Missed opportunities in aspirin prescribing for preeclampsia prevention

Short and long-term complications of hypertensive disorders of pregnancy: lifelong cardiovascular risks we cannot ignore

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy (HDP) pose a significant threat to maternal cardiovascular health, with emerging research shedding light on the enduring risks beyond the gestational period. This review highlights updates regarding cardiovascular risks associated with HDP and their implications for long-term health.

RECENT FINDINGS

Patients with a history of HDP are at an elevated risk of developing chronic hypertension, ischemic heart disease, stroke, valvular heart disease, and heart failure.Not surprisingly, patients with HDP experience higher rates of maternal and fetal adverse events in the antepartum and immediate postpartum periods, with high readmission rates for cardiovascular complications. The high risk of chronic hypertension after a HDP then leads to the development of subclinical disease over 5-10 years with overt cardiovascular disease becoming most prevalent in the decades following pregnancy. Early hypertension management in the antepartum and postpartum periods has lifelong health benefits and highlights the need for seamless postpartum transitions with close blood pressure monitoring and cardiovascular risk mitigation.

SUMMARY

HDP significantly increases the risk of short and long-term adverse cardiovascular events. Integrated healthcare models that assess and address postpartum cardiovascular risk are necessary to improve the cardiovascular health and longevity of those effected by HDP.

Missed opportunity for aspirin prophylaxis for preeclampsia prevention: a cross-sectional study from Sub-Saharan Africa

BACKGROUND

Recent studies showed that aspirin for preeclampsia prevention is underused despite its effectiveness in preventing preeclampsia among patients with moderate and high risk factors. Little is known about this issue in the Sub-Saharan setting, including Ethiopia.

OBJECTIVE

This study aimed to determine the missed opportunity for aspirin prophylaxis among candidates for this preeclampsia preventive intervention at a national tertiary referral hospital in Ethiopia.

STUDY DESIGN

This was a cross-sectional study on pregnant women who had preeclampsia and who were managed at the St. Paul's Hospital Millennium Medical College (Ethiopia) over a 6-month period (April 1-September 30, 2023). Data were collected prospectively using a structured questionnaire. The primary outcome was the proportion of women who had an indication for aspirin prophylaxis for preeclampsia prevention but were not given the opportunity (missed opportunity for aspirin) among all pregnant preeclampsia patients presenting to our hospital. Secondary outcomes were adverse maternal and perinatal outcomes. Data were analyzed using SPSS version 23. Descriptive statistics were employed to analyze the data. Proportions and percentages were used to present the results.

RESULTS

A total of 427 pregnant women with preeclampsia were screened for inclusion and 32 of them were excluded based on the study criteria. Among the 395 pregnant women with preeclampsia who were included in the final analysis, 195 (50.6%) had an indication for aspirin prophylaxis for the prevention of preeclampsia. The mean systolic and diastolic blood pressure measurements at presentation were 153.8±12.8 and 100.6±8.5 mm Hg, respectively. Most patients had proteinuria (51.7% of the participants had a urine test-strip protein level of +2, whereas 18.5% [74/395] had a urine test-strip protein level of +1 and 10.9% had 24-hour urine protein levels in the preeclampsia range). Among the women who had an indication for aspirin prophylaxis, only 1.1% received aspirin (the missed opportunity for aspirin prophylaxis for preeclampsia prevention was 98.9%). The perinatal morality rate was 11.9%, whereas the neonatal intensive care unit admission rate was 20.5%. The rate of a low Apgar score at 5 minutes was 8.9%. Eight mothers (2.1%) developed hemolysis, elevated liver enzymes, and low platelet count syndrome, whereas another 3 (0.8%) mothers developed a pulmonary edema.

CONCLUSION

In this study, the missed opportunity for administration of aspirin prophylaxis for the prevention of preeclampsia was high although more than half of the study subjects were candidates for this preventive intervention. Preeclampsia was also associated with higher rates of adverse perinatal outcomes and serious maternal morbidity.

Let's talk aspirin: A survey of barriers and facilitators faced by midwives when engaging in conversations about aspirin with women at risk of pre-eclampsia

OBJECTIVE

Adherence to low-dose aspirin is key in preventing pre-eclampsia. Midwives are well positioned to support women to take aspirin as prescribed. This study aimed to understand the barriers and facilitators that midwives face during consultations with pregnant women about prophylactic aspirin.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, UK-wide, quantitative and qualitative study of midwives was conducted between November 2020 and April 2021 using social media platforms. The survey was designed using the Theoretical Domains Framework by a team of researchers experienced in using it. An open-ended question was embedded in the survey to allow midwives to expand on matters related to the study subject.

FINDINGS

Out of 160 responders, 37.5 % indicated inadequate engagement in conversations with women about aspirin prophylaxis. Domains 'Knowledge' (OR 13.7, 95 %CI 5.7-32.7, p < 0.001), 'Professional role and Identity' (OR 15.3, 95 %CI 6.4-36.7, p < 0.001) and 'Beliefs about capabilities' (OR 13.6, 95 %CI 6.1-30.6, p < 0.001) were most prominently associated with effective engagement. Best fit model was comprised of 'Beliefs about Capabilities', 'Social/professional role and identity', and 'Knowledge'. Midwives' comments focused on barriers within 'environmental context' related to 'conflicting views' and 'deficit in resources' that compromise positive reinforcement of aspirin use. Responders also provided helpful 'Top tips' that streamline their daily practice.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Beliefs about Capabilities, Social/professional role and identity, Knowledge, and Environmental Context and resources are key domains related to midwives' engagement in conversations about aspirin in pregnancy. Clear, up-to date information for midwives and the public should be available in an easy access format to allow provision of unequivocal advice related to the use of aspirin in pregnancy.