Treatment options for immune thrombocytopenia (ITP) in pregnancy and postpartum

Immune thrombocytopenia (ITP) treatment goals vary by gestational period. In the first 8 months of gestation, treatment is not indicated unless platelets are <20,000/uL or for clinically significant bleeding. The platelet goal is >70,000/uL for epidural administration and delivery.

We review the data on efficacy and safety of medications used to treat ITP in pregnancy, including the associated risks and optimal timing of administration of the first-line treatments of corticosteroids and/or intravenous immunoglobulin (IVIG). We also discuss second-line treatment options.

The differential diagnosis of thrombocytopenia in pregnancy is broad. When ITP is the most likely diagnosis, the decision to treat versus monitor only will depend on the platelet nadir, gestational week, and signs of clinically significant bleeding. Many patients will not require treatment in the first 8 months of gestation. Starting at 34-36 weeks gestation, enhanced therapies may be required to prepare for labor and delivery. We recommend starting with prednisone 20-60 mg daily. If prednisone alone is insufficient, IVIG 1-2 g/kg should be added. Combined prednisone and IVIG will yield the desired platelet response in ~ 80% of cases. Approach to second-line therapy is complicated, but we consider TPO receptor agonist use in the peripartum period.