Antiplatelet agents for preventing pre‐eclampsia and its com | Figure 1

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Antiplatelet agents for preventing pre‐eclampsia and its complications

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We set out to assess the ability of antiplatelet agents, such as aspirin and dipyridamole, to prevent women from developing pre‐eclampsia during pregnancy and to improve health outcomes for them and their babies. We also wanted to find out whether these medicines had any undesirable effects for the mother or baby.

What is the question?

Do low doses of aspirin help to prevent pre‐eclampsia, and reduce the number of preterm births before 37 weeks, small‐for‐gestational‐age babies, infant deaths and other unwanted effects?

Why is this important?

Pre‐eclampsia is a condition experienced by some women during pregnancy and is evident as high blood pressure and protein in the urine. This condition can lead to serious complications for the mother and her baby (in fact, it is one of the leading causes of illness and death in pregnancy). The mother’s placenta may not be functioning properly, which limits the blood supply to the unborn baby so that it is at risk of poor growth and being born early as a result of preterm labour, or needing to be delivered early. Pre‐eclampsia affects the platelets in the women’s blood so that they are more ready to clump and cause the blood to clot. Antiplatelet drugs like aspirin prevent blood clotting and have a role in preventing pre‐eclampsia and its complications.

What evidence did we find?

We searched for randomised controlled trials in March 2018. Our review includes 77 trials, involving 40,249 women and their babies, although it wasn't possible to include results form three of these trials (233 women) . We included information about the results for women and babies in two different formats: 36 trials (34,514 women) reported 'individual participant data' (IPD), where we received information about each of the individuals involved; all the other trials reported 'aggregate data' (AD), where each study reports the average information about the individuals involved in the study. By using IPD, we could conduct very thorough and accurate analyses; and by combining both the AD and the IPD, we could include all the available information on this question.

Nine of the trials included more than 1000 women, and all of these large trials were at low risk of bias. Low‐dose aspirin alone was the intervention in all the large trials, and most trials overall. Almost all the women were recruited to the trials after 12 weeks' gestation. Most women were at risk of developing pre‐eclampsia, and the trials included women with normal blood pressure, existing long‐term high blood pressure or pregnancy‐induced high blood pressure. High‐quality evidence showed that the use of antiplatelet agents reduced the risk of pre‐eclampsia by 18%, or less than one sixth (36,716 women, 60 trials). This meant that 61 women had to be treated with an antiplatelet drug for one woman to benefit by avoiding pre‐eclampsia. The risk of preterm birth was reduced by 9% (35,212 women, 47 trials) and the number of infant deaths before or around the time of birth was reduced by 15% (35,391 women, 52 trials). Antiplatelet agents reduced the risk of small‐for‐gestational‐age babies (35,761 mothers, 50 trials) and pregnancies with serious adverse outcomes (17,382 mothers; 13 trials). Moderate‐quality evidence showed that only slightly more women lost more than 500 mL of blood immediately after birth, termed postpartum haemorrhage (23,769 mothers, 19 trials), indicating that aspirin is safe. Doses of aspirin less than 75 mg appear to be safe. Higher doses might be better, but we do not know whether they increase adverse effects.

What does this mean?

Low doses of aspirin slightly reduce the risk of pre‐eclampsia and its complications. As most women in this review were in trials evaluating low‐dose aspirin, the reassurance about the safety of aspirin may not apply to higher doses or other antiplatelet agents. Further research should aim to identify women who are most likely to respond to low‐dose aspirin treatment. While it is possible that higher doses of aspirin may be more effective, further studies are needed to determine whether higher doses are both more effective and safe for women and babies.

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