In pregnant individuals with risk factors for preeclampsia, prophylactic low-dose aspirin is recommended to reduce the risk of developing preeclampsia. Fifteen distinct risk factors are recognized, including elements of current and past medical and obstetrical history, family history, and examination findings. We present checklists intended to reduce the chance that risk factors might be inadvertently overlooked and to improve the probability of aspirin being recommended for all appropriate candidates. We also suggest how such a checklist can be implemented into practice.
Key words
Introduction
Preeclampsia complicates approximately 3% to 4% of pregnancies in the United States
1
and is a major cause of maternal and perinatal morbidity and mortality.2
, 3
, 4
, 5
, 6
Several known risk factors can be recognized by the late first trimester or early second trimester to identify those at increased risk of preeclampsia. A review by the United States Preventive Services Task Force (USPSTF)7
lists 6 high-risk factors (preeclampsia in a previous pregnancy, multifetal gestation, chronic hypertension, type 1 or 2 diabetes mellitus, renal disease, and autoimmune disease) and 9 moderate-risk factors (nulliparity, obesity, having a mother or sister who had preeclampsia, African American race, low socioeconomic status, age of 35 years or older, history of low birthweight or small-for-gestational age, previous adverse pregnancy outcome, and interpregnancy interval of more than 10 years).Prophylactic administration of low-dose aspirin starting in the second trimester in persons at increased risk of preeclampsia reduces the risk of developing preeclampsia by approximately 25%.
10
, 8
, 9
In 2014, a USPSTF Recommendation Statement concluded that low-dose aspirin should be recommended for individuals with any high-risk factors and should be considered for those with several moderate-risk factors.7
A joint committee opinion by the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) recommends aspirin prophylaxis for individuals with any high-risk factors or with more than 1 moderate-risk factor.11
It is difficult or impossible for many healthcare providers to remember a list of 15 risk factors (6 high-risk factors and 9 moderate-risk factors) to decide whether to recommend aspirin for a pregnant individual. The risk factors are scattered throughout various parts of the prenatal record (medical history, pregnancy history, history of present illness, family history, and examination findings). Furthermore, a routine prenatal care intake interview might never ascertain some of the factors, such as a history of preeclampsia in a mother or sister or maternal personal history of low birthweight. These items are not included on ACOG’s Antepartum Record form
12
and are likely absent from most other prenatal record forms.Screening for preeclampsia risk factors fulfills 2 criteria for the use of a checklist
13
: first, it is a procedure with multiple steps (items to be reviewed), and second, the omission of an item could have adverse consequences (failure to prevent preeclampsia when it might have been prevented). Therefore, we developed checklists to aid in the screening of preeclampsia risk factors. The checklists bring the disparate elements of history and examination findings together into a single location. Routine use of these checklists should facilitate a thorough assessment of those factors and help minimize errors of omission. The goal is to prevent individuals with risk factors from “falling through the cracks” because risk factors were missed.We offer 2 sample checklists: one that would be appropriate for a healthcare provider to use during the initial prenatal care visit and another that would be appropriate for a patient to self-complete before or during the initial visit. We offer suggestions on how practices might modify, implement, and use such a checklist. We anticipate that each practice will prefer 1 version or the other for routine use and will need to solve certain implementation issues before use.
Comments on the Checklists
For example, a checklist that can be completed by the healthcare provider at the first prenatal visit is presented in Box 1. This checklist is a straightforward listing of USPSTF’s high-risk and moderate-risk factors.
7
Box 1
Sample checklist of preeclampsia risk factors suitable for completion by healthcare providers
Combs. Checklists to guide recommendations for prophylactic low-dose aspirin. Am J Obstet Gynecol 2020.
A version that can be completed by the patient before the first prenatal visit is presented in Box 2. The boxed section at the bottom of the form is intended to be completed by the provider. This form asks the patient to fill in height and prepregnancy weight; using these responses, the provider calculates the body mass index. Patient-reported height and prepregnancy weight are generally valid approximations,
14
,15
although exceptions may occur.14
,16
One item on the USPSTF list that is missing from the patient version of the checklist is “low socioeconomic status.” There are several challenges with assessing this item, such as the lack of a standardized definition and potential for stigmatization. If providers choose to include this item, an evidence-based, a priori definition should be included to reduce the likelihood of provider bias. Indicators that have been used as proxies for low socioeconomic status include insurance status, education, and income level.17
Box 2
Sample checklist of preeclampsia risk factors suitable for completion by patients
BMI, body mass index; GA, gestational age.
Combs. Checklists to guide recommendations for prophylactic low-dose aspirin. Am J Obstet Gynecol 2020.
In developing the checklists, we relied on high-risk and moderate-risk categories defined by the USPSTF
7
because they are widely accepted throughout the United States.11
We designed the checklists using guidance from “A Checklist for Checklists” by Ariadne Labs.18
Despite the challenge of including 15 risk factors, the forms are designed to be as simple and uncluttered as possible. Each checklist is limited to a single page, uses a black sans-serif typeface on a white background, avoids the use of color, and includes a version date.Ariadne Labs
A checklist for checklists. 2010.
A checklist for checklists. 2010.
https://www.ariadnelabs.org/wp-content/uploads/sites/2/2019/10/checklist_for_checklists_final_10.3-1-1.pdf
Date: 2010
Date accessed: August 5, 2020
All items require a yes-or-no response to encourage an answer for each item. Items presented only as “check if yes” responses are potentially confusing because an unchecked item might signify either a “no” answer or a missed item.
Suggestions for Implementation
First, each practice should decide whether it will use a checklist at all or whether it will have providers rely on memory for preeclampsia risk-factor screening. The checklists are designed to be used by prenatal care providers (physician offices, clinics) and not primarily within inpatient hospital settings. Before implementing the checklists, we recommend assembling a team of relevant practice personnel, such as physicians and nurses involved in prenatal care, medical assistants, front-office staff, and others who may interact with the checklist. Team meetings and individual interviews can be used to seek input from all personnel. Team goals should be to develop a timetable for implementation, identify and solve any barriers to implementation, monitor usage and effectiveness of the checklist, and develop a strategy for sustainability. A proven, formal implementation framework such as the Behavior Change Wheel (based on the COM-B system of capability, opportunity, and motivation),
19
Consolidated Framework for Implementation Research (CIFR),20
or reach, effectiveness, adoption, implementation, maintenance model (RE-AIM)21
are examples that may help to guide key steps in the implementation process.Each practice will need to decide whether to use the provider-completed form (Box 1) or the patient-completed form (Box 2). There is generally no advantage for a practice to use both forms.
A decision should be made about the format of the checklist and the way it will be administered: either as a paper form to be filed in the patient chart, an electronic form incorporated into the practice’s electronic medical record (EMR), or verbally by provider interview and not incorporated as a separate item in the patient record. If paper forms are used, the practice must designate which patients will be given the form (eg, all new pregnant patients, all patients with a new prenatal visit, all patients presenting for their first ultrasound examination in pregnancy). If electronic forms are developed, the practice may need to have information technology specialists modify the EMR to automatically tabulate the answers to the questions and present a “flag” or “pop-up” warning if preeclampsia risk factors are identified. The SMFM Informatics Committee has liaisons with EMR vendors and may be able to encourage the incorporation of these checklists into their standard prenatal record packages.
The practice should develop a written process regarding who will be responsible for completing the form (physician, nurse, or medical assistant for the provider-completed checklist in Box 1) or for giving the form to the patient (front-desk staff or medical assistant for the patient-completed checklist in Box 2) and for evaluating the responses (physician or nurse).
Each practice should develop a consensus regarding the patients for whom low-dose aspirin is initiated. The ACOG and SMFM Committee Opinion concludes that low-dose aspirin should be recommended for patients with any high-risk factors and considered for patients with more than 1 moderate-risk factor.
11
Each practice should also decide on the gestational age range for starting aspirin. The ACOG and SMFM Committee Opinion recommends that low-dose aspirin prophylaxis be initiated at 12 to 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery.11
The practice should also develop a consensus regarding the dosage of aspirin. The ACOG and SMFM Committee Opinion recommends a dosage of 81 mg daily,11
but some practices may consider a higher dosage.10
References
- Pre-eclampsia rates in the United States, 1980–2010: age-period-cohort analysis.BMJ. 2013; 347: f6564
- Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017.MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429
- Predictive model of factors associated with maternal intensive care unit admission.Obstet Gynecol. 2019; 134: 216-224
- Severe maternal morbidity among stillbirth and live birth deliveries in California.Obstet Gynecol. 2019; 134: 310-317
- Serious maternal complications in relation to severe pre-eclampsia: a retrospective cohort study of the impact of hospital volume.BJOG. 2017; 124: 1246-1253
- Epidemiology of maternal morbidity and mortality.Semin Perinatol. 2017; 41: 332-337
- Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement.Ann Intern Med. 2014; 161: 819-826
- Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis.Obstet Gynecol. 2010; 116: 402-414
- Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force.Ann Intern Med. 2014; 160: 695-703
- Aspirin for the prevention of preterm and term preeclampsia: systematic review and metaanalysis.Am J Obstet Gynecol. 2018; 218: 287-293.e1
- ACOG Committee Opinion No. 743: Low-dose aspirin use during pregnancy.Obstet Gynecol. 2018; 132: e44-e52
- Guidelines for perinatal care.8th ed. American College of Obstetricians and Gynecologists, Washington, DC2017
- The development and implementation of checklists in obstetrics.Am J Obstet Gynecol. 2017; 217: B2-B6
- Assessing the accuracy of pregnant women in recalling pre-pregnancy weight and gestational weight gain.J Obstet Gynaecol Can. 2013; 35: 802-809
- Validity of prepregnancy weight status estimated from self-reported height and weight.Matern Child Health J. 2014; 18: 1667-1674
- Misperceived pre-pregnancy body weight status predicts excessive gestational weight gain: findings from a US cohort study.BMC Pregnancy Childbirth. 2008; 8: 54
- Socioeconomic status, preeclampsia risk and gestational length in black and white women.J Racial Ethn Health Disparities. 2019; 6: 1182-1191
- A checklist for checklists. 2010.(Available at:)https://www.ariadnelabs.org/wp-content/uploads/sites/2/2019/10/checklist_for_checklists_final_10.3-1-1.pdfDate: 2010Date accessed: August 5, 2020
- The behaviour change wheel: a new method for characterising and designing behaviour change interventions.Implement Sci. 2011; 6: 42
- Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.Implement Sci. 2009; 4: 50
- Evaluating the public health impact of health promotion interventions: the RE-AIM framework.Am J Public Health. 1999; 89: 1322-1327
Article info
Publication history
Published online: June 14, 2020
Footnotes
All authors and Committee members have filed a conflict of interest disclosure delineating personal, professional, and/or business interests that might be perceived as a real or potential conflict of interest in relation to this publication. Any conflicts have been resolved through a process approved by the Executive Board. The Society for Maternal-Fetal Medicine (SMFM) has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
This document has undergone an internal peer review through a multilevel committee process within SMFM. This review involves critique and feedback from the SMFM Document Review Committees and final approval by the SMFM Executive Committee. SMFM accepts sole responsibility for document content. SMFM publications do not undergo editorial and peer review by the American Journal of Obstetrics & Gynecology. The SMFM Patient Safety and Quality Committee reviews publications every 36-48 months and issues updates as needed. Further details regarding SMFM Publications can be found at www.smfm.org/publications.
SMFM has adopted the use of the word “woman” (and the pronouns “she” and “her”) to apply to individuals who are assigned female sex at birth, including individuals who identify as men as well as nonbinary individuals who identify as both genders or neither gender. As gender-neutral language continues to evolve in the scientific and medical communities, SMFM will reassess this usage and make appropriate adjustments as necessary.
All questions or comments regarding the document should be referred to the SMFM Patient Safety and Quality Committee at [email protected]
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© 2020 Published by Elsevier Inc.
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