Letter to the Editors ajog.

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Comment on: Preventing preeclampsia with aspirin: 56
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does dose or timing matter? 58
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6 TO THE EDITORS: Tong et al1 state that possible biological median at 24 weeks gestation. Also there was no signicant 61
7 mechanism of action of aspirin in the prevention of pre- difference between the observational and aspirin-treated co- 62
8 Q2 eclampsia are that it: (1) facilitates early placental embed- horts. These observations would tend to indicate that aspirin 63
9 ding, a process that is in fact poorly understood but is likely does not have an effect on the failure of the normal physio- 64
10 to be complete by 16 weeks gestation; and/or (2) also in- logical change of the spiral arterioles. Hence any effect on the 65
11 creases prostacyclin (vasodilator); and/or (3) may decrease uteroplacental circulation is more likely to be in the prevention 66
12 endothelial (blood vessel) dysfunction. Tong et al1 do not of acute atherosis probably via its action on platelets. - 67
13 mention the effect of aspirin on platelets. By the inhibition of Q4 68
Roger A. McMaster-Fay, MB BS
14 prostaglandin synthetase, aspirin blocks the production of Department of Obstetrics and Gynecology 69
15 thromboxane, the mediator of platelet activity. Thus aspirin Faculty of Medicine 70
16 renders the platelets nonfunctional and hence maintains Central Clinical 71
17 circulation in small diseased blood vessels. University of Sydney 72
18 As far as placentation is concerned: the spiral arteries after Sydney, Australia Q1
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19 being breeched by the non-villous trophoblast, undergo roger@rfay.com.au 74
20 extensive adaptations and structural alterations in order to Jonathan A. Hyett, MD, BS BSc 75
21 provide the intervillous space of the growing placenta with an Department of Obstetrics and Gynecology 76
22 adequate amount of maternal blood.2 This process they Faculty of Medicine 77
23 termed physiological change. Central Clinical 78
24 From 15 or 16 weeks gestation, there seems to be a wave University of Sydney 79
25 of intra-arterial trophoblast migration beyond the deciduo- Sydney, Australia 80
26 myometrial junction into the true myometrial segments of The authors report no conict of interest. 81
27 the spiral arteries.3 82
28 We used color Doppler ultrasound to describe the changes REFERENCES 83
29 in the uteroplacental circulation in the midtrimester of 1. Tong S, Mol BW, Walker SP. Preventing preeclampsia with aspirin: 84
30 nulliparous pregnancy observing and quantitating the devel- does dose or timing matter? Am J Obstet Gynecol 2017;216:95-7. 85
31 opment of a low-resistance circulation.4 We found that the 2. Brosens I, Robertson WB, Dixon HG. The physiological response of 86
32 indices of ow fell from 14-18 weeks and fell even further the vessels of the placental bed to normal pregnancy. J Pathol Bacteriol 87
from 18-24 weeks. 1967;93:569-79.
33 88
3. Pijnenborg R, Robertson WB, Brosens I, Dixon G. Review article:
34 Failure of this process of physiological change in the spiral trophoblast invasion and the establishment of hemochorial placentation. 89
35 Q3 arteries of the placental bed is found in cases of preeclampsia Placenta 1981;2:71-92. 90
36 and intrauterine growth restriction without preeclampsia. 4. Fay RA, Ellwood DA, Bruce S, Turner A. Color Doppler imaging of the 91
37 Thus the earliest known feature of preeclampsia, the failure of uteroplacental circulation in the middle trimester: observations on the 92
physiological change in the spiral arterioles, is probably an development of a low resistance circulation. Ultrasound Obstet Gynecol
38 93
1994;4:391-5.
39 event predominantly of the second trimester. 94
5. Zeek PM, Assali NS. Vascular changes in the deciduas associated
40 These spiral arterioles, where physiological change has not with eclampticogenic toxemia of pregnancy. Am J Clin Pathol 1950;20: 95
41 occurred, can then undergo atheromatous-like disease termed 1099-109. 96
42 acute atherosis.5 This results in a further restriction of 6. Leduc F, Park F, McMaster-Fay R, Johnson JM, Hyett J. Does low 97
43 blood ow and even complete vascular occlusion.2 dose aspirin effect mean uterine artery Doppler pulsatility index in women 98
deemed high risk for early pre-eclampsia? Ultrasound Obstet Gynecol
44 Our uterine artery Doppler observations of patients at high 99
2015;46(Suppl):210-1.
45 risk of preeclampsia at 12 weeks gestation6 were that both 100
46 patients treated with aspirin and those not treated showed a 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 101
47 reduction in uteroplacental resistance toward the expected 2017.05.014 102
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MONTH 2017 American Journal of Obstetrics & Gynecology 1

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