Preeclampsia and other hypertensive disorders of pregnancy affect one in eight pregnancies, impacting placental function, fetal growth and sometimes requiring early delivery. Hypertensive disorders of pregnancy can cause serious complications for both moms and babies and are associated with a higher risk of long-term cardiovascular disease, including hypertension, heart disease and stroke.
Preterm babies may face breathing and feeding problems and need neonatal intensive care, according to Michael Warren, MD, a pediatrician and chief medical and health officer for March of Dimes.
“We think of mom and baby together in this work, and what influences the health of mom can certainly have an impact on baby as well,” said Dr. Warren in an interview with the AMA.
In ideal circumstances, the goal would be to prevent those deliveries from happening early in the first place, he said.
When a patient screens at risk for preeclampsia, a healthcare professional may recommend low-dose aspirin, which may reduce the risks associated with preeclampsia. However, it remains significantly underutilized. HCA Healthcare and March of Dimes are working to address this gap through the Low Dose, Big Benefits campaign, an evidence-based initiative focused on care team education, patient and community awareness, and improved risk identification in community health settings.
Supported by a $1.5 million grant from the HCA Healthcare Foundation, March of Dimes and HCA Healthcare bring the Low Dose, Big Benefits initiative to communities in Houston and Miami, helping clinicians and patients better identify preeclampsia risk and understand when low-dose aspirin may be appropriate. The initiative provides education for patients, care teams, patients and communities, and supports quality improvement efforts in Federally Qualified Health Centers to help translate evidence-based recommendations into practice.
“Preeclampsia is one of the most serious conditions we monitor for—preeclampsia is high blood pressure and damage to the kidneys, liver or other organs which is unique to pregnancy,” said Kjersti Aagaard, MD, PhD, a maternal-fetal medicine physician and national physician advisor at HCA Healthcare. “Distinct from chronic hypertension, preeclampsia occurs after the 20th week of pregnancy, and roughly 75% of cases are diagnosed in the latter part of the third trimester or in the six weeks after giving birth.”
The condition may also cause damage to other organ systems.
“Preeclampsia affects approximately 4–8% of all pregnancies in the United States and can lead to complications including damage to the maternal kidneys and liver, blood cells—specifically, the platelets—and the brain, resulting in seizures, also called eclampsia,” she said. When preeclampsia “onsets early, it can also lead to complications with the fetus, including preterm fetal growth restriction and preterm birth.
“In severe cases, it can result in maternal and/or fetal death,” Dr. Aagaard added. “Fortunately, most people with preeclampsia have healthy babies and deliveries, especially when it is caught early and severe preeclampsia and eclampsia are prevented.”
HCA Healthcare is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
81 milligrams of aspirin can lower risk
Distinctions exist between high and moderate maternal risk factors that contribute to the development of preeclampsia, said Dr. Aagaard. Moderate risk factors include maternal age of 35 or older, pregnancy conceived with in vitro fertilization, being a first-time mom and having 10 or more years between pregnancies. Multifetal gestation, such as twins and triplets, is also considered a high-risk factor.
For the moderate risk factors, physicians and care teams should assess whether more than one is present when determining whether low-dose aspirin may be appropriate, she said, noting “our approach starts long before a crisis is set into motion. We emphasize early identification of risk factors for preeclampsia at the very first prenatal visit.”
“Using standardized screening protocols, we assess whether a patient has the risk factors that increase her likelihood of developing preeclampsia,” Dr. Aagaard explained. “Because hypertensive disorders remain among the leading contributors to pregnancy-related mortality, early and consistent prenatal care is critical.”
Chronic hypertension is also a notable, high-risk factor. Patients may come into pregnancy with a diagnosis of chronic hypertension. Other times, they may not have been able to see a physician in the time period before their pregnancy.
“It is important to distinguish early onset preeclampsia from chronic hypertension, which precedes pregnancy,” said Dr. Aagaard, noting the 2022 CHAP trial published in the New England Journal of Medicine provided the evidence base to guide us in the management of chronic high blood pressure, including treatment with safe in-pregnancy antihypertensive medications.”
“Sometimes we’ll diagnose chronic hypertension in that first or early second trimester of pregnancy, prior to 20 weeks,” she noted. In those situations, the clinical evidence guides physicians to treat the chronic hypertension and use low-dose aspirin once a day to reduce the risk of superimposed preeclampsia.
Other major risk factors include type 1 or 2 pregestational diabetes and other major medical comorbidities such as kidney disease, autoimmune disorders or other vascular disease, Dr. Aagaard added.
Evidence supports 81 milligrams of low-dose aspirin daily for patients who meet risk criteria, an approach that has been shown to reduce the risk of preeclampsia by 15% or the risk of fetal growth restriction by up to 18%.
“It is a significant percentage of folks who are at risk and may benefit from those 81 milligrams of low-dose aspirin once a day,” Dr. Aagaard said, noting that March of Dimes has done a great job at developing a toolkit for clinical teams that can help remind physicians as well as patients and their families about the benefits of low-dose aspirin.
Close the evidence-to-practice gap
Medicine can have years-long gaps between research and actual practice change, said Dr. Warren, identifying three areas that have to line up:
- Health professionals must understand the science and recommendations.
- Patients must understand their own risk and why taking medication during pregnancy may be appropriate and safe.
- Health systems must make screening and recommendations part of routine workflow, potentially including EHR support.
“There is often a big gap, many years in fact, between when we have the research and even the recommendations to do something and when it actually gets implemented into clinical practice,” said Dr. Warren.
Then there are the practical barriers that keep eligible patients from taking low-dose aspirin, noted Dr. Aagaard.
Recognizing who’s at risk and helping eligible patients discuss low-dose aspirin with their entire care team—including physicians, midwives, doulas and family members—is one obstacle. The second is adherence. Dr. Aagaard noted that, for patients who have been advised to take low-dose aspirin, writing a prescription and adding it to their medical profile can help reinforce adherence rather than relying only on an over-the-counter recommendation.
Reinforce the message throughout care
There are ways to explain the potential benefits, risks and timing of low-dose aspirin so that patients can make informed decisions without feeling overwhelmed. Physicians should assess risk for all patients at the first prenatal visit, revisit it during mid-pregnancy and reassess risk when clinically appropriate or if new information or a new risk factor emerges.
Physicians should also continue to reinforce preeclampsia education during the third trimester and postpartum period.
When recommended, low-dose aspirin is typically started between 12 and 28 weeks of pregnancy, ideally before 16 weeks, Dr. Aagaard said. “However, we are also aware of the documented benefits even when there are delays resulting in initiation of aspirin therapy as late as 28 weeks of pregnancy.”
For example, patients can often bring their partners or family members to their detailed anatomy ultrasound at 20 weeks. This visit can be an ideal opportunity to discuss not only initiation of low-dose aspirin with patients and their partners, but also to remind them of the signs and symptoms of preeclampsia and the value of monitoring their blood pressure at home.
“There should not be a hesitancy that just because you may have missed that early second trimester mark in initiating low-dose aspirin therapy, you’re not going to benefit from starting it in the latter window,” she added.
Similarly, recommendations are to continue low-dose aspirin until the time of delivery and not discontinue at 36 weeks, Dr. Aagaard explained. Since it is 81 mg daily, there is minimal additional risk for having a postpartum hemorrhage or bleeding with delivery, and it won’t preclude someone from getting an epidural.
These individual care decisions should be discussed with a physician and may vary based on a patient’s clinical circumstances, including bleeding risk and the use of other medications.
Blood pressure checks can serve as a teaching opportunity with patients. Caring for HCA Houston Healthcare patients in Texas, Dr. Aagaard makes a point of reminding soon-to-be-moms about the importance of this reading during their clinic visits.
“Hey, do you know why we’re checking your blood pressure in clinic today? We’re screening for preeclampsia,” she’ll say. The practice will also remind patients of the importance of continuing blood pressure readings after delivery, through that postpartum interval.
“We do know that folks can have completely normal blood pressure and no proteinuria throughout pregnancy and still get postpartum preeclampsia,” she added.
It’s all in the family
Working with families is important—it’s not just following the mother, Dr. Aagaard stressed. Patients and their families may assume that you shouldn’t use aspirin in pregnancy. What the campaign brings out is that a low-dose aspirin is a safe, evidence-based prevention option when recommended by their physician.
Low-dose aspirin is already used to prevent cardiovascular disease and stroke at other stages in life, she said. “Similar to preeclampsia, microvascular and endothelial cell disorders, such as atherosclerotic cardiovascular disease and stroke, also benefit from low-dose aspirin preventative therapy.”
Additionally, partners and family members can support patients who are pregnant in the use of low-dose aspirin while keeping an eye out for signs and symptoms of preeclampsia.
Some warning signs can overlap with common pregnancy symptoms, such as swelling in the hands and feet. This is why checking blood pressure at home can be hugely beneficial, emphasized Dr. Aagaard. Patients should also be counseled on how to take an accurate reading and when their care team’s recommendation thresholds should prompt follow-up.
“Working with patients to bring in a blood pressure log that they’re using at home can help screen for preeclampsia,” said Dr. Aagaard, who added that family members can support them in these efforts.
Beyond medication, she advises patients to:
- Keep all prenatal appointments.
- Work hand in hand with their physician and care team to effectively manage existing health conditions such as hypertension or diabetes with medications that are safe in pregnancy.
- Monitor blood pressure daily if recommended.
- Report concerning symptoms promptly, including severe headaches, vision changes, swelling in the hands, face or feet, or upper abdominal pain.
Take prevention into communities
Better outcomes mean getting beyond hospitals and into communities, educating people about preeclampsia risk and equipping community clinicians to incorporate screening and aspirin recommendations into routine practice, said Dr. Warren.
Support from HCA Healthcare and the HCA Healthcare Foundation is helping March of Dimes expand this work in Houston and Miami. The broader Low Dose, Big Benefits campaign has expanded to other parts of the country, with March of Dimes engaging clinics across multiple states. The initiative helps patients understand preeclampsia risk and encourages them to talk with their health professional about whether low-dose aspirin may be appropriate.
Being able to share this message in partnership with HCA Healthcare “really allows us to amplify our reach and get to more people, so that more women can get the care that is recommended for them,” said Dr. Warren.
The goal is to bring compassionate and evidence-based prenatal care to people in the communities where they live, rather than bringing people to care, Dr. Aagaard said. With the Low Dose, Big Benefits campaign, physicians are recognizing the role that many different avenues play in reinforcing evidence-based medicine. Social media is one of these tools.
This campaign has done a fantastic job of working with trusted community voices and social media channels and saying, “Hey, this is the science, and this is the clinical evidence behind why we’re making these recommendations. How can you help us reinforce this in a way that’s accessible to patients and their families?” said Dr. Aagaard.
Physicians spend a lot of time combating the disinformation that comes through social media channels, she said, but “this is an example of where we can also use those social media channels to render high-quality, clinically relevant information” from trusted sources such as HCA Healthcare and March of Dimes.
Build on a model that worked
The March of Dimes’ partnership with HCA Healthcare goes back several decades, demonstrating how partnership can translate recommendations into practice.
“One of the earliest ways that we worked together was on research looking at early elective delivery,” said Dr. Warren.
That collaboration included research across 27 HCA Healthcare hospitals involving 18,000 births that found elective deliveries before 39 weeks were associated with increased complications for mothers and babies, including higher rates of neonatal intensive care unit admissions.
“That gave us important information that for those babies, we need not rush delivery. We need to let labor start on its own unless there is an indication,” said Dr. Warren.
That work led to the My 39 Weeks initiative and the “Healthy Babies Are Worth the Wait” effort: clinician and patient education, and hospital “hard stop” policies designed to curb nonmedically indicated early deliveries.
Those findings helped drive a nationwide shift in clinical practice and informed how health systems approach safe delivery timing today. “That really started because of the work that HCA Healthcare and March of Dimes did together,” he said.
In other projects, HCA Healthcare has been a big supporter of the March of Dimes’ “It Starts with Mom” campaign, which provides consumer-facing education and awareness. The work with low-dose aspirin “is another way where they really are helping us be on the leading edge of getting information out to healthcare professionals and consumers,” said Dr. Warren.
Research will further test aspirin approach
Investigators are studying biomarkers that could lead to improvements in predicting preeclampsia, aspirin dosing and timing, and additional preventive and therapeutic strategies.
Some promising biomarker approaches still lack sufficient real-world evidence, said Dr. Aagaard, adding that significant gaps remain in treatment once preeclampsia develops.
Research is exploring whether better prediction, dosing and timing could further improve on the risk reduction associated with low-dose aspirin for eligible patients, she noted. “Could we improve that to a 25% risk reduction or even higher? We don’t know the answer to that as it stands today.”
In the meantime, HCA Healthcare is committed to bringing care to people in the communities where they live. The Low Dose, Big Benefits campaign with March of Dimes “enables us to do that extraordinarily well,” Dr. Aagaard said.
