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Letter to the Editors ajog.


Antiplatelet therapy before or after 16 weeks

gestation for preventing preeclampsia
TO THE EDITORS: We read with interest the meta-analysis (<37 weeks) associated with aspirin started 16 weeks at a
of Meher et al1 on antiplatelet therapy for the prevention of dose >60 or 75 mg? -
preeclampsia. While their results suggest modest benets
Stphanie Roberge, PhD
from aspirin, we believe the authors should have considered Suzanne Demers, MD, Msc, FRCSC
some methodological limitations and some aspects of peri- Department of Obstetrics and Gynecology
natal diseases mechanisms in their analyses that could have Faculty of Medicine
led them to different conclusions. Universit Laval
Only selected randomized trials published before 2005 Quebec City, Quebec, Canada
were included. At that time, there was little scientic evidence Harris Birthright Research Center of Fetal Medicine
about the optimal posology of aspirin during pregnancy. Kings College Hospital
Therefore, most participants were taking only 60 mg of London, United Kingdom
aspirin daily, which is probably insufcient, and potentially in Emmanuel Bujold, MD, MSc, FRCSC
the morning when aspirin has minimal effects.2 The results Department of Obstetrics and Gynecology
were stratied according to gestational age (16 weeks) and Faculty of Medicine
dosage (75 mg daily) but the authors did not report the Universit Laval
combination of both (aspirin >75 mg 16 weeks). We Quebec City, Quebec, Canada
recently demonstrated that the benets of aspirin initiated emmanuel.bujold@crchudequebec.ulaval.ca
16 weeks of gestation was following a dose-response effect The Canadian Institute of Health Research supported Dr Roberge
while the benets were modest or absent when aspirin was (postdoctoral fellowship). The Fond de Recherche du Qubec-Sant
supported Drs Bujold (clinician scientist award) and Demers (MSc award)
initiated >16 weeks.3 during the study. The current study was funded by the Jeanne and Jean-
The most important point that needs to be addressed is the Louis Lvesque Perinatal Research Chair at Universit Laval, Quebec
selection of outcomes. Most obstetricians will dene preterm City, Quebec, Canada.
birth (PTB) as a delivery <37 weeks and not <34 weeks.
Recent literature stratied PTB into early onset (<32 or <34 The authors report no conict of interest.
weeks) and late onset (32-36 or 32-36 weeks) because of
evidence showing that mechanisms of disease leading to PTB REFERENCES
are different according to gestational age. Most cases of 1. Meher S, Duley L, Hunter K, Askie L. Antiplatelet therapy before or
spontaneous early-onset PTB are associated with intra- after 16 weeks gestation for preventing preeclampsia: an individual
participant data meta-analysis. Am J Obstet Gynecol 2017;216:121-8.
amniotic infection and inammation and it is biologically e2.
unlikely that 60 mg of aspirin taken daily could prevent such 2. Ayala DE, Ucieda R, Hermida RC. Chronotherapy with low-dose
cases. On the other hand, mechanisms leading to late-onset aspirin for prevention of complications in pregnancy. Chronobiol Int
PTB are less well understood and it could be interesting to 2013;30:260-79.
know whether low-dose aspirin could be benecial. Similarly, 3. Roberge S, Nicolaides K, Demers S, Hyett J, Chaillet N, Bujold E. The
role of aspirin dose on the prevention of preeclampsia and fetal growth
most cases of preterm or early-onset preeclampsia are asso- restriction: systematic review and meta-analysis. Am J Obstet Gynecol
ciated with deep placentation disorders that represent a fail- 2017;216:110-20.e6.
ure of the physiological transformation of uterine spiral 4. Ogge G, Chaiworapongsa T, Romero R, et al. Placental lesions
arteries, which typically occurs <16 weeks of gestation.4 We associated with maternal underperfusion are more frequent in early-onset
previously observed that aspirin initiated <16 weeks was than in late-onset preeclampsia. J Perinat Med 2011;39:641-52.
5. Roberge S, Villa P, Nicolaides K, et al. Early administration of low-dose
benecial to reduce the risk of preterm but not the term form aspirin for the prevention of preterm and term preeclampsia: a systematic
of preeclampsia.5 review and meta-analysis. Fetal Diagn Ther 2012;31:141-6.
For the benet of readers and pregnant women, could the
authors provide the relative risks of preterm preeclampsia 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.
(<37 weeks), early-onset preeclampsia (<34 weeks), and PTB 2017.01.034

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