Appraisal of clinical practice guidelines and consensus statements on aspirin in pregnancy: a systematic review using the AGREE II instrument

Abstract

Objective: Recommendations regarding the use of aspirin in obstetrics vary across clinical practice guidelines and consensus statements of differing quality. This study aimed to systematically evaluate the quality of these documents, with particular focus on the recommended daily dosage, timing of initiation, and cessation of aspirin in the obstetric setting. This study employed a systematic review and quality appraisal approach using the Appraisal of Guidelines for Research and Evaluation (AGREE) II methodology. Methods :The study included the most recent versions of all international and national/regional clinical practice guidelines and consensus statements on aspirin use in pregnancy, published in English or Chinese. Data were retrieved from PubMed (11 April 2025), three Chinese academic databases (the Chinese Medical Association Database, Wanfang Data and China National Knowledge Infrastructure) and four guideline databases (11 April 2025). Two reviewers independently screened the searched items and extracted data. Four reviewers independently scored documents using AGREE II. Recommendations from all documents were tabulated and visualized using a color-coded grid. Results: A total of 32 documents were include, encompassing six obstetric conditions: Antiphospholipid Syndrome (APS), Fetal Growth Restriction (FGR), advanced maternal age, pregnancy loss, stillbirth and hypertension/pre-eclampsia. The included documents demonstrated strong performance in the domains of scope and purpose (median score: 89.67%, inter-quartile range [IQR] 61.11%-98.61%) and clarity of presentation (median 87.93%, IQR 50%-100%). The editorial independence domain also received relatively high score (median 73.59%, IQR 0%-100%). However, performance was lower in the domain of applicability (median 45.08%, IQR 0%-89.58%). Although aspirin 75-100 mg daily represents the most commonly recommended dosage, a broad range of dosing recommendations exists across most clinical scenarios. However, considerable controversy existed regarding the optimal timing of discontinuation, particularly in cases of hypertensive disorders of pregnancy/pre-eclampsia. Conclusion: Guidelines and consensus statements, which were generally of relatively high quality, demonstrated that most documents support the use of aspirin for specific obstetric complications. Given these substantial variations in dosage ranges, treatment timing, and combination therapy recommendations, developing standardized, evidence-based protocols is essential to improve the consistency and quality of aspirin therapy in obstetric care.