A Case of Refractory Thrombocytopenia in Pregnancy

Immune thrombocytopenia is an acquired autoimmune disorder characterized by isolated thrombocytopenia due to antibody-mediated platelet destruction and impaired platelet production. Thrombocytopenia in pregnancy is common, but severe thrombocytopenia requires prompt evaluation to distinguish benign gestational thrombocytopenia from immune thrombocytopenia, hypertensive disorders of pregnancy, hemolysis, elevated liver enzymes, low platelet count syndrome, and thrombotic microangiopathies. We present the case of a 19-year-old gravida 1 para 0 patient with sickle cell trait and iron deficiency anemia who was initially diagnosed with pregnancy-associated immune thrombocytopenia in the first trimester after presenting with severe thrombocytopenia, with a platelet count of 9 × 10³/µL. She initially responded to intravenous immunoglobulin and corticosteroids, with platelet recovery to 107 × 10³/µL during hospitalization and 264 × 10³/µL shortly after discharge. However, despite outpatient hematology follow-up and prednisone therapy, her platelet count progressively declined. She was readmitted at 22 weeks and 5 days of gestation after routine obstetric laboratory testing showed relapsing severe thrombocytopenia with platelets of 15 × 10³/µL. The patient was otherwise asymptomatic, aside from intermittent blood-tinged nasal discharge and mild vaginal spotting a few days before presentation that resolved spontaneously. She was normotensive and had no evidence of hemolysis, renal dysfunction, significant hepatic dysfunction, or coagulopathy. Hematology and maternal-fetal medicine were consulted, and she was treated with intravenous immunoglobulin with post-treatment platelet improvement to 53 × 10³/µL. She was discharged on a prednisone taper with plans for scheduled outpatient intravenous immunoglobulin and close follow-up in a combined hematology and maternal-fetal medicine clinic. This case highlights the importance of a structured, multidisciplinary approach to severe thrombocytopenia in pregnancy and the need to exclude pregnancy-specific and life-threatening alternative etiologies before confirming immune thrombocytopenia.