Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234.
Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234.
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自发早产的预测和预防：ACOG练习公告，编号234。
DOI：
10.1097/aog.0000000000004612
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发表时间：
2021-12-01
影响因子：
7.2
通讯作者：
Hoffman MK
中科院分区：
文献类型：
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作者：
Hoffman MK
我感谢作者在2021年8月号上对自发性早产的预测和预防所做的深思熟虑的评论。正如实践公报所强调的，早产仍然是现代产科面临的最大挑战之一，不幸的是，在过去几年中，美国的结果不断恶化。2尽管其方法详细而合理，但我想强调一个潜在的遗漏，以进一步考虑，即以预防早产为目的的低剂量阿司匹林。尽管美国食品和药物管理局并未对此进行指示，但超过48项随机试验（包括47,000多例妊娠）表明，怀孕期间低剂量阿司匹林可使早产发生率降低约10%。同样，这些试验表明，怀孕期间低剂量阿司匹林可使新生儿死亡率或出院前死亡率降低15%。包括这些研究在内的两项大型随机试验对14000多名健康的未生育妇女进行了研究，结果显示早期早产（妊娠少于34周）发生率显著降低（比值比[OR] 0.43, 95% CI 0.26-0.845, OR 0.75, 95% CI 0.61-0.934），而早期早产是导致儿童发病率和死亡率的主要原因。这些证据使低剂量阿司匹林成为产科研究最多的干预措施之一，并导致其他组织，如美国预防服务工作组，在其对妊娠期阿司匹林的证据审查中强调了这一益处。虽然低剂量阿司匹林与子痫前期的关联已经有40多年的历史了，但临床和生物学证据都表明，早产和子痫前期之间有很大的重叠。同样，上述证据表明，低剂量阿司匹林对这两种疾病都是有效的预防策略。尽管《实践公报》专门针对自发性早产，但应该注意的是，由于这些研究的局限性，引用的文献并没有具体说明自发性早产。尽管如此，考虑到现在几十年来无法提高早产率和新生儿死亡率，以及大量证明有效性和安全性的试验，我认为现在是时候考虑教育卫生保健专业人员，将低剂量阿司匹林作为预防早产和先兆子痫的策略。
I thank the authors for their thoughtful review on the prediction and prevention of spontaneous preterm birth in the August 2021 issue. 1 As the Practice Bulletin highlights, preterm birth remains among the largest challenges facing modern obstetrics, with unfortunately worsening outcomes over the past several years in the United States. 2 Though detailed and reasoned in its approach, I want to highlight one potential omission for further consideration, namely low-dose aspirin for the purpose of preventing preterm birth. Though not US Food and Drug Administration–indicated for this purpose, more than 48 randomized trials, 3, 4 including more than47,000 pregnancies, have demonstrated that low-dose aspirin during pregnancy decreases the occurrence of preterm birth by approximately 10%. Similarly, these trials demonstrate that low-dose aspirin during pregnancy decreases neonatal death or death before discharge by 15%. 3 Inclusive of these studies are two large randomized trials of more than 14,000 healthy nulliparous women that have demonstrated a significant (odds ratio [OR] 0.43, 95% CI 0.26–0.845 and OR 0.75, 95% CI 0.61–0.934) reduction in early preterm birth (less than 34 weeks of gestation), which results in the majority of morbidity and mortality in children. This body of evidence makes low-dose aspirin one of the most studied interventions in obstetrics and has led other organizations, such as the US Preventive Services Task Force, to highlight this benefit in its evidence review of aspirin in pregnancy. 6Though the association of low-dose aspirin with preeclampsia now spans more than 40 years, there is both clinical and biological evidence that there is substantial overlap between preterm birth and preeclampsia. Similarly, the above-cited body of evidence suggests that low-dose aspirin is an effective preventive strategy for both. Though the Practice Bulletin specifically addresses spontaneous preterm birth, it should be noted that the cited literature does not specifically speciate out spontaneous preterm birth owing to the limitations of these studies. Nonetheless, given the now decades-long inability to improve rates of preterm birth and neonatal death and the large number of trials demonstrating both efficacy and safety, I believe it is now time to consider educating health care professionals about low-dose aspirin as a strategy for the prevention of preterm birth as well as preeclampsia.