Management of Immune Thrombocytopenia in Pregnancy

Diagnosis and Treatment Thresholds

The American College of Obstetricians and Gynecologists recommends excluding gestational thrombocytopenia, preeclampsia, HELLP syndrome, DIC, acute fatty liver, and antiphospholipid antibody syndrome through blood pressure measurement and liver function testing in pregnant women with low platelet counts 1
Observation alone is appropriate for platelet counts >50,000/μL throughout pregnancy, according to the American Society of Hematology 2, 3, 4, 1
Treatment is required for counts <10,000/μL at any gestational age, as recommended by the American Society of Hematology 2, 3, 4, 1
The American College of Obstetricians and Gynecologists recommends treatment for counts of 10,000-30,000/μL with active bleeding, regardless of trimester 2, 3, 4

Prednisone 10-20 mg/day is recommended as initial treatment, adjusted to the minimum dose that maintains hemostatic platelet counts, according to the American College of Obstetricians and Gynecologists 1
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, as recommended by the American Society of Hematology 2, 3, 4, 1

The mode of delivery should be determined by obstetric indications alone, not by maternal platelet count, according to the American College of Obstetricians and Gynecologists 1
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, as recommended by the American Society of Hematology 5, 1

Check neonatal platelet counts for 3-4 days after birth, as neonates can develop or worsen thrombocytopenia during the first week of life, according to the American Academy of Pediatrics 2, 3, 4, 5, 1
IVIg is appropriate for neonatal platelets <20,000/μL without evidence of intracranial hemorrhage, as recommended by the American Academy of Pediatrics 1

Prenatal care should involve or be managed by an obstetrician specializing in high-risk pregnancies, according to the American College of Obstetricians and Gynecologists 2, 3, 4
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, as recommended by the American Society of Hematology 2, 3, 4