<div>Risk assessment to target aspirin is accurate but not universal</div><div>Low dose aspirin, for the prevention of early onset pre-eclampsia is an
established antenatal intervention; it is safe, effective, cheap and
accessible in many health care settings.</div><div>Optimal implementation strategies including dose, timing and screening
are currently debated. The evidence supports starting aspirin early
(before 16 weeks), prescribe at night, give up to 150mg and continue
until at least 36 weeks gestation ((Poon et al. Int J Gynaecol Obstet.
2019 May;145 Suppl 1(Suppl 1):1-33). From the women’s perspective, many
may not be happy to routinely medicate an apparently normal pregnancy,
to prevent an unknown or unfamiliar disease.</div><div>Despite campaigns by APEC and others, too many women only hear of
pre-eclampsia when it affects them. Generally, as perceived risks
escalate the acceptance of taking aspirin is greater which improves
compliance by both physicians prescribing, and by pregnant women. Any
strategy that allows targeting of aspirin is likely to prevent
unnecessary treatment and would be welcomed. It should be noted that the
MBRAACE Report (Knight et al. University of Oxford 2019. ISBN:
978-0-9956854-8-2) called for a national patient direction for midwives
to prescribe aspirin which has not yet happened.</div><div>This current analysis compared two such strategies to target antenatal
aspirin NICE guidance uses history to establish risk (Guy et al. BJOG
2020 xxxx). It is relatively simple, requiring either a combination of
minor risk factors or a single major risk factor to dictate the need for
aspirin. The FMF algorithm uses a combination of tests, including scans,
blood pressure and blood markers to dictate risk; this requires skill
and more resource which may not be consistently available in lower
income settings.</div><div>When compared in a real-world setting, in a London teaching hospital,
the FMF algorithm had a screen positive rate that was half that of NICE,
while aspirin was given to far more high-risk women. The FMF algorithm
was changed to suit local circumstances, including details of the tests
used (PAPPA, rather than PLGF) and thresholds adopted for treatment, but
the real-world findings are impressive.</div><div>The dosage of aspirin was higher in the FMF group, (150mg vs 75mg) which
could explain some of the additional clinical benefit. Aspirin has
recently been shown to impact on preterm birth when given routinely to
all women who have never given birth in a low resource setting. In these
settings, the cost and practicalities of implementing the algorithm
maybe prohibitive. However, elements of the algorithm such as blood
pressure measurement are simple and potentially more generalisable.</div><div>It is exciting we have an intervention that can impact on one of the
world’s most significant pregnancy disorders; but if resources allow, we
clearly now have the tools to predict risk and improve outcomes. The
challenge is how to deliver this to the global south, where most of
pre-eclampsia occurs.</div><div>At Action on Pre-Eclampsia, in the UK, we will continue to push for easy
availability of aspirin. This paper is a welcome piece of the jigsaw and
we hope it offers further tools in the armoury to defeat pre-eclampsia.</div><div><b>No disclosures:</b> Completed disclosure of interest forms are
available to view online as supporting information.</div>