Effect of pregnancy on the course of immune thrombocytopenia: a retrospective study of 118 pregnancies in 82 women

Key Points• Maternal platelet count response was not different for IVIg and corticosteroids in this retrospective study of pregnant women with ITP.• Neonatal outcomes were overall favorable and similar after treatment of maternal ITP with IVIg or corticosteroids.Treatment options for immune thrombocytopenia (ITP) in pregnancy are limited, and evidence to guide management decisions is lacking. This retrospective study of singleton pregnancies from 2 tertiary centers compared the effectiveness of intravenous immunoglobulin (IVIg) and corticosteroids in treatment of ITP. Data from 195 women who had 235 pregnancies were reviewed. Treatment was not required in 137 pregnancies (58%). Of the remaining 98 pregnancies in 91 women, 47 (48%) were treated with IVIg and 51 were treated with corticosteroids as the initial intervention. Mean maternal platelet count at birth did not differ between groups (IVIg 69 3 10 9 /L vs corticosteroids 77 3 10 9 /L; P 5 .71) nor did the proportion of mothers who achieved a platelet count response (IVIg 38% vs corticosteroids 39%; P 5 .85). There were no fatal or severe maternal, fetal, or neonatal hemorrhages. Of 203 neonates in whom platelet counts were available, 56 (28%) had a birth platelet count <150 3 10 9 /L and 18 (9%) had platelet counts <50 3 10 9 /L. Nadir platelet counts for most affected neonates occurred at birth, although for some neonates, nadir platelet counts occurred up to 6 days postnatally. Intracranial hemorrhage was noted in 2 neonates (nadir platelet counts were 135 and 18 3 10 9 /L). There were no neonatal deaths. The majority of pregnant women with a history of ITP did not require treatment, and neonatal outcomes were comparable for mothers who received IVIg or corticosteroids for treatment of maternal ITP. (Blood. 2016;128(10):1329-1335

Section: Discussionsupporting

confidence: 92%

Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy

Sun

Shehata

et al. 2016

“…88 As in nonpregnant patients, ITP may be primary or associated with an underlying autoimmune condition. 89 It may present for the first time or be exacerbated during pregnancy and is the most common cause of thrombocytopenia in the first trimester. Severe maternal or neonatal bleeding is rare when these pregnancies are managed by an experienced, multidisciplinary team.…”

Section: Itp In Pregnancymentioning

confidence: 99%

“…Maternal therapy and platelet count appear to be poor predictors of the neonate's platelet count, the only reliable predictor the platelet count and course of thrombocytopenia of that of an older sibling. 89 Patients refractory to first-line treatment may benefit from a combination of IVIg and corticosteroids. 92 Options for second-line therapy are limited by fetal risk.…”

Section: Itp In Pregnancymentioning

confidence: 99%

Clinical updates in adult immune thrombocytopenia

Lambert

Gernsheimer

2017

361

319

Immune thrombocytopenia (ITP) occurs in 2 to 4/100 000 adults and results in variable bleeding symptoms and thrombocytopenia. In the last decade, changes in our understanding of the pathophysiology of the disorder have led to the publication of new guidelines for the diagnosis and management of ITP and standards for terminology. Current evidence supports alternatives to splenectomy for second-line management of patients with persistently low platelet counts and bleeding. Long-term follow-up data suggest both efficacy and safety, in particular, for the thrombopoietin receptor agonists and the occurrence of late remissions. Follow-up of patients who have undergone splenectomy for ITP reveals significant potential risks that should be discussed with patients and may influence clinician and patient choice of second-line therapy. Novel therapeutics are in development to address ongoing treatment gaps.

“…Platelet counts may fall during gestation, and at least 15% to 35% of mothers require treatment even prior to management of labor and delivery. [14][15][16] This figure depends on practice patterns, so that the need for treatment is likely to be more prevalent in tertiary-care referral centers. Maternal and neonatal outcomes are generally favorable.…”

Section: Immune Thrombocytopeniamentioning

confidence: 99%

Thrombocytopenia in pregnancy

Cines¹,

Levine

2017

134

137

Thrombocytopenia develops in 5% to 10% of women during pregnancy or in the immediate postpartum period. A low platelet count is often an incidental feature, but it might also provide a biomarker of a coexisting systemic or gestational disorder and a potential reason for a maternal intervention or treatment that might pose harm to the fetus. This chapter reflects our approach to these issues with an emphasis on advances made over the past 5 to 10 years in understanding and managing the more common causes of thrombocytopenia in pregnancy. Recent trends in the management of immune thrombocytopenia translate into more women contemplating pregnancy while on treatment with thrombopoietin receptor agonists, rituximab, or mycophenylate, which pose known or unknown risks to the fetus. New criteria to diagnose preeclampsia, judicious reliance on measurement of ADAMTS13 to make management decisions in suspected thrombotic thrombocytopenic purpura, new evidence supporting the efficacy and safety of anticomplement therapy for atypical hemolytic uremic syndrome during pregnancy, and implications of thrombotic microangiopathies for subsequent pregnancies are evolving rapidly. The goals of the chapter are to help the hematology consultant work through the differential diagnosis of thrombocytopenia in pregnancy based on trimester of presentation, severity of thrombocytopenia, and coincident clinical and laboratory manifestations, and to provide guidance for dealing with some of the more common and difficult diagnostic and management decisions.