key: cord-345464-9cnbco2i
authors: Kwiatkowski, S.; Borowski, D.; Kajdy, A.; Poon, L. C.; Rokita, W.; Wielgos, M.
title: Why we should not stop giving aspirin to pregnant women during the COVID‐19 pandemic
date: 2020-06-01
journal: Ultrasound Obstet Gynecol
DOI: 10.1002/uog.22049
sha: 
doc_id: 345464
cord_uid: 9cnbco2i

With the current outbreak and spread of the coronavirus disease 2019 (COVID-19) worldwide many questions arise. There have been issued precautions regarding the use of anti-inflammatory medications, including aspirin. To our knowledge, there is insufficient data to suggest an increased risk between prophylactic use of low-dose aspirin and progression of COVID-19 infection in pregnant women at risk of placental complications. This article is protected by copyright. All rights reserved.

COVID-19 seems to have a milder natural history 2 . The available data regarding COVID-19 are limited; therefore, maternal outcomes may be underreported at present.

Published observations in non-pregnant patients have shown that non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can cause progression of pulmonary disease. This relationship has been observed in bacterial pulmonary infections. Experimental data suggest that NSAIDs alter the function of neutrophils and delay bacterial clearance and inflammation resolution 3, 4 . Observational data suggest an association between exposure to NSAIDs and the occurrence of pleuropulmonary complications (pleural empyema, excavation and abscess). Similar observations have also been made in a small group of young people taking ibuprofen for COVID-19 symptoms 3, 4 . As a result, French health officials have issued a precaution regarding the use of NSAIDs, including aspirin. This has started an international debate among healthcare professionals regarding the usage of NSAIDs, primarily ibuprofen, in patients with COVID-19 5 . The Spanish Ministry of Health has stated that there is no evidence that ibuprofen (or other NSAIDs) could worsen SARS-CoV-2 infection. However, it stated that ibuprofen might mask the symptoms of infection, therefore delaying diagnosis 6 . The Royal College of Obstetricians and Gynaecologists in the UK recommends paracetamol for COVID-19 symptoms 7 .

There is therefore cause for concern regarding the wellbeing of pregnant women taking aspirin for prophylaxis of pre-eclampsia and fetal growth restriction. The debate could have resulted in a misunderstanding among both healthcare professionals and pregnant women, leading to withdrawal of prophylactic low-dose aspirin therapy. Currently, there are no available data regarding the association between the risk of COVID-19 progression and intake of low-dose aspirin.

Pre-eclampsia affects 2-8% of pregnancies worldwide and is one of the leading causes of maternal death and perinatal mortality and morbidity 8 . Currently, around the world, there are more than 350 536 active cases of COVID-19 and this number is increasing every day 9 . On the other hand, there are fewer than 100 published cases of COVID-19 in pregnant women. Based on these case series and reports, it appears that the natural history of SARS-CoV-2 infection among pregnant women is not different from that in non-pregnant adults. A World Health Organization (WHO) report from China states that only 1% of the described cases in pregnant women have been critical and 8% were severe 10 . At the time of writing, there were no reported maternal deaths related to SARS-CoV-2 infection. None of the cases of COVID-19 in pregnant women in the series of Schwartz was severe 11 .

Low-dose aspirin has been proven to be an effective regimen for the prevention of placental complications during pregnancy, including pre-eclampsia and fetal growth restriction. Intake of low-dose aspirin during pregnancy is not associated with an increased risk of congenital defects, bleeding or premature closure of the ductus arteriosus 8 . The recommended dosage of 150 mg of aspirin daily for the prevention of pre-eclampsia is based on the results of the ASPRE trial. In the trial, preterm pre-eclampsia occurred in 1.6% of women in the low-dose aspirin group, as compared with 4.3% in the placebo group (odds ratio, 0.38; 95% CI, 0.20-0.74; P = 0.004) 8 .

The WHO has published an official statement recommending not to avoid the use of ibuprofen based on the current available data 12 . To our knowledge, there are limited data to suggest that there is an association between prophylactic use of low-dose aspirin and increased risk of progression of SARS-CoV-2 infection.

In our opinion, during the COVID-19 pandemic, it is still essential to provide first-trimester screening for placental complications and to prescribe low-dose aspirin in women who are identified as high risk for pre-eclampsia and fetal growth restriction. Based on the current knowledge of the epidemiological situation, the benefits of placental complication prevention outweigh the potential risks of adverse outcome related to the usage of low-dose aspirin in patients with SARS-CoV-2 infection.

Potential Maternal and Infant Outcomes from (Wuhan) Coronavirus 2019-nCoV Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Coronavirus Infections

Coronavirus in pregnancy and delivery: rapid review

Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists

Misguided drug advice for COVID-19

La AEMPS informa que ningún dato indica que el ibuprofeno agrave las infecciones por COVID-19

Coronavirus (COVID-19) infection and pregnancy

ASPRE trial: performance of screening for preterm pre-eclampsia

Report of the WHO-China Joint Mission on Coronavirus Disease

An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes

Now Doesn't Recommend Avoiding Ibuprofen For COVID-19 Symptoms