Is Aspirin necessary for women who are pregnant after 40?

Question

Hello doctor,

I am 48 years old and currently 13 weeks pregnant after transferring an embryo that we froze when I was 40. After my 12-week scan, I started reducing the dose of estrogen pills I was taking and plan to stop them at week 14. I have also reduced my progesterone injections (Lubion 25) to every other day for two weeks instead of daily, before stopping them entirely. Additionally, I am using Crinone 8% progesterone pessaries twice a day, which, according to my IVF doctor, I should continue until week 18. I have read that NICE guidelines suggest that Crinone can be stopped at 16 weeks. What is your opinion? Should I stop at 16 weeks instead of 18?

Also, I have been taking daily Clexane injections (40 mg). After my 12-week scan, a hospital midwife advised me to take 150 mg of Aspirin daily as part of their protocol to prevent pre-eclampsia and fetal growth restriction, conditions I am more prone to due to my age. However, when I mentioned this to my IVF doctor, he expressed concern about the risk of bleeding because I am already on Clexane. He recommended either not taking Aspirin or taking a lower dose of 75 mg daily. I chose to take 75 mg.

I am confused and would appreciate a second opinion. Is Clexane necessary because of my age? Also, is it safe for me to take 150 mg of Aspirin while on Clexane?

Please advise.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concerns and appreciate how carefully you are managing your pregnancy.

Regarding your queries, here is some guidance based on the NICE (National Institute for Health and Care Excellence) guidelines:

A. Threatened miscarriage:

For a woman with a confirmed intrauterine pregnancy and fetal heartbeat who presents with vaginal bleeding but no history of previous miscarriage:

If the bleeding worsens or persists beyond 14 days, she should return for further assessment.
If the bleeding stops, she should continue routine antenatal care.

For women with vaginal bleeding and a history of miscarriage, NICE recommends offering vaginal micronized progesterone 400 mg twice daily if an intrauterine pregnancy with a fetal heartbeat is confirmed by scan. Progesterone should be continued until 16 completed weeks of pregnancy.

Therefore, you can stop using Crinone 8% progesterone pessaries after completing 16 weeks of pregnancy.

B. Regarding Aspirin dosage (75 mg or 150 mg):

NICE advises pregnant women at high risk of pre-eclampsia to take 75 mg to 150 mg of Aspirin daily, starting from 12 weeks of pregnancy until delivery. High-risk factors include:

Hypertensive disease during a previous pregnancy.
Chronic kidney disease.
Autoimmune diseases such as systemic lupus erythematosus or antiphospholipid syndrome.
Type 1 or type 2 diabetes.
Chronic hypertension.

Women with more than one moderate risk factor should also take 75 mg to 150 mg of Aspirin daily from 12 weeks until birth. Moderate risk factors include:

Nulliparity.
Age 40 years or older.
Pregnancy interval of more than 10 years.
Body mass index (BMI) of 35 kg/m² or more at first visit.
Family history of pre-eclampsia.
Multi-fetal pregnancy.

Based on your history, your age over 40 is considered a moderate risk factor. If you have additional moderate or high-risk factors, a 150 mg Aspirin dose is indicated.

Recommendation:

I recommend continuing Aspirin 150 mg as you have started, as it is safe and helps reduce the risk of complications such as pre-eclampsia.

I hope this clarifies your concerns. If you have any further questions, please do not hesitate to contact me.

Thank you again for your careful attention to your pregnancy. I am here to help if you need any further assistance.

Answer 2

Hello,

Welcome back to icliniq.com.

Yes, you can stop Crinone (Progesterone) after completing 16 weeks of pregnancy without tapering. You should definitely continue taking 150 mg of Aspirin daily until the end of your pregnancy. You should also continue Clexane (Enoxaparin sodium) alongside Aspirin 150 mg until delivery, as this will help reduce the risk of pre-eclampsia.

Additional recommendations for fetal monitoring: Women requiring additional fetal monitoring should undergo ultrasound assessments for fetal growth, amniotic fluid volume, and umbilical artery Doppler velocimetry starting between 28 and 30 weeks of gestation (or at least two weeks before the previous gestational age of onset if earlier than 28 weeks). This should be repeated four weeks later in women with a history of:

Severe pre-eclampsia.
Pre-eclampsia resulting in birth before 34 weeks.
Pre-eclampsia with a baby whose birth weight was below the 10th centile.
Intrauterine death.
Placental abruption.

Cardiotocography should be performed only if clinically indicated.

Assessment of proteinuria in hypertensive disorders of pregnancy:

Interpret proteinuria measurements in the context of a full clinical review of symptoms, signs, and investigations for pre-eclampsia.
Use an automated reagent-strip reading device for dipstick screening for proteinuria in pregnant women in secondary care settings.
If dipstick screening is positive (1+ or more), quantify proteinuria using the albumin: creatinine ratio or protein: creatinine ratio.
Do not use the first morning urine to quantify proteinuria.
Routine 24-hour urine collection is not recommended to quantify proteinuria.
When using the protein: creatinine ratio to quantify proteinuria, use 30 mg/mmol as the threshold for significant proteinuria. If the result is 30 mg/mmol or above and the diagnosis of pre-eclampsia is uncertain, consider retesting on a new sample alongside a clinical review.
When using albumin: creatinine ratio as an alternative, use 8 mg/mmol as the diagnostic threshold. If the result is 8 mg/mmol or above and the diagnosis remains uncertain, consider retesting and clinical review.

You should also have an anomaly scan at 18 to 20 weeks.

I appreciate you reaching out with your questions. If you have any further queries, please don’t hesitate to contact me.

Thank you.