ITP in pregnancy

Even during uncomplicated pregnancies, platelet count may fall,  platelet clearance may be accelerated, surgical delivery may be required, some treatments are interdicted, and IgG antiplatelet antibodies not only drive maternal thrombocytopenia, but also can be transported across the present it to the fetus.

There is no evidence that pregnancy affects antiplatelet antibody production or platelet destruction by macrophage,

Serum thrombopoietin levels are higher in pregnant women with ITP than in non-pregnant women with ITP, suggesting an impairment in platelet production.

ITP is the most common cause of thrombocytopenia in the first and second trimesters and of maternal platelet counts below 80,000 through gestation and otherwise healthy women. 

ITP is identified for the first time during pregnancy in approximately 10% of pregnant women with ITP in the US.

Gestational thrombocytopenia, the most common cause of low platelet count in pregnancy, is often attributed to increased plasma volume, sequestration in the placental vasculature, increased platelet clearance, or a combination of the above.

Less than 1% of women with gestational thrombocytopenia have platelet count below 100,000×10 to the 3rd per cubicmm³ and 0.1% of accounts below 80×10 to the 3rd per cubic millimeter. Gestational thrombocytopenia has not been found to cause maternal bleeding or neonatal thrombocytopenia.

Almost all women with ITP have a decrease in the platelet count during gestation. 

No maternal deaths from ITP have been reported in recent studies, and most studies indicate there is no increase in the most common complications of gestation, including preeclampsia, premature delivery, abruption, and thromboembolic complications.

Indications for treatment during the first two trimesters are the same as those for non-pregnant women with ITP.

The method of delivery is  usually based on obstetrical indications. 

Platelet count of 30×10 to the third per cubic millimeter is generally accepted is the minimum count that is sufficient to reduce the risk of untoward bleeding after vaginal delivery an account of 50,000×10 to the third per cubic millimeter is the minimum for cesarean section.

A neuraxial anesthesia in patients with platelet count below 70,000×10 to the third- 80×10 to the third cubic millimeter is not usually performed, although procedure is relatively safe at lower platelet counts.

In rare cases, platelet transfusion is warranty. 

Tranexamic acid can be considered after delivery. 

They use a vacuum extraction, and other procedures may increase the risk of injury to the fetus with thrombocytopenia should be avoided, and forceps used judiciously.

Platelet counts should be maintained above 30×10 to the third power to 50×10 to the third power per cubic millimeter.

No treatment of ITP and pregnancy has been approved by regulatory agencies. 

Prednisone is giving it the lowest effective dose. 

Dexamethasone is more likely to affect the fetus, whereas prednisone is almost completely an activated by the placenta.

No consensus for second line treatment is available.

Rituximab may take multiple weeks for efficacy, compromises response to vaccinations for 6 to 12 months, and may increase the risk of neonatal hypogammaglobulinemia,, but has better responses in women of childbearing age with ITP.

Splenectomy can be performed in the early second trimester.

Safety for dapsone RhO(D) immune globulin, vincaalkaloids, cyclophosphamide, mycophenolate, danazol, are not established for safety, or are contra indicated.

Thrombopoiesis and receptor agonists are not approved for use in pregnancy.

Approximately 9 to 15% of neonates are born with more thrombocytopenia in the presence of maternal ITP.

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