1
|
Lin X, Yong J, Gan M, Tang S, Du J. Impact of low-dose aspirin exposure on obstetrical outcomes: a meta-analysis. J Psychosom Obstet Gynaecol 2024; 45:2344079. [PMID: 38712869 DOI: 10.1080/0167482x.2024.2344079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/12/2024] [Indexed: 05/08/2024] Open
Abstract
OBJECTIVE To assess the impact of low-dose aspirin (LDA) on obstetrical outcomes through a meta-analysis of placebo-controlled randomized controlled trials (RCTs). METHODS A systematic search of the PubMed, Cochrane Library, Web of Science and Embase databases from inception to January 2024 was conducted to identify studies exploring the role of aspirin on pregnancy, reporting obstetrical-related outcomes, including preterm birth (PTB, gestational age <37 weeks), small for gestational age (SGA), low birth weight (LBW, birthweight < 2500g), perinatal death (PND), admission to the neonatal intensive care unit (NICU), 5-min Apgar score < 7 and placental abruption. Relative risks (RRs) were estimated for the combined outcomes. Subgroup analyses were performed by risk for preeclampsia (PE), LDA dosage (<100 mg vs. ≥100 mg) and timing of onset (≤20 weeks vs. >20 weeks). RESULTS Forty-seven studies involving 59,124 participants were included. Compared with placebo, LDA had a more significant effect on low-risk events such as SGA, PTB and LBW. Specifically, LDA significantly reduced the risk of SGA (RR = 0.91, 95% CI: 0.87-0.95), PTB (RR = 0.93, 95% CI: 0.89-0.97) and LBW (RR = 0.94, 95% CI: 0.89-0.99). For high-risk events, LDA significantly lowered the risk of NICU admission (RR = 0.93, 95% CI: 0.87-0.99). On the other hand, LDA can significantly increase the risk of placental abruption (RR = 1.72, 95% CI: 1.23-2.43). Subgroup analyses showed that LDA significantly reduced the risk of SGA (RR = 0.86, 95% CI: 0.77-0.97), PTB (RR = 0.93, 95% CI: 0.88-0.98) and PND (RR = 0.65, 95% CI: 0.48-0.88) in pregnant women at high risk of PE, whereas in healthy pregnant women LDA did not significantly improve obstetrical outcomes, but instead significantly increased the risk of placental abruption (RR = 5.56, 95% CI: 1.92-16.11). In pregnant women at high risk of PE, LDA administered at doses ≥100 mg significantly reduced the risk of SGA (RR = 0.77, 95% CI: 0.66-0.91) and PTB (RR = 0.56, 95% CI: 0.32-0.97), but did not have a statistically significant effect on reducing the risk of NICU, PND and LBW. LDA started at ≤20 weeks significantly reduced the risk of SGA (RR = 0.76, 95% CI: 0.65-0.89) and PTB (RR = 0.56, 95% CI: 0.32-0.97). CONCLUSIONS To sum up, LDA significantly improved neonatal outcomes in pregnant women at high risk of PE without elevating the risk of placental abruption. These findings support LDA's clinical application in pregnant women, although further research is needed to refine dosage and timing recommendations.
Collapse
Affiliation(s)
- Xiaoyan Lin
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Jingchao Yong
- The First Clinical Medical College, Nanjing Medical University, Nanjing, China
| | - Ming Gan
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, China
| | - Shaowen Tang
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Jiangbo Du
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, China
- Department of Epidemiology, School of Public Health, Center for Global Health, Nanjing Medical University, Nanjing, China
- State Key Laboratory of Reproductive Medicine (Suzhou Centre), The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, China
| |
Collapse
|
2
|
Habelrih T, Ferri B, Côté F, Sévigny J, Augustin TL, Sawaya K, Lubell WD, Olson DM, Girard S, Chemtob S. Preventing Preterm Birth: Exploring Innovative Solutions. Clin Perinatol 2024; 51:497-510. [PMID: 38705654 DOI: 10.1016/j.clp.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
This review examines the complexities of preterm birth (PTB), emphasizes the pivotal role of inflammation in the pathogenesis of preterm labor, and assesses current available interventions. Antibiotics, progesterone analogs, mechanical approaches, nonsteroidal anti-inflammatory drugs, and nutritional supplementation demonstrate a limited efficacy. Tocolytic agents, targeting uterine activity and contractility, inadequately prevent PTB by neglecting to act on uteroplacental inflammation. Emerging therapies targeting toll-like receptors, chemokines, and interleukin receptors exhibit promise in mitigating inflammation and preventing PTB.
Collapse
Affiliation(s)
- Tiffany Habelrih
- Université de Montréal, Pavillion Roger-Gaudry, 2900 boul Edouard-Montpetit, H3T 1J4, Montréal, Québec, Canada; Centre de recherche du CHU Sainte-Justine, 3175 ch de la Côte-Sainte-Catherine, H3T 1C5, Montréal, Québec, Canada
| | - Béatrice Ferri
- Université de Montréal, Pavillion Roger-Gaudry, 2900 boul Edouard-Montpetit, H3T 1J4, Montréal, Québec, Canada; Centre de recherche du CHU Sainte-Justine, 3175 ch de la Côte-Sainte-Catherine, H3T 1C5, Montréal, Québec, Canada
| | - France Côté
- Université de Montréal, Pavillion Roger-Gaudry, 2900 boul Edouard-Montpetit, H3T 1J4, Montréal, Québec, Canada; Centre de recherche du CHU Sainte-Justine, 3175 ch de la Côte-Sainte-Catherine, H3T 1C5, Montréal, Québec, Canada
| | - Juliane Sévigny
- Département de Biologie, Université de Sherbrooke, Voie 9, J1X 2X9, Sherbrooke, Québec, Canada
| | - Thalyssa-Lyn Augustin
- Université de Montréal, Pavillion Roger-Gaudry, 2900 boul Edouard-Montpetit, H3T 1J4, Montréal, Québec, Canada; Centre de recherche du CHU Sainte-Justine, 3175 ch de la Côte-Sainte-Catherine, H3T 1C5, Montréal, Québec, Canada
| | - Kevin Sawaya
- Centre de recherche du CHU Sainte-Justine, 3175 ch de la Côte-Sainte-Catherine, H3T 1C5, Montréal, Québec, Canada; Department of Microbiology and Immunology, McGill University, 3775 Rue University, Room 511, H3A 2B4, Montréal, Québec, Canada
| | - William D Lubell
- Département de Chimie, Université de Montréal, Complexe des Sciences, 1375 avenue Thérèse-Lavoie-Roux, Montréal, Québec, H2V 0B3, Canada
| | - David M Olson
- Departments of Obstetrics and Gynecology, Pediatrics, and Physiology, University of Alberta, 220 HMRC, T6G 2S2, Edmonton, Alberta, Canada
| | - Sylvie Girard
- Department of Obstetrics and Gynecology, Department of Immunology, Mayo Clinic, 200 First Street SW, Guggenheim Building 3rd floor, Rochester, MN 55905, USA
| | - Sylvain Chemtob
- Université de Montréal, Pavillion Roger-Gaudry, 2900 boul Edouard-Montpetit, H3T 1J4, Montréal, Québec, Canada; Centre de recherche du CHU Sainte-Justine, 3175 ch de la Côte-Sainte-Catherine, H3T 1C5, Montréal, Québec, Canada.
| |
Collapse
|
3
|
Baradwan S, Tawfiq A, Hakeem GF, Alkaff A, Hafedh B, Faden Y, Khadawardi K, Abdulghani SH, Althagafi H, Abu-Zaid A. The effects of low-dose aspirin on preterm birth: a systematic review and meta-analysis of randomized controlled trials. Arch Gynecol Obstet 2024; 309:1775-1786. [PMID: 38372754 DOI: 10.1007/s00404-024-07373-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/02/2024] [Indexed: 02/20/2024]
Abstract
AIM To conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) that evaluated the efficacy of low-dose aspirin (LDA, ≤ 160 mg/day) on preventing preterm birth (PB). METHODS Five databases were screened from inception until June 25, 2023. The RCTs were assessed for quality according to Cochrane's risk of bias tool. The endpoints were summarized as risk ratio (RR) with 95% confidence interval (CI). RESULTS Overall, 40 RCTs were analyzed. LDA significantly decreased the risk of PB < 37 weeks (RR: 0.91, 95% CI 0.87, 0.96, p < 0.001, moderate certainty of evidence) with low between-study heterogeneity (I2 = 23.2%, p = 0.11), and PB < 34 weeks (RR: 0.78, 95% CI 0.61, 0.99, p = 0.04, low certainty of evidence) with high between-study heterogeneity (I2 = 58.3%, p = 0.01). There were no significant differences between both groups regarding the risk of spontaneous (RR: 0.94, 95% CI 0.83, 1.07, p = 0.37) and medically indicated (RR: 1.28, 95% CI 0.87, 1.88, p = 0.21) BP < 37 weeks. Sensitivity analysis revealed robustness for all outcomes, except for the risk of PB < 34 weeks. For PB < 37 weeks and PB < 34 weeks, publication bias was detected based on visual inspection of funnel plots for asymmetry and statistical significance for Egger's test (p = 0.009 and p = 0.0012, respectively). CONCLUSION LDA can significantly reduce the risk of PB < 37 and < 34 weeks. Nevertheless, further high-quality RCTs conducted in diverse populations, while accounting for potential confounding factors, are imperative to elucidate the optimal aspirin dosage, timing of initiation, and treatment duration for preventing preterm birth and to arrive at definitive conclusions.
Collapse
Affiliation(s)
- Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Afaf Tawfiq
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ghaidaa Farouk Hakeem
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Alya Alkaff
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Bandr Hafedh
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Yaser Faden
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Khalid Khadawardi
- Department of Obstetrics and Gynecology, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Sahar H Abdulghani
- Department of Obstetrics and Gynecology, Security Forces Hospital Program, Riyadh, Saudi Arabia
| | - Hanin Althagafi
- Department of Obstetrics and Gynecology, Faculty of Medicine at Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Abu-Zaid
- Department of Obstetrics and Gynecology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| |
Collapse
|
4
|
Yan X, Zheng W, Wang J, Yuan X, Li G. Low-dose aspirin for the prevention of preterm birth in nulliparous women: systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:260. [PMID: 38605330 PMCID: PMC11008052 DOI: 10.1186/s12884-024-06413-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/12/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVE The objective was to assess the efficacy and safety of low-dose aspirin for the prevention of preterm birth in nulliparous women. DATA SOURCES We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to June 2022. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared aspirin to placebo in nulliparous women were eligible. METHODS This study was reported in accordance with the PRISMA 2020 checklist. The primary outcomes of this study were the rates of preterm birth at less than 37 weeks and less than 34 weeks of gestation. The secondary outcomes included postpartum hemorrhage, placental abruption, cesarean section, any hypertensive disorder of pregnancy and small for gestational age. Relative risks with their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed by Cochran's Q test and Higgins's I2. A random-effects model was used when I2 was > 50% to generate the RR and 95% CI; otherwise, a fixed-effects model was used. The risk of publication bias was assessed by funnel plots. We performed sensitivity analysis by sequentially omitting each included study to confirm the robustness of the analysis. RESULTS Seven studies with a total of 29,029 participants were included in this review. Six studies were assessed as having a low risk of bias or an unclear risk of bias, and one study was judged as having a high risk of bias. In nulliparous women, low-dose aspirin was associated with a significant reduction in the rate of preterm birth at less than 34 weeks of gestational age (RR 0.84,95% CI: 0.71-0.99; I2 = 0%; P = 0.04), but we did not observe a significant difference in the rate of preterm birth at less than 37 weeks of gestation (RR 0.96,95% CI: 0.90-1.02; I2 = 31%; P = 0.18). Low-dose aspirin was associated with a significant increase in the rates of postpartum hemorrhage (RR 1.32,95% CI: 1.14-1.54; I2 = 0%; P = 0.0003), placental abruption (RR 2.18,95% CI: 1.10-4.32; I2 = 16%; P = 0.02) and cesarean section (RR 1.053, 95% CI: 1.001-1.108; I2 = 0%; P = 0.05) in nulliparous women. We also did not observe a significant effect of low-dose aspirin on the rates of any hypertensive disorder of pregnancy (RR 1.05, 95% CI: 0.96-1.14; I2 = 9%; P = 0.28) or small for gestational age (RR 0.96, 95% CI: 0.91-1.02; I2 = 0%; P = 0.16) in nulliparous women. Funnel plots indicated that no significant publication bias existed in this meta-analysis. Except for preterm birth at less than 34 weeks of gestation, placental abruption and cesarean section, the sensitivity analysis showed similar results, which confirmed the robustness of this meta-analysis. CONCLUSIONS Low-dose aspirin might reduce the risk of preterm birth at less than 34 weeks of gestation in nulliparous women. The use of low-dose aspirin in nulliparous women increased the risk of postpartum hemorrhage and might increase the risk of placental abruption and cesarean section.
Collapse
Affiliation(s)
- Xin Yan
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Wei Zheng
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Jia Wang
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Xianxian Yuan
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Guanghui Li
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China.
| |
Collapse
|
5
|
Mirzamoradi M, Dehghani Z, Azadi P, Mohammadi M, Khavandegar A, Bakhtiyari M. Evaluation of the Effect of Low-dose Aspirin on the Prevention of Preterm Delivery in Women with a History of Spontaneous Preterm Delivery. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e646-e653. [PMID: 38029766 PMCID: PMC10686757 DOI: 10.1055/s-0043-1772480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/16/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE Currently, uteroplacental vascular disorders are considered one of the main mechanisms of spontaneous preterm delivery (PTD). Low-dose aspirin is used to prevent pre-eclampsia, which has a similar mechanism; hence, the present study aimed to investigate the effect of low-dose aspirin on the prevention of PTD in women with a history of spontaneous PTD. METHODS The present pilot randomized clinical trial was conducted on 54 pregnant women in the aspirin group (taking 80 mg daily until the 36th week and classic treatment) and 53 patients in the control group (only receiving classic treatment). RESULTS Forty-three patients (40%) presented before 37 weeks due to symptoms of PTL. Preterm delivery (< 37 weeks) occurred in 28 patients (26%), and there was no significant difference between the aspirin and control groups (10 patients [19%] and 18 patients [34%], respectively; p = 0.069). The time of preterm delivery was early (< 34 weeks) in 6 patients (21%), and its cause was spontaneous labor in 23 patients (82%) which was not significantly different between the two groups (p > 0.05). Out of 40 patients with spontaneous labor, 25 patients (63%) had a PTD, which was significantly lower in the aspirin group than in the control group (9 patients [45%] versus 16 patients [80%], respectively; p = 0.022). CONCLUSION The findings of the present study demonstrated that despite the reduction in the incidence of PTD using low-dose aspirin, the reduction rate was not statistically significant. On the other hand, in patients with spontaneous labor prone to PTD, aspirin was effective in reducing the incidence of PTD.
Collapse
Affiliation(s)
- Masoumeh Mirzamoradi
- Department of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Dehghani
- Department of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pegah Azadi
- Department of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Mohammadi
- Department of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Khavandegar
- Sina Trauma and Surgery Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmood Bakhtiyari
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| |
Collapse
|
6
|
Bij de Weg JM, Landman AJEMC, de Vries JIP, Thijs A, Harmsze AM, Oudijk MA, de Boer MA. The effect of low-dose aspirin on platelet function during pregnancy compared to placebo: An explorative study. Eur J Obstet Gynecol Reprod Biol 2022; 278:67-71. [PMID: 36116392 DOI: 10.1016/j.ejogrb.2022.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/24/2022] [Accepted: 08/27/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To evaluate the effect of aspirin 80 mg compared to placebo on platelet function tests in the second and third trimester of pregnancy. STUDY DESIGN An explorative study was performed to assess laboratory platelet function in a subpopulation of the APRIL trial: a randomized double-blind trial comparing aspirin 80 mg once daily to placebo for the prevention of recurrent preterm birth. Platelet function was measured between 18 and 22, and between 28 and 32 weeks gestational age with three platelet function tests: VerifyNow®, Chronolog light transmission aggregometry (Chronolog LTA) and serum thromboxane B2 (TxB2). Medication adherence was evaluated by pill counts, self-reported diaries and structured interviews. RESULTS We included 11 women, six in the aspirin and five in the placebo group. In women receiving aspirin, platelet function was significantly lower compared to women receiving placebo for all three tests: VerifyNow® Aspirin Reaction Units (450.5 vs 648.0, p = 0.017); Chronolog LTA (9.5% vs 94.5%, p = 0.009); serum TxB2 levels (11.9 ng/mL versus 175.9 ng/mL, p = 0.030). For all three tests, platelet function did not differ between the second and third trimester of pregnancy in the aspirin group. In the placebo group, serum TxB2 levels were significantly higher in the third trimester. One non-adherent participant in the aspirin group showed results similar to the placebo group. CONCLUSION Aspirin 80 mg has a clear inhibitory effect on laboratory platelet function during pregnancy compared to placebo. This effect is similar in the second and third trimester of pregnancy.
Collapse
Affiliation(s)
- Jeske M Bij de Weg
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.
| | - Anadeijda J E M C Landman
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Johanna I P de Vries
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Abel Thijs
- Amsterdam UMC, Vrije Universiteit Amsterdam, Internal Medicine, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Ankie M Harmsze
- St. Antonius Hospital, Clinical Pharmacy, Koekoekslaan 1, Nieuwegein, The Netherlands
| | - Martijn A Oudijk
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Marjon A de Boer
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| |
Collapse
|
7
|
Affiliation(s)
| | - Sarah J Stock
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
8
|
Landman AJEMC, de Boer MA, Visser L, Nijman TAJ, Hemels MAC, Naaktgeboren CN, van der Weide MC, Mol BW, van Laar JOEH, Papatsonis DNM, Bekker MN, van Drongelen J, van Pampus MG, Sueters M, van der Ham DP, Sikkema JM, Zwart JJ, Huisjes AJM, van Huizen ME, Kleiverda G, Boon J, Franssen MTM, Hermes W, Visser H, de Groot CJM, Oudijk MA. Evaluation of low-dose aspirin in the prevention of recurrent spontaneous preterm labour (the APRIL study): A multicentre, randomised, double-blinded, placebo-controlled trial. PLoS Med 2022; 19:e1003892. [PMID: 35104279 PMCID: PMC8806064 DOI: 10.1371/journal.pmed.1003892] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/14/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Preterm birth is the leading cause of neonatal morbidity and mortality. The recurrence rate of spontaneous preterm birth is high, and additional preventive measures are required. Our objective was to assess the effectiveness of low-dose aspirin compared to placebo in the prevention of preterm birth in women with a previous spontaneous preterm birth. METHODS AND FINDINGS We performed a parallel multicentre, randomised, double-blinded, placebo-controlled trial (the APRIL study). The study was performed in 8 tertiary and 26 secondary care hospitals in the Netherlands. We included women with a singleton pregnancy and a history of spontaneous preterm birth of a singleton between 22 and 37 weeks. Participants were randomly assigned to aspirin 80 mg daily or placebo initiated between 8 and 16 weeks of gestation and continued until 36 weeks or delivery. Randomisation was computer generated, with allocation concealment by using sequentially numbered medication containers. Participants, their healthcare providers, and researchers were blinded for treatment allocation. The primary outcome was preterm birth <37 weeks of gestation. Secondary outcomes included a composite of poor neonatal outcome (bronchopulmonary dysplasia, periventricular leukomalacia > grade 1, intraventricular hemorrhage > grade 2, necrotising enterocolitis > stage 1, retinopathy of prematurity, culture proven sepsis, or perinatal death). Analyses were performed by intention to treat. From May 31, 2016 to June 13, 2019, 406 women were randomised to aspirin (n = 204) or placebo (n = 202). A total of 387 women (81.1% of white ethnic origin, mean age 32.5 ± SD 3.8) were included in the final analysis: 194 women were allocated to aspirin and 193 to placebo. Preterm birth <37 weeks occurred in 41 (21.2%) women in the aspirin group and 49 (25.4%) in the placebo group (relative risk (RR) 0.83, 95% confidence interval (CI) 0.58 to 1.20, p = 0.32). In women with ≥80% medication adherence, preterm birth occurred in 24 (19.2%) versus 30 (24.8%) women (RR 0.77, 95% CI 0.48 to 1.25, p = 0.29). The rate of the composite of poor neonatal outcome was 4.6% (n = 9) versus 2.6% (n = 5) (RR 1.79, 95% CI 0.61 to 5.25, p = 0.29). Among all randomised women, serious adverse events occurred in 11 out of 204 (5.4%) women allocated to aspirin and 11 out of 202 (5.4%) women allocated to placebo. None of these serious adverse events was considered to be associated with treatment allocation. The main study limitation is the underpowered sample size due to the lower than expected preterm birth rates. CONCLUSIONS In this study, we observed that low-dose aspirin did not significantly reduce the preterm birth rate in women with a previous spontaneous preterm birth. However, a modest reduction of preterm birth with aspirin cannot be ruled out. Further research is required to determine a possible beneficial effect of low-dose aspirin for women with a previous spontaneous preterm birth. TRIAL REGISTRATION Dutch Trial Register (NL5553, NTR5675) https://www.trialregister.nl/trial/5553.
Collapse
Affiliation(s)
- Anadeijda J. E. M. C. Landman
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Marjon A. de Boer
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Laura Visser
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Tobias A. J. Nijman
- Department of Obstetrics and Gynaecology, Haaglanden Medical Centre, Den Haag, the Netherlands
| | | | - Christiana N. Naaktgeboren
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Marijke C. van der Weide
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Ben W. Mol
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Aberdeen Centre for Women’s Health Research, University of Aberdeen Aberdeen, United Kingdom
| | | | | | - Mireille N. Bekker
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marieke Sueters
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, the Netherlands
| | - David P. van der Ham
- Department of Obstetrics and Gynaecology, Martini Hospital, Groningen, the Netherlands
| | - J. Marko Sikkema
- Department of Obstetrics and Gynaecology, Hospital Group Twente Almelo, Almelo, the Netherlands
| | - Joost J. Zwart
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, the Netherlands
| | - Anjoke J. M. Huisjes
- Department of Obstetrics and Gynaecology, Gelre Hospitals Apeldoorn, Apeldoorn, the Netherlands
| | | | - Gunilla Kleiverda
- Department of Obstetrics and Gynaecology, Flevo Hospital Almere, Almere, the Netherlands
| | - Janine Boon
- Department of Obstetrics and Gynaecology, Diakonessenhuis, Utrecht, the Netherlands
| | - Maureen T. M. Franssen
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Wietske Hermes
- Department of Obstetrics and Gynaecology, Haaglanden Medical Centre, Den Haag, the Netherlands
| | - Harry Visser
- Department of Obstetrics and Gynaecology, Tergooi Hospitals, Hilversum, the Netherlands
| | - Christianne J. M. de Groot
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Martijn A. Oudijk
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| |
Collapse
|
9
|
Ye Y, Wen L, Liu X, Wang L, Liu Y, Saffery R, Kilby MD, Tong C, Qi H, Baker P. Low-dose aspirin for primary prevention of adverse pregnancy outcomes in twin pregnancies: an observational cohort study based on propensity score matching. BMC Pregnancy Childbirth 2021; 21:786. [PMID: 34802426 PMCID: PMC8607699 DOI: 10.1186/s12884-021-04217-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background Since the effectiveness of low-dose aspirin (LDA) in twin pregnancies is uncertain, we aimed to preliminarily assess whether LDA is beneficial in preventing preeclampsia in twin pregnancies. Methods This study is an observational study in two hospitals in China. Among 932 women, 277 in the First Affiliated Hospital of Chongqing Medical University were routinely treated with aspirin (100 mg daily) from 12 to 16 weeks to 35 weeks of gestational age, while 655 in Chongqing Health Center for Women and Children were not taking aspirin during pregnancy. We followed each subject and the individual details were recorded. Results LDA significantly reduced the risk of preeclampsia (RR 0.48; 95% CI 0.24–0.95) and preterm birth 34 weeks (RR 0.50; 95% CI 0.29–0.86) and showed possible benefits to lower the rate of SGA babies (RR 0.74; 95% CI 0.55–1.00). Moreover, the risk of postpartum hemorrhage was not increased by LDA (RR 0.89; 95% CI 0.35–2.26). Conclusions Treatment with low-dose aspirin in twin pregnancies could offer some protection against adverse pregnancy outcomes in the absence of significantly increased risk of postpartum hemorrhage. Trial registration Chinese Clinical Trial Registry (ChiCTR); ChiCTR-OOC-16008203, Retrospectively registered date: April 1st, 2016; Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04217-2.
Collapse
Affiliation(s)
- Ying Ye
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Li Wen
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiyao Liu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lan Wang
- Department of Obstetrics, Chongqing Women and Children's Health Center, Chongqing, 401147, China
| | - Yamin Liu
- Department of Obstetrics, Chongqing Women and Children's Health Center, Chongqing, 401147, China
| | - Richard Saffery
- Cancer, Disease and Developmental Epigenetics, Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, 3052, Australia
| | - Mark D Kilby
- Institute of Metabolism and System Research, University of Birmingham, Edgbaston, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, B15 2TG, UK
| | - Chao Tong
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China. .,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| | - Hongbo Qi
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China. .,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| | - Philip Baker
- College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester, LE1 7RH, UK
| |
Collapse
|
10
|
Jayaram A, Collier CH, Martin JN. Preterm parturition and pre-eclampsia: The confluence of two great gestational syndromes. Int J Gynaecol Obstet 2020; 150:10-16. [PMID: 32524594 DOI: 10.1002/ijgo.13173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/15/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Preterm birth (PTB) and pre-eclampsia independently, and frequently concurrently, adversely affect the pregnancy outcomes of millions of mothers and infants worldwide each year. OBJECTIVES To fill the gap between PTB and pre-eclampsia, which continue to constitute the two most important current global challenges to maternal and perinatal health. METHODS Pubmed, Embase, and Cochrane databases were searched from inception until December 2019 using the terms spontaneous PTB (SPTB), indicated preterm delivery (IPTD), early-onset pre-eclampsia, and pre-eclampsia. RESULTS History of PTB and pre-eclampsia were the strongest risk factors contributing to the occurrence of SPTB or IPTB. The risk of PTB and pre-eclampsia among non-Hispanic African American women was higher than the rate among all other racial/ethnic groups in the United States. Low-dose aspirin (LDA) has been reported to reduce the risk of pre-eclampsia by at least 10% and PTB by at least 14%. Lastly, women and their fetuses who develop early-onset pre-eclampsia are at higher risk for developing hypertension and cardiovascular disease later in life. CONCLUSIONS While better clarity is needed, efforts to coordinate prevention of both PTB and pre-eclampsia, even though imperfect, are critically important as part of any program to make motherhood as safe as possible.
Collapse
Affiliation(s)
- Aswathi Jayaram
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charlene H Collier
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - James N Martin
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| |
Collapse
|
11
|
El-Achi V, de Vries B, O'Brien C, Park F, Tooher J, Hyett J. First-Trimester Prediction of Preterm Prelabour Rupture of Membranes. Fetal Diagn Ther 2020; 47:624-629. [PMID: 32268324 DOI: 10.1159/000506541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 02/13/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Preterm prelabour rupture of membranes (PPRoM) is commonly associated with preterm delivery and affects up to 3% of all pregnancies. It is associated with high rates of morbidity and mortality for the mother and the newborn. OBJECTIVES To identify risk factors for PPRoM and develop a model for first-trimester prediction of risk of PPRoM. METHODS A retrospective analysis of a series of women who had first-trimester (11-13+6 weeks) screening for aneuploidy and pre-eclampsia and delivered in the same institution was performed. Univariate and multivariate logistic regression analyses were used to identify maternal and pregnancy factors and then develop a clinical prediction model for PPRoM. RESULTS 10,280 women were screened between April 2010 and October 2016. 144 (1.4%) had PPRoM. Maternal factors predictive of PPRoM included nulliparity (parous women, OR 0.53; 95% CI 0.4-0.8), pre-existing diabetes mellitus (DM) (Type 1 DM, OR 6.7; 95% CI 2.3-19.4, Type 2 DM, OR 5.3; 95% CI 1.6-18.3), maternal age group (p = 0.004), and BMI category (p = 0.012). Uterine artery pulsatility index (UAPI) and biochemical parameters (PAPP-A, free βHCG) did not reach statistical significance. The predictive model had moderate efficacy with an area under the ROC curve of 0.67. CONCLUSIONS Several maternal characteristics collected during first-trimester screening predict PPRoM. Biomarkers currently measured during first-trimester screening (PAPP-A, βHCG, and UAPI) do not predict PPRoM. Whilst a predictive model can be generated with information currently collected at 11-13+6 weeks, this has only modest screening performance. First-trimester screening provides a structured framework where other predictors could improve model performance, and future studies should focus on the addition of other risk factors and biomarkers that may improve screening efficacy.
Collapse
Affiliation(s)
- Vanessa El-Achi
- Sydney Institute for Women, Children and their Families, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia,
| | - Bradley de Vries
- Sydney Institute for Women, Children and their Families, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Cecelia O'Brien
- Sydney Institute for Women, Children and their Families, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Maternal and Fetal Medicine, Townsville Hospital, Townsville, Queensland, Australia
| | - Felicity Park
- Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Jane Tooher
- Sydney Institute for Women, Children and their Families, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jon Hyett
- Sydney Institute for Women, Children and their Families, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
12
|
Duley L, Meher S, Hunter KE, Seidler AL, Askie LM. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev 2019; 2019:CD004659. [PMID: 31684684 PMCID: PMC6820858 DOI: 10.1002/14651858.cd004659.pub3] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pre-eclampsia is associated with deficient intravascular production of prostacyclin, a vasodilator, and excessive production of thromboxane, a vasoconstrictor and stimulant of platelet aggregation. These observations led to the hypotheses that antiplatelet agents, low-dose aspirin in particular, might prevent or delay development of pre-eclampsia. OBJECTIVES To assess the effectiveness and safety of antiplatelet agents, such as aspirin and dipyridamole, when given to women at risk of developing pre-eclampsia. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (30 March 2018), and reference lists of retrieved studies. We updated the search in September 2019 and added the results to the awaiting classification section of the review. SELECTION CRITERIA All randomised trials comparing antiplatelet agents with either placebo or no antiplatelet agent were included. Studies only published in abstract format were eligible for inclusion if sufficient information was available. We would have included cluster-randomised trials in the analyses along with individually-randomised trials, if any had been identified in our search strategy. Quasi-random studies were excluded. Participants were pregnant women at risk of developing pre-eclampsia. Interventions were administration of an antiplatelet agent (such as low-dose aspirin or dipyridamole), comparisons were either placebo or no antiplatelet. DATA COLLECTION AND ANALYSIS Two review authors assessed trials for inclusion and extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For this update we incorporated individual participant data (IPD) from trials with this available, alongside aggregate data (AD) from trials where it was not, in order to enable reliable subgroup analyses and inclusion of two key new outcomes. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE. MAIN RESULTS Seventy-seven trials (40,249 women, and their babies) were included, although three trials (relating to 233 women) did not contribute data to the meta-analysis. Nine of the trials contributing data were large (> 1000 women recruited), accounting for 80% of women recruited. Although the trials took place in a wide range of countries, all of the nine large trials involved only women in high-income and/or upper middle-income countries. IPD were available for 36 trials (34,514 women), including all but one of the large trials. Low-dose aspirin alone was the intervention in all the large trials, and most trials overall. Dose in the large trials was 50 mg (1 trial, 1106 women), 60 mg (5 trials, 22,322 women), 75mg (1 trial, 3697 women) 100 mg (1 trial, 3294 women) and 150 mg (1 trial, 1776 women). Most studies were either low risk of bias or unclear risk of bias; and the large trials were all low risk of bas. Antiplatelet agents versus placebo/no treatment The use of antiplatelet agents reduced the risk of proteinuric pre-eclampsia by 18% (36,716 women, 60 trials, RR 0.82, 95% CI 0.77 to 0.88; high-quality evidence), number needed to treat for one women to benefit (NNTB) 61 (95% CI 45 to 92). There was a small (9%) reduction in the RR for preterm birth <37 weeks (35,212 women, 47 trials; RR 0.91, 95% CI 0.87 to 0.95, high-quality evidence), NNTB 61 (95% CI 42 to 114), and a 14% reduction infetal deaths, neonatal deaths or death before hospital discharge (35,391 babies, 52 trials; RR 0.85, 95% CI 0.76 to 0.95; high-quality evidence), NNTB 197 (95% CI 115 to 681). Antiplatelet agents slightly reduced the risk of small-for-gestational age babies (35,761 babies, 50 trials; RR 0.84, 95% CI 0.76 to 0.92; high-quality evidence), NNTB 146 (95% CI 90 to 386), and pregnancies with serious adverse outcome (a composite outcome including maternal death, baby death, pre-eclampsia, small-for-gestational age, and preterm birth) (RR 0.90, 95% CI 0.85 to 0.96; 17,382 women; 13 trials, high-quality evidence), NNTB 54 (95% CI 34 to 132). Antiplatelet agents probably slightly increase postpartum haemorrhage > 500 mL (23,769 women, 19 trials; RR 1.06, 95% CI 1.00 to 1.12; moderate-quality evidence due to clinical heterogeneity), and they probably marginally increase the risk of placental abruption, although for this outcome the evidence was downgraded due to a wide confidence interval including the possibility of no effect (30,775 women; 29 trials; RR 1.21, 95% CI 0.95 to 1.54; moderate-quality evidence). Data from two large trials which assessed children at aged 18 months (including results from over 5000 children), did not identify clear differences in development between the two groups. AUTHORS' CONCLUSIONS Administering low-dose aspirin to pregnant women led to small-to-moderate benefits, including reductions in pre-eclampsia (16 fewer per 1000 women treated), preterm birth (16 fewer per 1000 treated), the baby being born small-for-gestational age (seven fewer per 1000 treated) and fetal or neonatal death (five fewer per 1000 treated). Overall, administering antiplatelet agents to 1000 women led to 20 fewer pregnancies with serious adverse outcomes. The quality of evidence for all these outcomes was high. Aspirin probably slightly increased the risk of postpartum haemorrhage of more than 500 mL, however, the quality of evidence for this outcome was downgraded to moderate, due to concerns of clinical heterogeneity in measurements of blood loss. Antiplatelet agents probably marginally increase placental abruption, but the quality of the evidence was downgraded to moderate due to low event numbers and thus wide 95% CI. Overall, antiplatelet agents improved outcomes, and at these doses appear to be safe. Identifying women who are most likely to respond to low-dose aspirin would improve targeting of treatment. As almost all the women in this review were recruited to the trials after 12 weeks' gestation, it is unclear whether starting treatment before 12 weeks' would have additional benefits without any increase in adverse effects. While there was some indication that higher doses of aspirin would be more effective, further studies would be warranted to examine this.
Collapse
Affiliation(s)
- Lelia Duley
- Nottingham Health Science PartnersNottingham Clinical Trials UnitC Floor, South BlockQueen's Medical CentreNottinghamUKNG7 2UH
| | | | - Kylie E Hunter
- University of SydneyNHMRC Clinical Trials CentreLocked Bag 77CamperdownNSWAustralia2050
| | - Anna Lene Seidler
- University of SydneyNHMRC Clinical Trials CentreLocked Bag 77CamperdownNSWAustralia2050
| | - Lisa M Askie
- University of SydneyNHMRC Clinical Trials CentreLocked Bag 77CamperdownNSWAustralia2050
| | | |
Collapse
|
13
|
Weinberg A, Huo Y, Kacanek D, Patel K, Watts DH, Wara D, Hoffman RM, Klawitter J, Christians U. Brief Report: Markers of Spontaneous Preterm Delivery in Women Living With HIV: Relationship With Protease Inhibitors and Vitamin D. J Acquir Immune Defic Syndr 2019; 82:181-187. [PMID: 31513074 PMCID: PMC6760328 DOI: 10.1097/qai.0000000000002111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Women living with HIV (WLHIV) have increased risk of spontaneous preterm delivery (SPTD). We sought to identify plasma predictors of SPTD and their correlations with factors that increase the risk of SPTD, such as vitamin D deficiency and use of protease inhibitors. DESIGN Plasma was obtained from 103 WLHIV with SPTD (≤35 weeks gestation) and 205 controls with term deliveries (TDs; ≥37 weeds) matched to cases 2:1 by race and gestational age at blood draw. TNFα, IFNγ, IL6, IL8, IL1β, IL18, IL17, granulocyte colony stimulating factor (GCSF), MCP1, IP10, sIL2Rα, sCD14, vascular endothelial factor a, monocyte colony stimulation factor, GROα, MMP9, IL10, TGFβ, sCTLA4, and eicosanoids were compared between cases adjusting for known SPTD risk factors. RESULTS Participants had similar demographic characteristics, but cases had higher plasma HIV RNA, lower CD4 cells, and more advanced HIV disease compared with controls. High sIL2Rα was associated with increased risk of SPTD. High sCD14, GCSF, PGF2α, and 5-HEPE were marginally associated with increased risk of SPTD. Women who initiated protease inhibitors-containing antiretroviral treatment before or during the first trimester had higher levels of GCSF and 5-HEPE compared with women without such exposure before plasma collection. Vitamin D insufficiency was associated with higher inflammatory sCD14 and PGF2α, and lower anti-inflammatory 5-HEPE. CONCLUSIONS The best plasma predictor of SPTD in WLHIV was sIL2Rα, a marker of T-cell activation. Markers of monocyte activation and eicosanoids were marginally increased in WLHIV and SPTD, suggesting that they may also play a role in the pathogenesis of this disorder.
Collapse
Affiliation(s)
- Adriana Weinberg
- Department of Pediatrics, Medicine and Pathology, Anschutz Medical Center, University of Colorado Denver, Aurora, CO 80045
| | - Yanling Huo
- Center for Biostatistics in AIDS Research (CBAR), Harvard T.H. Chan School of Public Health, Boston, MA 02115
| | - Deborah Kacanek
- Center for Biostatistics in AIDS Research (CBAR), Harvard T.H. Chan School of Public Health, Boston, MA 02115
| | - Kunjal Patel
- Center for Biostatistics in AIDS Research (CBAR), Harvard T.H. Chan School of Public Health, Boston, MA 02115
| | - D. Heather Watts
- National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Risa M. Hoffman
- University of California San Francisco, San Francisco, CA
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA
| | - Jelena Klawitter
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045
| | - Uwe Christians
- iC42 Clinical Research and Development, Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045
| | | |
Collapse
|
14
|
Andrikopoulou M, Purisch SE, Handal-Orefice R, Gyamfi-Bannerman C. Low-dose aspirin is associated with reduced spontaneous preterm birth in nulliparous women. Am J Obstet Gynecol 2018; 219:399.e1-399.e6. [PMID: 29913174 DOI: 10.1016/j.ajog.2018.06.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/03/2018] [Accepted: 06/09/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Preterm birth is one of the leading causes of perinatal morbidity and mortality. Clinical data suggest that low-dose aspirin may decrease the rate of overall preterm birth, but investigators have speculated that this is likely due to a decrease in medically indicated preterm birth through its effect on the incidence of preeclampsia and other placental disease. We hypothesized that low-dose aspirin may also have an impact on the mechanism of spontaneous preterm labor. OBJECTIVE Our objective was to determine whether low-dose aspirin reduces the rate of spontaneous preterm birth in nulliparous women without medical comorbidities. STUDY DESIGN This is a secondary analysis of a randomized, placebo-controlled trial of low-dose aspirin for the prevention of preeclampsia in healthy, low-risk, nulliparous women. Low-risk women were defined by the absence of hypertension, renal disease, diabetes, other endocrine disorders, seizures, heart disease, or collagen vascular disease. Our study was limited to singleton, nonanomalous gestations. Women were eligible if they had prior pregnancy terminations but not prior spontaneous pregnancy loss <20 weeks. Current pregnancies that resulted in a loss or termination <20 weeks or antepartum stillbirth or had missing follow-up data were excluded. The treatment intervention was 60 mg of aspirin, initiated at 13-25 weeks' gestation or matching placebo. The primary outcome was spontaneous preterm birth <34 weeks' gestation. Secondary outcomes included spontaneous preterm birth <37 weeks and overall preterm birth <37 and <34 weeks. Baseline demographics and primary and secondary outcomes were compared between treatment groups. A logistic regression model was used to adjust for confounders related to spontaneous preterm birth. RESULTS Of 2543 included women, 1262 (49.6%) received low-dose aspirin and 1281 (50.4%) placebo. Baseline characteristics were similar between groups, except for marital status. The rate of spontaneous preterm birth <34 weeks was 1.03% (n = 13) and 2.34% (n = 30) in the low-dose aspirin and placebo group, respectively (odds ratio, 0.43, 95% confidence interval, 0.26-0.84). Additionally, the rate of spontaneous preterm birth <37 weeks was 6.58% (n = 83) in the low-dose aspirin group and 7.03% (n = 90) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.71-1.33), and the rate of overall preterm birth <37 weeks was 7.84% (n = 99) in the low-dose aspirin group and 8.2% (n = 105) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.72-1.31). After adjustment for variables that were clinically relevant or statistically significant, including body mass index, race, tobacco use, marital status, and education level, there was a significant reduction in spontaneous preterm birth <34 weeks in the low-dose aspirin group (adjusted odds ratio, 0.46, 95% confidence interval, 0.23-0.89). The rates of overall preterm birth <34 and <37 weeks and spontaneous preterm birth <37 weeks were similar in women who received low-dose aspirin compared with placebo. CONCLUSION Low-dose aspirin is associated with a substantial decrease in spontaneous preterm birth <34 weeks in healthy nulliparous women without comorbidities. These findings suggest a new therapeutic option for preterm birth prevention that requires further study.
Collapse
|
15
|
Abstract
Preterm birth (PTB) remains a major obstetric healthcare problem and a significant contributor to perinatal morbidity, mortality, and long-term disability. Over the past few decades, the perinatal outcomes of preterm neonates have improved markedly through research and advances in neonatal care, whereas rates of spontaneous PTB have essentially remained static. However, research into causal pathways and new diagnostic and treatment modalities is now bearing fruit and translational initiatives are beginning to impact upon PTB rates. Successful PTB prevention requires a multifaceted approach, combining public health and educational programs, lifestyle modification, access to/optimisation of obstetric healthcare, effective prediction and diagnostic modalities, and the application of effective, targeted interventions. Progress has been made in some of these areas, although there remain areas of controversy and uncertainty. Attention is now being directed to areas where greater gains can be achieved. In this mini-review, we will briefly and selectively review a range of PTB prevention strategies and initiatives where progress has been made and where exciting opportunities await exploitation, evaluation, and implementation.
Collapse
Affiliation(s)
- Jeff A Keelan
- Division of Obstetrics & Gynaecology, School of Medicine, University of Western Australia King Edward Memorial Hospital, Perth, Australia
| | - John P Newnham
- Division of Obstetrics & Gynaecology, School of Medicine, University of Western Australia King Edward Memorial Hospital, Perth, Australia
| |
Collapse
|
16
|
van Zijl MD, Koullali B, Mol BW, Pajkrt E, Oudijk MA. Prevention of preterm delivery: current challenges and future prospects. Int J Womens Health 2016; 8:633-645. [PMID: 27843353 PMCID: PMC5098751 DOI: 10.2147/ijwh.s89317] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Preterm birth (PTB), defined as delivery at <37 weeks of gestation, is the most important cause of neonatal morbidity and mortality. Therefore, preventing PTB is one of the main goals in obstetric care. In this review, we provide an overview of the current available literature on screening for risk factors for PTB and a summary of preventive strategies in both low-risk and high-risk women with singleton or multiple gestations. Furthermore, current challenges and future prospects on PTB are discussed. For an optimal prevention of PTB, risk stratification should be based on a combination of (maternal) risk factors, obstetric history, and screening tools. Cervical length measurements can help identify women at risk. Thereafter, preventive strategies such as progesterone, pessaries, and cerclage may help prevent PTB. Effective screening and prevention of PTB vary between the different pregnancy populations. In singleton or multiple pregnancies with a short cervix, without previous PTB, a pessary or progesterone might prevent PTB. In women with a (recurrent) PTB in the past, progesterone and a cerclage may prevent recurrence. The effect of a pessary in these high-risk women is currently being studied. A strong collaboration between doctors, patients' organizations, pharmaceutical companies, and (international) governments is needed to reduce the morbidity and mortality as a result of spontaneous PTB.
Collapse
Affiliation(s)
- Maud D van Zijl
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bouchra Koullali
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ben Wj Mol
- The Robinson Research Institute, School for Reproductive Health and Pediatrics, University of Adelaide, Adelaide, SA, Australia
| | - Eva Pajkrt
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, the Netherlands
| |
Collapse
|