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- [00:00]
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Dr. Chapa
We heard you nine years of bring back the snack wrap and you've won. But maybe you should have asked for more. Say hello to the Hot Honey Snack Wrap. Now you've really won. Go to McDonald's and get it while you can. 19:20 oh, he's good. He's good. Another 100 chips, please. Changing 100. That's it, Clark, show him who's boss. Okay, wise guy, let's see how you do against three hands.
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- [01:34]
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- [02:08]
Pharmaceutical Advertiser
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Dr. Chapa
Oh, gee, that's it. I've had enough.
- [02:23]
Microsoft 365 Copilot Announcer
Let's get out of here.
- [02:25]
Dr. Chapa
Good luck, sir. I ain't seen a beating like that since somebody stuck a banana in my pants and turned a monkey loose. I haven't seen a beating like that since the last time somebody put a banana in my pants and turned a monkey loose. Words of wisdom. You know, I'm surprised that Vegas vacation with Chevy Chase and Beverly d'. Angelo. I mean, how did that miss the Oscar nod? Okay, the Oscar nomination, Vegas vacation. What does this have to do with what we're talking about? Well, loosely, everything. And close on inspection, nothing at all. Except for the fact that SMFM just finished its annual pregnancy meeting in, say, with me. Guys, you guessed it, sunny Las Vegas. Yep, it was February 8th through the 13th. And that's what we're going to focus on in this episode. We're going to take one data set. Okay, so this was an abstract that was presented at the pregnancy meeting from SMFM from my old alma mater. This is from UT Southwestern. And we are back to the traditional question about aspirin in pregnancy. I mean, you'd figure that we would have figured this thing out by now, but no, lo and behold, controversies abound. And it really has to do with two main things. Guys, here's where we're going. And I want to be very quick, even though of course we're going to review some, some data and summarize what professional societies say about these two things. The two areas of controversy that are perpetual until we have some new guidance, which ideally will be coming out soon on this whole issue of low dose aspirin is who gets this and at what dose should we get this? Right? So those are the two controversies. Let me say that again. Who gets this? In other words, should it just be everybody gets it universal? Why not? It's pretty darn low risk versus those with risk factors, which is the current ACOG and SMFM strategy. Right? Low risk, get nothing too moderate risk factors or more. Get a low dose aspirin or one or more high risk factors. They get started on prophylactic aspirin, mainly for preeclampsia prevention. Of course. Now that is the risk stratification model, although some absolutely call for a universal aspirin. I'm kind of in that camp because, well, we're gonna get into it here, but the potential concerns of this thing, oh, what about bleeding? What about gastroschisis in the child? Well, if you give it after 12 weeks, the chances that it's pretty small and the bleeding actually really has not been found to be a clinically relevant issue outside of maybe some bleeding above 500mls. But now that postpartum hemorrhage is at or, or over 1000mls by an absolute volume outside of symptoms or signs of hypovolemia, yeah, you may get like maybe 700mls. And I'm not saying that that's good, but it's not pph. All right, so while it may increase maybe some postpartum hemorrhage in some studies, not all, it's found to be of little clinical relevance with the big factors like abruption or interventricular hemorrhage or other significant bleeding events. Just that really hasn't panned out in the data. We'll touch on that a little bit in this episode. So the first thing is who gets this? Universal or risk factors? I'm in the universal camp, as are many others. Although the official stance right now, I have to be clear, is a risk strategy approach. Now the opinions are changing, things are moving fast. Remember that right now, in terms of screening for pre existing diabetes in pregnancy, which we just covered, there is the official ACOG stance, which is, well, those with risk factors, you can look under 16 weeks to see if it's pre existing, whereas others say, hey, BMIs are higher anyway, we're going to miss this thing by a risk based approach. So just do universal screening either with or without risk factors as either hemoglobin A1c in the general no risk population, or if they have risk factors for DM, just give them an early 75 gram glucose challenge. We just covered that in the last episode. My point is things are changing and opinions are changing. All right, but we're not talking about GDM in this episode, we're talking about aspirin. So the first controversy is who gets it everybody. Which is what my camp is or risk factor approach. And then the other controversy is, okay, fine, well, what dose are we going to use? The current U.S. recommendation from ACOG is 81 milligrams. But not everybody agrees. Some say we should do 162 milligrams, which is two baby aspirins, similar to what the UK does, which is give two tablets of 75 milligrams, totaling one hundred and fifty. Now we don't have 75 milligrams. That would be ideal. But in lieu of that, taking two baby aspirins. In my Texas math, even I know that 81 milligrams times two is 162. And that's the focus of what we're going to present in this episode. So there's two controversial things that were presented out of UT Southwestern at the pregnancy meeting that just ended in sunny Las Vegas. Vegas. And the two controversial things are, number one, was this given selectively based on high risk factors or universally? And then number two, what dose was it? Was it the 81 milligrams or the 162? And what did they find? So that's where we're going. Very quickly. I'm going to summarize just the, the nuts and bolts results of this new study which again is going to be formal publication later. But out of UT Southwestern from the pregnancy meeting from, from SMFM from Las Vegas that just ended showing the benefit. Let me just spill it here, guys. I, I, I know I ruined this all the time. I'm supposed to do this after the intro. Let me just tell you here and then I want you to hear the data. Yes, they did it universal. Yes, they did it at 162mg and compared that that era when everybody got that aspirin at their and they were dispensed that aspirin so that they didn't have to go buy it at high risk clinic at Parkland compared to when they did not do universal and the rates of preeclampsia one versus the other. Okay, it's a good study. I love it. Even though it's not, you know, an rct, it's comparing one cohort in time compared to the previous cohort in time still gives valuable information from a population level. We're going to cover this. And then again briefly, we're just going to talk about and remind ourselves some of the differences in opinions here on the data because we do know that there is a dose response effect. Guys, there is a dose response effect with aspirin. With the majority of meta analyses saying you need at least 100 milligrams of aspirin to be the most effective here in a dose dependent relationship. Okay, so we've got plenty saying we're under dosing, it should be at least 100. And since we don't really have anything else, we do two baby aspirins totaling 162 milligrams. There is data before that. All right, so right after this intro we will be right back with the oral abstract. Number two, universal Aspirin Administration for Prevention of Preeclampsia, which is also published in the February 2026 issue of Pregnancy from UT Southwestern from the SMFM meeting in Las Vegas. We'll be right back. Foreign this is Dr. Chapa's OB GYN Clinical Pearls, no Spin podcast. So right off the bat, let me just clear the air here. You do what you want to do. You do what you want to do. You do what you want to do. I'm not mad at you. I like universal dosing. I believe that there is some benefit over 100 milligrams. That is the the best evidence that we have. Most of the data shows that although 81mg is, it's not like it's not going to work. It does something. But most of the benefit especially for those with higher risk. And again, some advocates and some experts, trust me guys, I've been involved with these conversations for years. Some say, well, if you are just. If you have two moderate risk factors, I'm going to give you the 81 milligrams. If you have high one high risk factor, I'm going to give you THE 162 milligrams. So they even. They risk stratify the dose. That's fine. I think we're making it more complex versus like what UT Southwestern did just say, look, there's no real risk here. We don't see any increased risk of bleeding. So we're gonna carte blanc. Boom. Everybody gets the stamp boom on your forehead. You're 162 milligrams. So whatever you wanna do, if you wanna stick with 81 phenomenal, that is current guidance. Say the word current. Current guidance. Some risk stratified. That's okay too. Some say I'm doing 162 milligrams. So you do you. I'm just telling you I believe the data is definitely there, like the latest data or outside of this one from UT Southwestern, which was in the fall of 2025. Just in October of 2025 in the gray Journal, somebody who we've talked about before. Again, I've done work with this physician. Remarkable. We've covered a lot of his work in the past on hysterotomy closure. This is Emmanuel Bujold. I remember we were in the Netherlands. Where were we? It was Amsterdam and we were in Amsterdam. Oh my gosh. Had to be 15 years ago in some big conference about historical closure. What's best practice? Phenomenal. First time I met Emmanuel Bujold and Stephanie, which was then his like fellow at that time. Anyway, so Emmanuel Bujold is on this authorship from the gray journal from October 2025 and the title was the Effect of aspirin on the risk of preeclampsia based on the Fetal Medicine foundation first trimester risk. Short of it is, yes, risk factors did work. They found those that were obviously at higher risk. That's fine. But the surprising thing is that this new data set, this was out of the RE review as well. Post hoc analysis of the ASPRE data. Right. So that was the big study on aspirin and preeclampsia prevention. We're not going to get into it, but remember, the aspre, that's aspre aspirin for preeclampsia reduction. It actually showed, look, you have almost, almost universal protection of preeclampsia with 150 milligrams of aspirin when it was started early. And it prevented almost all cases of preeclampsia up to 37 weeks. After 37 weeks, it really kind of didn't do very much. The point is, that's why there's a push on stopping aspirin at 36 weeks. And guys, how circular is this? I trained with aspirin, aspirin discontinuation at 36 weeks. And then we said, no, no, no, go all the way up until delivery. Now, the data is, the latest data is you can probably stop it at 36 weeks because it's likely not going to prevent term preeclampsia, is going to prevent preterm preeclampsia. Okay, so that's what this, this 2025 post hoc analysis of the ASPREE data actually found. It found that in those patients who had compliance over 90%. I'm not gonna get into how they figured that out, but over 90% compliance, 150 milligrams of ASP, it prevented almost all cases of preeclampsia with delivery up to 37 weeks when it was started. Of course, early on. Okay, so they made the push that, hey, 81 milligrams is fine, but 150 milligrams, you're gonna get much more of a dose response. And there's plenty of data that has also signaled that. Now, if you're saying bachapa, what about the safety? Well, what about it? What about it? Early on there was concern about placental abruption or if you started it too early in the first trimester, maybe gastroschisis. And neither of those worked out. No safety differences. Listen to this, guys, the big clinical pearl. No safety differences have been identified between the 81 milligram and the 150 milligram of aspirin use in pregnancy. Now, I know what you're saying, but you said 162. Yes. There doesn't seem to be, when you look at that higher clamp chunk of data for the higher dose. Anything else for the 162, although most of the data is for 150, I'll give you that. Okay. However, the point is, if you're talking about the extra 12 milligrams from 150 to 162 is probably not going to move the needle. Most agree that anything under traditionally 300 milligrams, it's all kind of a low risk. But there is a dose response or preeclampsia prevention and risk reduction. So very quickly, no safety concerns have been identified between the 81 milligram and the 150 dose. And that includes a USPSTF review that included 21 trials. No greater risk of placental abruption, no greater risk of fetal intracranial bleeding. No greater risk. Here it is, guys. Of postpartum hemorrhage. Okay, now I'm gonna get into something that's very surprising. Listen to this, guys. Very surprising in this UT Southwestern abstract that we're about to get into regarding bleeding. Okay, so hang on to your hats there, ladies and gentlemen. Are you all wearing hats? That was weird. So hold on, don't leave because there's gonna be something very surprising here that's like, I don't know. I don't know what to do with that either. Regarding bleeding and the higher dose of aspirin used in the cohort later cohort compared to the earlier cohort who did not get the universal higher dose aspirin. Okay, so there's something kind of weird in this. Now, even though, even though the Cochrane review, if you read the last Cochrane review, it said, well, it may. Higher doses may increase the risk of postpartum hemorrhage. You have to dig into that Cochrane review to go, wait, it was over 500mls and it actually didn't increase potential abruption or any kind of catastrophic bleeding. So. Okay, well, that's weird. That was back in 2019. Okay. Antiplatelet agents for preventing preeclampsia and its complications. That was a Cochrane database of systematic reviews from 2019. So it seems to be that the safety, while there was some concern about bleeding, the safety seems to be there at the 150 to 162. Okay. And there is disagreements that this, these guidelines that differ from the US and international. And that's okay. We all have different opinions. The point is, aspirin definitely does work. The question is who should get it and at what dose. I think that's all I want to say about that as a quick recap because I want to dive into now, this, the new study, the new data from UT Southwestern, my old peeps, my alma mater, and I'm very proud of them because, man, great work. There's so many patients that go through the UT Southwestern parkland system that it's a great database. They're also of course, part of the MFM networks unit study base database. So very quickly, here's what they did. There was two main groups here. Okay, so there was those before the initiation of universal higher dose aspirin, and then those that were followed obviously after. Now those that were in the after camp was basically August of 2022. So everybody who came in for prenatal care before 16 weeks of gestation was given, given. So that's a nice one. They gave them to them. 162 milligrams of aspirin and said, take this until we tell you not to and or, you know, 36 weeks, ish. The point is they gave them the medication. I love that. Remember, we also have an episode in the past as to when aspirin should be taken. Now, I'm not going to dive into it, into this study, but short of it is there is very strong data and guidelines do say that aspirin should be taken at night. All right, so if they take it midday, there's less effect, has to do with circadian rhythms and vascular reactivity. Aspirin should be taken at night. You can go back to our archive. I give you all of the data as to why aspirin is better at nighttime. Okay, so what they did is starting from August 2022, when these patients were dispensed directly the aspirin at that dose, they then compared the outcomes to those who gave birth before. So those who gave birth at parkland between 2023 and 2025 compared to the universal aspirin change to see what happened there with their severe preeclampsia rates of diagnosis. Okay, so this wasn't just like hypertensive disorders. This was severe preeclampsia. Okay. Short of it is, let me just tell you, universal 162 dose, that cohort compared to the earlier Cohort had a 29%. So let's stop there. That's pretty high, guys. 29% is a lot. 29% lower rate of developing severe preeclampsia compared with the group who had not received aspirin in this form. It worked. It worked. They also found that the patients given aspirin who did develop severe preeclampsia did so later on in pregnancy compared to the control. Which makes sense because remember, it's great at preventing preterm preeclampsia, but likely it's not having a big dent into term preeclampsia. And you're like, well, that kind of sucks. No, no, no, it doesn't, because at least they're at term. Okay. We don't want to add another morbidity which is severe preeclampsia or preeclampsia with severe features and be preterm. So if you can get at least get him to term, that's a win because then you can just deliver. Okay. That's the goal there. So patients with pre existing chronic hypertension before pregnancy who were given aspirin were also less likely to develop preeclampsia with severe features. And here's the catch. Here's the catch. There was no increase in maternal hemorrhage or placental abruption with aspirin therapy. So that's. There you go. If the fear was, well, you're going to cause more bleeding. There was no increase in maternal hemorrhage or placental abruption with aspirin therapy. All right, now here is the weird part. We're about to start wrapping this up. Here's the weird thing that I don't know what to do with. I mean, it's good, it's reassuring. Be like, okay, well, that's weird, but whatever. So here's what they found. Quote. There was a decrease in the rate of postpartum hemorrhage, defined as the blood loss of greater than 1000mls with aspirin at 8.9 versus 9.5%. So it's not a big change. But if we're going to be worried about bleeding, this actually showed. Again, this was the weird thing here, the curveball thrown in. There was a decrease in the rate of postpartum hemorrhage, defined as a blood loss greater than 1000mls with aspirin at 8.9 versus 9.5%, end quote. What are you going to do? I don't know. I mean, I'm just throwing that out there. You talk amongst yourselves. And the last piece of reassurance is that while there was no change in postpartum hemorrhage, meaning no increase with the additional dose, while there was no increase in neonatal intraventricular hemorrhage There was also no increase in the rates of gastroschisis. So all to say, good news. So this is making the press cycles, right? It's ready in SMFM news. It's in Medical Update online. And it should. This is a big deal because it said universal and the higher dose and potentially lower risk of bleeding, although, you know, the percentage wasn't great there. And these authors, that's why the authors say, look, this is kind of a, we can't ignore this. This is eye opening. There's something to this. And so the benefit of continuing with this strategy seems to be legit. So it's changing. There's a lot of things here. Again, medicine is done by questioning and adapting and changing. So 81 milligrams. Nothing wrong with that. There is benefit to that. I'm not saying not to do that. But since there is a dose response and there has not been a solid link in bleeding complications, perhaps until we have a 75 milligram where we take two and get 150 milligrams, perhaps, at least according to UT Southwestern, it is reasonable to offer 162 milligrams universally without fear of postpartum hemorrhage, intraventricular neonatal hemorrhage, or even gastroschisis. Good stuff. Good stuff. So congratulations to Elaine and her team from UT Southwestern. Phenomenal. Oh the lands. I got my first child as a Parkland baby. How about that? I mean I'd, that's, that's how inbred the, the, the, the teaching and the training was. Met my wife at UT Southwestern of a Parkland baby. Proud, proud roots at UT Southwestern in Parkland Hospital. So I think we've done what we're supposed to do. This is brand new data that just happened a couple of days ago out of SMFM in sunny Las Vegas. Not a sponsor podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, let's take it home.
- [24:24]
Microsoft 365 Copilot Announcer
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Dr. Chapa
This is Dr. Chapa's ob gyn clinical pearls, no spin podcast.