What corticosteroids (e.g. prednisone) should be given to a pregnant woman at 29 weeks gestational age with thrombocytopenia (platelet count of 69,000) to increase platelet count?

From the Guidelines

For a pregnant woman at 29 weeks gestational age with thrombocytopenia (platelet count of 69,000), oral prednisone at a low dose of 10-20 mg/d is the recommended corticosteroid treatment to increase platelet count, as suggested by the international consensus report on the investigation and management of primary immune thrombocytopenia 1. This approach is based on the principle of using the minimum dose that produces a hemostatically effective platelet count, while minimizing potential side effects such as hypertension, hyperglycemia, and osteoporosis. The dose should be adjusted based on clinical response, and tapering should not be pursued aggressively, especially in the last weeks before delivery, to avoid worsening of the thrombocytopenia. It is essential to monitor the platelet count and taper corticosteroids slowly after delivery to avoid a rapid fall in platelet count and ensure the mother's mental state is not affected. Although other guidelines, such as the American Society of Hematology 2019 guidelines for immune thrombocytopenia 1, suggest the use of IVIG or anti-D as first-line treatment in certain cases, the use of prednisone at a low dose is a more appropriate initial approach for this patient, given its relatively safe profile for both mother and fetus. Close monitoring of platelet counts and potential side effects is crucial during treatment. Key considerations in the management of this patient include:

• Initiating treatment with oral prednisone at a low dose of 10-20 mg/d
• Adjusting the dose based on clinical response
• Monitoring platelet counts regularly
• Tapering corticosteroids slowly after delivery
• Being aware of potential side effects, such as hypertension, hyperglycemia, and osteoporosis.

From the Research

Treatment Options for Thrombocytopenia in Pregnancy

The treatment of thrombocytopenia in pregnancy, particularly at 29 weeks gestational age with a platelet count of 69,000, involves several options. The primary goal is to increase the platelet count to prevent maternal and fetal complications.

Corticosteroids as a Treatment Option

• Corticosteroids, such as prednisone, are commonly used to treat immune thrombocytopenia (ITP) in pregnancy 2, 3, 4.
• A study comparing intravenous immunoglobulin (IVIg) and corticosteroids found that both treatments were effective in increasing platelet counts, with no significant difference in maternal or fetal outcomes 2.
• High-dose dexamethasone has been compared to prednisone for previously untreated primary immune thrombocytopenia, with results showing no difference in long-term platelet count response, but a higher initial response rate with dexamethasone 4.

Other Treatment Options

• Intravenous immunoglobulin (IVIg) is also used to treat ITP in pregnancy, with similar efficacy to corticosteroids 2, 5.
• Recombinant human thrombopoietin (rhTPO) has been shown to be effective and safe in a murine model of ITP in pregnancy, but its use in humans is still being explored 6.
• Splenectomy may be considered as a second-line option for pregnant women with refractory ITP who are at significant risk of hemorrhage due to thrombocytopenia 3.

Specific Steroids for Increasing Platelet Count

• Prednisone is a commonly used corticosteroid for treating ITP in pregnancy 2, 3, 4.
• Dexamethasone may be preferred over prednisone for patients with severe ITP who require a rapid rise in platelet count 4.
• The choice of corticosteroid and treatment regimen should be individualized based on the patient's specific needs and medical history.