Management of immune thrombocytopenia in pregnancy

Abstract

Immune thrombocytopenia (ITP) presents unique challenges in the peripartum setting. The diagnosis of ITP is similar to the nonpregnant patient except pregnancy related causes of thrombocytopenia must be considered. Management of ITP will change over the course of pregnancy and closer monitoring is critical as delivery approaches when the recommended platelet goal increases from 20×10–30×10/L to above 50×10/L for a vaginal delivery. If an epidural is required, the platelet count should be above 70×10/L. The mode of delivery is based on obstetrical indications. First line therapies are glucocorticoids or intravenous immunoglobulin (IVIG). Many second line therapies may be safe in pregnancy. Contraindicated therapies include syk inhibitors, vinca alkaloids, mycophenolate mofetil, cyclophosphamide and danazol. Limited case series report safe administration of the thrombopoietin receptor agonists (TPORAs) without adverse fetal outcomes. While the majority of neonates are unaffected, neonatal platelet counts can decline in the first days after delivery and may require therapy. Maternal treatment and platelet count do not appear to predict the risk of neonatal thrombocytopenia; the strongest predictor is a previous sibling’s history. ITP is not a contraindication for pregnancy; women with a history of ITP should not be discouraged from becoming pregnant as their ITP can be safely managed with close monitoring and multidisciplinary coordination with obstetrics and pediatrics.