Gaps in Low-Dose Aspirin Use for Preeclampsia Prevention: Insights and Clinical Implications

Objective: To evaluate real-world prescribing patterns of low-dose aspirin for preeclampsia prevention among pregnant women who met the Israeli or American College of Obstetricians and Gynecologists (ACOG) guideline criteria for preeclampsia prophylaxis, and to identify disparities and missed opportunities in implementing risk-based prophylaxis in a diverse obstetric population. Methods: This retrospective study analyzed women who delivered live births at a tertiary medical center in northern Israel between March 2020 and April 2024. Eligibility for low-dose aspirin prophylaxis was assessed using Israeli guidelines, focusing on major risk factors, and the broader ACOG criteria, which include moderate-risk factors. This dual approach reflects debates in Israel about incorporating moderate-risk factors into routine clinical practice. Results: Of 18,838 women included, 1,160 (6.2%) met the criteria for low-dose aspirin prophylaxis under Israeli guidelines, and 511 (44.1%) of these received prescriptions. The prescription rate was highest among women with a history of preeclampsia (79.0%) and pregestational diabetes (66.3%) but notably lower among those with chronic hypertension (30.3%) and autoimmune diseases (41.3%). Under ACOG criteria, 2,559 women (13.6%) were eligible for low-dose aspirin, but only 27.9% (715/2,559) received prophylaxis. The prescription rate was significantly higher among women with high-risk factors than among those with only moderate-risk factors (OR=0.16, p<0.001). Arab women were more likely to receive low-dose aspirin than were Jewish women (31.2% vs 24.5%, p<0.001), consistent with higher prevalences of risk factors. Multivariate analysis showed that a history of preeclampsia (OR=7.15, p<0.001) and pregestational diabetes (OR=3.80, p<0.001) were strongly associated with low-dose aspirin prescription. Conclusion: Our findings reveal suboptimal prescription of low-dose aspirin according to guideline criteria, especially among women with moderate-risk factors. Even among women with high-risk factors, disparities in prescribing practices persisted. These gaps highlight the need for better provider education, consistent risk assessment, and structured implementation strategies to improve guideline adherence.