What is the recommended management of Immune Thrombocytopenia Purpura (ITP) in pregnancy?

Management of ITP in Pregnancy

Management of ITP in pregnancy is stratified by platelet count and trimester, with observation alone appropriate for counts >50,000/μL, while treatment with corticosteroids or IVIg is indicated for counts <20,000-30,000/μL or any bleeding regardless of count. 1

Diagnosis and Exclusion of Pregnancy-Specific Causes

The diagnosis of ITP in pregnancy is primarily clinical and requires systematic exclusion of pregnancy-specific thrombocytopenias before attributing low platelets to ITP:

• Exclude gestational thrombocytopenia, preeclampsia, HELLP syndrome, DIC, acute fatty liver, and antiphospholipid antibody syndrome through blood pressure measurement and liver function testing 1
• Bone marrow examination is not required for diagnosis in pregnant women with otherwise typical presentations 1
• Antiplatelet antibody testing has no diagnostic value and should not be routinely performed 1

Treatment Thresholds by Platelet Count

No Treatment Required

• Observation alone is appropriate for platelet counts >50,000/μL throughout pregnancy 2, 1
• Counts of 30,000-50,000/μL in the first and second trimesters can be managed with observation alone 2

Treatment Indicated

• Treatment is required for counts <10,000/μL at any gestational age 2, 1
• Counts of 10,000-30,000/μL with active bleeding require treatment regardless of trimester 2
• Counts of 20,000-30,000/μL in the second or third trimester with bleeding warrant treatment 1

First-Line Treatment Options

Corticosteroids

• Prednisone 10-20 mg/day is recommended as initial treatment, adjusted to the minimum dose that maintains hemostatic platelet counts 1
• Corticosteroids are inappropriate when platelet counts exceed 50,000/μL in any trimester 2
• There was significant disagreement among experts regarding corticosteroid use for counts <10,000/μL, reflecting uncertainty about optimal first-line therapy 2

Intravenous Immunoglobulin (IVIg)

• IVIg is appropriate first-line treatment in the third trimester for counts <10,000/μL or counts of 10,000-30,000/μL with bleeding 2, 1
• IVIg should be used when corticosteroids are ineffective, cause significant side effects, or when rapid platelet increase is required 1

Splenectomy

• Splenectomy is appropriate only in the second trimester for women who have failed both corticosteroids and IVIg and are actively bleeding 2
• This narrow indication reflects the surgical risks and timing considerations unique to pregnancy

Management at Delivery

Mode of Delivery

• The mode of delivery should be determined by obstetric indications alone, not by maternal platelet count 1
• Cesarean section is not indicated based on maternal ITP or platelet count when maternal platelets are >50,000/μL 2
• Fetal platelet counts cannot be reliably predicted from maternal counts, and routine fetal scalp sampling or percutaneous umbilical blood sampling is not recommended 2

Platelet Transfusion Thresholds

• Prophylactic platelet transfusions before delivery are appropriate when maternal platelets <10,000/μL with planned cesarean section or with epistaxis/mucous membrane bleeding and expected vaginal delivery 2, 1
• Platelet transfusions are unnecessary when counts exceed 30,000/μL without bleeding symptoms 2
• A maternal platelet count >50,000/μL is considered sufficient to prevent excessive bleeding at vaginal or cesarean delivery 2

Neonatal Management

Monitoring

• Check neonatal platelet counts for 3-4 days after birth, as neonates can develop or worsen thrombocytopenia during the first week of life 2, 1
• Consider brain imaging if the neonatal platelet count at birth is <20,000/μL 1

Treatment

• IVIg is appropriate for neonatal platelets <20,000/μL without evidence of intracranial hemorrhage 1
• Approximately 10% of infants born to mothers with ITP have platelet counts <50,000/μL, and 4% have counts <20,000/μL 2

Multidisciplinary Care

• Prenatal care should involve or be managed by an obstetrician specializing in high-risk pregnancies 2
• Women with ITP should not be discouraged from pregnancy if platelet counts are >50,000/μL, but should be counseled against pregnancy if counts remain <10,000/μL after splenectomy and other treatments 2

Critical Pitfalls to Avoid

• Do not routinely perform fetal platelet count testing (PUBS or fetal scalp sampling), as these procedures carry risks and do not change management in most cases 2
• Do not base cesarean section decisions on maternal platelet count alone when counts are adequate for hemostasis 2, 1
• Do not treat asymptomatic pregnant women with platelets >50,000/μL, as treatment exposes them to unnecessary medication risks 2, 1
• Do not assume neonatal platelet counts are safe at birth—continued monitoring for 3-4 days is essential 2, 1