Management of Idiopathic Thrombocytopenic Purpura (ITP) during Pregnancy

Evaluation of Risk and Management of Thrombocytopenia during Pregnancy

For a patient with ITP and a platelet count of 75-80 G/L, induction of labor is not recommended based solely on the platelet count if intravenous immunoglobulins (IgIV) are planned to increase the platelet count before delivery, according to the American Society of Hematology 1, 2
A platelet count >75 G/L is generally considered adequate for neuraxial anesthesia (epidural or spinal) in cases of ITP, as recommended by the American Society of Anesthesiologists 3, 4
For patients with a platelet count between 50-75 G/L, an individual assessment of the risk-benefit ratio is necessary, with consultation of an experienced anesthesiologist 5, 6
The mode of delivery should be determined solely by obstetric indications and not by the maternal platelet count or fear of fetal thrombocytopenia, as recommended by the American College of Obstetricians and Gynecologists 1, 7

Intravenous immunoglobulins (IgIV) are an effective first-line treatment for rapidly increasing the platelet count before delivery, according to the American Society of Hematology 8, 9
Low-dose corticosteroids (prednisone 10-20 mg/day) are also a first-line option, but may have maternal side effects 2
For patients with a stable platelet count between 75-80 G/L, no treatment is generally necessary until the approach of delivery, as recommended by the American Society of Hematology 9, 2

The fetal platelet count cannot be reliably predicted from the maternal platelet count, history of splenectomy, or levels of antiplatelet antibodies, according to the American Academy of Pediatrics 6
Attempts to measure the fetal platelet count before delivery (by cordocentesis or scalp sampling) are not recommended due to associated risks 1, 6
The incidence of severe neonatal thrombocytopenia is 8.9% to 14.7%, with a risk of intracranial hemorrhage of 0% to 1.5%, as reported by the American Society of Hematology 1, 7

Regular monitoring of platelet count, with increased frequency as term approaches 9
Monitoring of platelet count trend (stable or decreasing) 6
If platelet count remains stable at 75-80 G/L: no induction necessary, wait for spontaneous labor 1, 2
If platelet count starts to decrease or delivery is imminent: consider administration of IgIV 8, 2
With a platelet count of 75-80 G/L: neuraxial anesthesia (epidural or spinal) is generally possible, as recommended by the American Society of Anesthesiologists 3, 4
Prior consultation with anesthesiologist to plan management 5, 6
Decision based solely on obstetric indications, as recommended by the American College of Obstetricians and Gynecologists 1, 7
Avoid procedures with a risk of fetal hemorrhage (scalp electrodes, fetal blood sampling, vacuum extraction, rotational forceps) 6
Determination of platelet count in cord blood after delivery 6
Clinical and hematological monitoring of the newborn, particularly between the 2nd and 5th day 6
Transcranial ultrasound if platelet count <50 G/L 6