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Strategies for Prescribing Aspirin to Prevent Preeclampsia

A Cost-Effectiveness Analysis

Mallampati, Divya MD, MPH; Grobman, William MD, MBA; Rouse, Dwight J. MD, MSPH; Werner, Erika F. MD, MS

doi: 10.1097/AOG.0000000000003413
Contents: Hypertensive Diseases of Pregnancy: Original Research

OBJECTIVE: To evaluate the cost effectiveness of various preeclampsia screening and aspirin prophylaxis strategies, including a strategy based on biomarker and ultrasound measures.

METHODS: We designed a decision analysis to compare preeclampsia-related costs and effects of four strategies for aspirin use in pregnancy initiated before 16 weeks of gestation to prevent preeclampsia. The four strategies were: 1) no aspirin use, 2) biomarker and ultrasound measure–predicated use, 3) use based on the U.S. Preventive Services Task Force guidelines, and 4) universal aspirin use. Our outcomes were preeclampsia-related costs and number of cases per 100,000 pregnant women. Using a threshold of $90,843 per case of preeclampsia, one-way, two-way, and Monte-Carlo sensitivity analyses incorporating varying probabilities of risk reduction due to aspirin use, aspirin-related side effects, and costs were performed to identify ranges at which costs and risks of aspirin-related complications shifted the preferred strategy.

RESULTS: Compared with universal aspirin administration, the use of U.S. Preventive Services Task Force guidelines is associated with $8,011,725 higher health care costs and 346 additional cases of preeclampsia per 100,000 pregnant women; biomarker and ultrasound screening is associated with an additional $19,216,551 and 308 additional cases. Similarly, no aspirin use is associated with an increased cost of $18,750,381 and 762 additional cases. Thus, universal aspirin use dominated all three other strategies. In a Monte Carlo simulation of 10,000 pregnant women, universal aspirin was the preferred strategy in 91% of simulations. The U.S. Preventive Task Force screen was preferred in 8.5% of simulations, and biomarker and ultrasound screening and no aspirin were preferred in 0% and 0.5% of simulations, respectively.

CONCLUSION: Over a broad range of assumptions, universal aspirin administration is associated with fewer cases of preeclampsia and fewer costs relative to no aspirin administration and aspirin administration based on serum and ultrasound measures or clinical risk factors.

Universal aspirin administration prevents more cases of preeclampsia and saves more money than other aspirin strategies.

Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and Department of Obstetrics and Gynecology, Alpert Medical School, Brown University, Providence, Rhode Island.

Corresponding author: Divya Mallampati, MD, MPH, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented as a poster at the Society for Maternal-Fetal Medicine's 39th Annual Meeting, February 11–16, 2019, Las Vegas, Nevada.

Dr. Rouse, Associate Editor (Obstetrics) of Obstetrics & Gynecology, was not involved in the review or decision to publish this article.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.