beth Abramson is a preventive cardiologist and helps women manage the risk of heart disease.  In this video by North American Menopause Society (NAMS), she answers many vital questions about menopausal hormone therapy, midlife weight gain, smoking, alcohol, and aspirin therapy.  

Regular Aspirin use reduces the risk of cancer death: News from AACR annual meeting.

courtesy:corbis 

Long term, regular use of aspirin cut down the death rate in several types of cancers, according to an observational study presented at the American Association for Cancer Research(AACR) 2017 Annual Meeting, April 1-5.

The overall mortality rate was 7% lower in women and 11% lower for men in aspirin users and cancer mortality rate was 7% lower for women and 15% lower for men.

The researchers did a follow-up of 130,183 health professionals consisting of 86,206 women who were participants in the Nurses’ Health Study between 1980 and 2012, and 43,977 men who were recruited in the Health Professionals Follow-Up Study from 1986 to 2012.

The cohort was followed up for 32 years with aspirin use assessed at baseline and thereafter every two years.

During the follow up period 25% women and 33% men died, of which 37.5% women and 31% men’s death were because of cancer.

The strongest reduction in deaths were observed in colorectal cancer, with the relative risk lowered by 31% for women and 30% for men. Men who took aspirin regularly also had 23% lower relative risk of mortality due to prostate cancer, while women had 11% lower risk of dying from breast cancer.

Aspirin was beneficial in standard dose of .5 to 7 tablets per week, with a minimum of 6 years for reaping the benefits of lower mortality in cancer.

The USPSTF recommends “Initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.”

The study’s lead author, Yin Cao said “These findings suggest that aspirin’s established benefits in cardiovascular disease and colorectal cancer reduction may extend to other common causes of death, including several major cancers. She said that while the study supports the long-term use of aspirin, patients and physicians should consider all potential benefits and risks, as well as individual health factors, when considering whether a patient should routinely take aspirin.”

“We need to conduct additional work to balance these benefits against the harms of use, such as gastrointestinal tract bleeding and hemorrhagic stroke,” she said.

The study’s observational design was a limiting factor making it less definitive than results of randomized trial.

Low dose aspirin in prevention of spontaneous preterm births- A Systematic Review and Meta-analysis.

fda.gov

Antiplatelet agents(Aspirin) reduce spontaneous preterm birth(PTBs) in pregnant women at risk for preeclampsia according to a study published in February issue of Journal of Obstetrics and Gynecology.

This is an additional analysis of data from The Perinatal Antiplatelet Review of International Studies Individual Participant Data meta-analysis which showed moderate reduction in risk of preeclampsia (relative risk [RR] 0.90, 95% confidence interval [CI] 0.84–0.97).

Preterm birth(PTB) is the birth of an infant before 37 weeks of pregnancy, according to WHO statistics an estimated 15 million babies born preterm out of whom 1 million succumb. PTB is also responsible for long term neurological complications in children like cerebral palsy, learning disabilities and visual and hearing problems.

The current global preterm birth rate is 5% to 18% and statistic shows a steady increase recently. More than 60% of preterm births occur in Africa and South Asia, India topping the list with 3 519 100 PTBs.

Three forth of these births could be prevented, saving lives and money across the globe. History of uterine evacuation is an independent risk factor for preterm birth.[1] Other risk factors for PTBs are Myometrial contractions, mother's cervicovaginal microbiota and Intrauterine infections. Myometrial contractions are triggered by interplay between mechanical, endocrine and immune factors. Increasing body of evidence suggests that uteroplacental ischemia could play an important role in bringing on preterm births similar to its role in preeclampsia. 

The evidence comes from examining the placental tissues in women with spontaneous PTBs. At least one third biopsies depicted placental vascular pathology in terms of failure of physiological transformation of spiral arteries as seen in preeclampsia.

Keeping in view the similar pathologies for PTBs and preeclampsia the authors wanted to know whether aspirin could prevent iatrogenic as well as spontaneous preterm births.

After excluding the women who did not meet the study criteria, 27,510 women were randomized to receive low dose aspirin vs. Placebo. These women were at low to moderate risk for developing preeclampsia.

Low dose aspirin was started between 16- 20 weeks  depending upon the gestational age upon entering into the studies. 

The study was evaluated based on 3 primary endpoints: spontaneous preterm birth at < 37 weeks, < 34 weeks, and < 28 weeks of gestation.

Antiplatelet agent (Aspirin) significantly reduced the risk of PTBs by 7%. PTBs before 34 weeks were reduced by 14%. The study did not find significant reduction in preterm births before 28 weeks of gestation. It may be because of lack of power in that subgroup or pathologies other than placental ischemia may play a role in very early PTBs.

Incidence of antepartum hemorrhage, placental abruption or neonatal bleeding remained the same for the two study arms. Slight higher incidence of PPH was seen in aspirin group, but was not statistically significant.

The administration of antiplatelet agents such as aspirin during pregnancy is considered a safe intervention as a recent review commissioned by the U.S. Preventive Services Task Force concluded.

The authors concluded “The current findings might be applicable to a broader population of pregnant women. Because there is a paucity of preventive strategies for spontaneous preterm birth, we suggest that the use of antiplatelet agents may be a promising intervention for women who have a history of spontaneous preterm birth.” They further added “The current study provides clinicians with the best available evidence to counsel women regarding who might benefit from this intervention.”

Full text of the article can be accessed here.

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[1] https://obgynupdated.blogspot.com/2016/06/history-of-uterine-evacuation-is.html

The best agent to prevent preeclampsia: A systematic review and network meta-analysis--News from SMFM 2017, Las Vegas.

Calcium supplements 

Out of various agents used for prevention of preeclampsia calcium supplementation has got the highest likelihood of being successful in bringing down its incidence and perinatal mortality as per a study presented by Sanchez-Ramos L. et al. at the pregnancy meeting, SMFM 2017, Las Vegas.

Preeclampsia complicates approximately 3-5% of pregnancies, accounting for 10-15% of maternal deaths and 3% of perinatal deaths.

Numerous agents have been studied for their ability to prevent preeclampsia and conventional studies have gauged the effectiveness of these agents. But these have been small, single center trials.

This was a systematic review and network meta-analysis of large RCTs comparing the effectiveness of multiple treatment options in preventing preeclampsia. Only data from meta-analysis of large RCTs with more than 450 subjects were included.

The study was registered under PROSPERO,[1] an international prospective register of systematic reviews in areas of healthcare all around the world and guided by PRISMA guidelines.[2]

A search of electronic databases from 1966 through July15, 2016 picked up 27 large multicenter trials with total of 60, 425 pregnant women. This large cohort was used to compare various exposures against Placebo or no treatment for the development of preeclampsia. The secondary outcome studied were severity of preeclampsia and maternal and neonatal morbidity and mortality. The various agents studied were:

• Low-dose aspirin: aspirin given at low doses (50-100mg) during pregnancy
• Calcium supplementation: given at doses of 500-2000mg
• Low molecular weight heparin: anticoagulant
• Vitamin E/C: vitamin supplements in varying doses as defined by the study
• Fish oil: supplement derived from fatty tissue of fish containing omega-3 fatty acids

Direct and indirect pairwise comparison was done using STATA for multivariate random effect models.

It was seen that women who regularly received Calcium supplementation had a 61% and 74% less odds of developing preeclampsia in direct and indirect comparison.

Women receiving calcium supplementation has 68% less likelihood of developing preeclampsia as compared to women receiving fish oil.  

Taking Calcium was also associated with less chances of perinatal mortality as compared to low-dose aspirin, vitamins C & E, and placebo. 

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[1] https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/2046-4053-1-2

[2] http://www.prisma-statement.org/