Wednesday, March 15, 2023

Aspirin, preeclampsia, and heart disease in later life and children

Preeclampsia affects an estimated 4 million pregnancies worldwide each year and has lifelong health consequences for women and children. The U.S. Preventive Services Task Force (USPSTF) recommends screening for preeclampsia with blood pressure measurements throughout pregnancy; last month it released an updated draft statement that expands the screening indication to identify all hypertensive disorders of pregnancy. Exercise during pregnancy is recommended to reduce risk of gestational hypertension and preeclampsia. Additionally, the USPSTF and the American College of Obstetricians and Gynecologists recommend that pregnant patients at high risk for preeclampsia start taking daily low-dose (81 mg) aspirin at 12 weeks’ of gestation and continue until delivery. The high prevalence of preeclampsia risk factors has made preventive aspirin use increasingly common in the U.S. An analysis of 2019 birth certificate data found that low-dose aspirin was indicated in more than half of all pregnancies and could have been considered in more than 85 percent based on USPSTF criteria.

Since aspirin may increase peripartum bleeding risk, an open-label, noninferiority randomized trial in Spain compared discontinuing aspirin at 24 to 28 weeks’ gestation to continuation until 36 weeks (the standard of care in Europe) in pregnant patients judged to be at lower risk of preeclampsia based on second-trimester biomarkers. The incidence of preterm preeclampsia, the primary outcome, was similar between the groups. Of note, the aspirin dose was 150 mg daily, and high risk individuals were identified in the first trimester based on a screening algorithm that combined clinical factors with objective measurements such as mean uterine artery pulsatility index and serum placental growth factor. Differences in the European approach to preeclampsia prevention make it difficult to determine this study’s implications for U.S. practice.

A 2017 systematic review and meta-analysis of 22 studies found that preeclampsia is associated with a 4-fold increase in future heart failure risk and 2-fold increases in heart disease, stroke, and cardiovascular death. Should a history of adverse pregnancy outcomes be considered in atherosclerotic cardiovascular disease (ASCVD) risk assessments? To shed light on this question, Swedish researchers did a cross-sectional study of a population-based cohort of 10,000 women with one or more deliveries in 1973 or later who underwent coronary computed tomography angiography at age 50 to 65 years as part of a study from 2013-2018. Patients with histories of gestational hypertension and preeclampsia were more likely to have coronary atherosclerosis and significant stenosis even if their predicted ASCVD risk was low. Whether intensive primary prevention with statin therapy would improve outcomes in these patients is not known.

Finally, maternal preeclampsia has been associated with increased cardiovascular risks in children. In a population-based cohort study of individuals born in Denmark, Finland, and Sweden from 1973 to 2016, offspring of pregnancies with preeclampsia had increased risks of ischemic heart disease (adjusted hazard ratio, 1.33) and stroke (aHR, 1.34), independent of preterm or small for gestational age birth.


This post first appeared on the AFP Community Blog.