Use of Eltrombopag for the First Trimester Pregnancy Complicated with Refractory Idiopathic Thrombocytopenic Purpura: A Case Report and Literature Review

Abstract

Severe idiopathic thrombocytopenic purpura (ITP) is thought to occur in approximately one in 10,000 pregnancies and refractoriness for conventional treatment is life-threatening. We herein describe a pregnant case of refractory ITP successfully treated with eltrombopag, orally medicated thrombopoietin receptor agonist (TPO-RA). The patient was diagnosed with ITP at the age of 22 and corticosteroid, immune globulin treatments, or splenectomy was invalid. Eltrombopag was administered at 25 mg/day and the platelet count was maintained at 50-80 × 10 9 /L. At the age of 32, she discontinued the medication out of fear of the possible adverse events of TPO-RA. She became pregnant and visited our hospital at the gestational age of 9th week with the result of a platelet count at 18 × 10 9 /L. Two weeks later, her platelet counts further decreased to 9 × 10 9 /L, and eltrombopag administration was resumed with 12.5 mg/day after informed written consent. The platelet counts subsequently increased and were maintained between 30 and 90 × 10 9 /L. At 34th gestational week, the dose of eltrombopag was increased to 25 mg/day in preparation for delivery and the count increased to 123 × 10 9 /L by the 38th gestational week. A healthy female infant weighing 2370 g was vaginally delivered by induced labor. Maternal blood loss was 0.4 L at delivery, and the newborn's platelet count was 173 × 10 9 /L on the second day after birth and 174 × 10 9 /L on the fifth day. The infant is neurologically and developmentally intact at 6 months of age. Regarding TPO-RA treatment for refractory ITP during pregnancy, only six pregnant cases including the present one treated with eltrombopag have been reported so far. This case is rare with reference to the use of eltrombopag for the first trimester and we increased the dose of eltrombopag at the gestational age of 34 in preparation for delivery and vaginal delivery was successful without platelet transfusion. Despite the very limited information on eltrombopag, its use might be a possible optional treatment for refractory ITP during pregnancy.

Treatment of immune thrombocytopenia during pregnancy with thrombopoietin receptor agonists

“…Twenty‐four relevant articles were identified describing 45 pregnancies: an international retrospective study of 15 patients (17 pregnancies: eltrombopag n = 10, romiplostim n = 7) and 23 case reports comprising 27 mothers (28 pregnancies: eltrombopag n = 11, romiplostim n = 15, both eltrombopag and romiplostim in the same pregnancy n = 2) 24–47 …”

Application of recombinant human thrombopoietin in pregnant women with immune thrombocytopenia: a single-center experience of four patients and literature review

“…Aside from rhTPO, TPO-RAs (e.g., romiplostim, eltrombopag, and avatrombopag) also show efficacy in refractory P-ITP. [38][39][40][41][42] In a multicenter study, 40 15 women with ITP were treated with eltrombopag or romiplostim during 17 pregnancies, with the successful delivery of 18 neonates (one twin pregnancy). These findings indicate that the transient use of TPO-RAs in pregnant women with refractory ITP (refractory to at least corticosteroids and IVIg) is safe.…”

Case Report: Thrombopoietin receptor agonists in resistant thrombocytopenia in pregnancy: a case series and review of literature

“…There is limited data on the use of TPO receptor agonists such as Romiplostim or Eltrombopag in pregnancy, and most of the available data comes from case reports (17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31). Both medications can cross the placenta and potentially cause unwanted side effects to the fetus.…”