key: cord-0703599-glntveye
authors: Gavillet, M.; Rolnik, D. L.; Hoffman, M. K.; Panchaud, A.; Baud, D.
title: Should we stop aspirin prophylaxis in pregnant women diagnosed with COVID‐19?
date: 2020-06-01
journal: Ultrasound Obstet Gynecol
DOI: 10.1002/uog.22063
sha: c39a876a381606b66299cda9723725593597dbfa
doc_id: 703599
cord_uid: glntveye

nan

The current coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can progress to critical illness with acute respiratory distress and disseminated intravascular coagulation (DIC). Biomarkers of DIC (elevated D-dimer and thrombocytopenia) are detectable early in the course of the disease and correlate with a poor prognosis 1,2 . In the first SARS outbreak, thrombocytopenia was reported in 20-55% of patients 2 . Data for the current SARS-CoV-2 pandemic are less mature and the reported rate of thrombocytopenia varies between 5% and 41.7% of cases 2 . Multiple phenomena underpin SARS-CoV-2-associated thrombocytopenia, namely decreased thrombocyte production in infected hematopoietic marrow as well as increased consumption by DIC and in damaged lung tissue and capillaries 3 . The natural course of COVID-19 in non-pregnant adults, in which patients show mild symptoms for days before clinical deterioration, including those who will subsequently present with a severe form or a fatal outcome, is not different from that in pregnant women 4 . Furthermore, as children with COVID-19 have mild or asymptomatic disease, those within a household are highly contagious to future mothers. Prophylactic administration of low-dose aspirin to pregnant women is common. It is currently indicated in those at moderate to high risk of pre-eclampsia 5 , a group which represents 10-15% of all pregnancies. In the Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia Prevention (ASPRE) trial, daily administration of 150 mg of aspirin, initiated between 11 and 14 weeks of gestation, resulted in a 62% reduction in the incidence of preterm pre-eclampsia when compared with placebo in high-risk women (incidence of 1.6% in the aspirin group vs 4.3% in the placebo group; odds ratio, 0.38 (95% CI, 0.20-0.74); P = 0.004) identified by means of a predictive algorithm that combines maternal characteristics, medical history and biomarkers 5 . Low-dose aspirin is also indicated in pregnant women with antiphospholipid syndrome and those with a mechanical heart valve, or may be prescribed for prevention of early pregnancy loss, fetal growth restriction or stillbirth (Table 1) 6 .

During the current COVID-19 pandemic, systematic testing of all suspected cases of SARS-CoV-2 infection in pregnancy is recommended 4 . Positive cases should have careful evaluation of the risk-to-benefit ratio of low-dose aspirin therapy, taking into account the indication, gestational age and platelet count ( Table 1) . Aspirin belongs to the group of non-steroidal anti-inflammatory drugs, the use of which is controversial in COVID-19 patients. As aspirin irreversibly inhibits platelet cyclooxygenase, its effect persists for the duration of the circulating life of platelets (7-10 days). Thus, the delay between SARS-CoV-2 test positivity and clinical deterioration is similar in length to the delay between the last aspirin intake and the end of its clinical effect. Furthermore, aspirin is not indicated for the treatment of DIC or other venous thromboembolic complications that might be associated with severe COVID-19, and may increase the bleeding risk in severely thrombocytopenic patients.

While we support the continuous use of prophylactic aspirin in pregnant women during the COVID-19 pandemic, which is consistent with the views expressed recently by Kwiatkowski et al. 7 in this Journal, our view is more nuanced. We recommend immediate cessation of aspirin prophylaxis prescribed for pre-eclampsia upon diagnosis of SARS-CoV-2 infection, avoidance of aspirin for the duration of the disease and restarting the medication after full recovery (Table 1) , especially in women in the third trimester of pregnancy as the benefit of aspirin is minimal and could contribute to severe bleeding in thrombocytopenic COVID-19 patients or if emergency Cesarean delivery is indicated by the maternal condition. The above-listed propositions should help in tailoring individualized therapeutic decisions for pregnant women during the COVID-19 pandemic.

Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia

Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis

Thrombocytopenia in patients with severe acute respiratory syndrome (review)

2019-nCoV epidemic: what about pregnancies?

Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia

Antithrombotic Therapy and Prevention of Thrombosis

Why we should not stop giving aspirin to pregnant women during the COVID-19 pandemic