Idiophatic Thrombocytopenic Purpura (ITP)

in Pregnancy
 DEFINITION

INSIDENCE

IMUNOLOGY AND
PATHOPHYSIOLOGY

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

MANAGEMENT
 DEFINITION

American College of Obstetrics and Gynecology

(ACOG), ITP : (1) persistent thrombocytopenia
(platelet count < 100×109/L with or without
megakaryocytes in peripheral smear), (2) normal
or increased medullary megakaryocytes,(3)
exclusion of other systematic diseases or drugs
that are associated with thrombocytopenia, and
(4) absence of splenomegaly

Ben S et al. Obstetrics and Gynecology International Volume 2010

 INSIDENCE

 Approximately 200.000 individuals in the

USA have ITP.
 Helsinski, 1,8:1000 labor
 Thrombocytopenia has been observed in 7 to
10 percent of all pregnancies.

Thrombocytopenia at delivery: a prospective survey of 6715 deliveries. Am J Obstet Gynecol and

Platelet Disorders Support Asociation.
 This shows the Incidence of the types of Thrombocytopenic Purpura during
Pregnancy Thrombocytopenia in Pregnancy (n=15,000)
Gestational Thrombocytopenia 74%
Hypertension in pregnancy (PET) 21%
Immune (Allo-Immune thrombocytopenia) 4%
Other 1%

Burrows RF, Kelton JG.

Low fetal risks in pregnancies associated with idiopathic thrombocytopenic purpura. Am J Obstet Gynecol.
IMUNOLOGY AND PATHOPHYSIOLOGY
Chronic Idiopathic Thrombositopenic Purpura. The New England Journal Medicine Vol.331 No.18.
Molecular
mimicry
 DIAGNOSTIC APPROACH

 ITP diagnosis is of exclusion

 Thrombocytopenia can be caused by myriad
conditions including systemic disease,
infection, drugs, and primary hematologic
disorders
 An increased risk of ITP is also associated
with measles-mumps-rubella vaccination
Patient History

 Symptoms, type, severity, and duration of

bleeding
 Hemostasis with prior surgeries or pregnancies
 Weight loss, fever, and headache
 Symptoms of autoimmune disorders
(atrhralgias, skrin rash)
 Risk factor for HIV infection
 Pregnancy status
 Medication
 Transfussion history
Physical examination

 Signs, type, and severity of bleeding

 Liver, spleen, and lymph node, jaundice
 Evidance of infection (HIV)
 Evidance of autoimmune disease (athritis,
goiter, nephritis)
 Evidance of thrombosis
 Neurologic function
 Skeletal anomalies
 Peripheral blood count
 Evaluation of peripheral blood smear
 Bone marrow examination
 Helicobacter pylori testing
 HIV and HCV testing
 Quantitative immunoglobulin level testing
 Direct antiglobulin test
 Blood group Rh(D) typing
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
 Maternal management during gestation
(Immune Thrombocytopenia in Pregnancy. Hematol Oncol Clin
North Am. 2009 )

 collaboration between the obstetrician and

hematologist.
 should be seen monthly in the first and
second trimester, every 2 weeks after 28
weeks, and weekly after 36 weeks.
 blood pressure, weight, urine dipstick analysis
for protein, and serial platelet counts.
 Treatment has been recommended for
women with a platelet count below 10,000/μl
at any time during pregnancy, or below
30,000/μl in the second or third trimester or
when associated with bleeding
 1st line prednisone is 1 mg/kg/day (based on
the pre-pregnancy weight)
 therapy is indicated but not urgent 20-30
mg/day of prednisone
 intravenous immunoglobulin (IVIg)  first
line agent for severe thrombocytopenia, or
thrombocytopenic bleeding in 3th trimester
 2 gm/kg over 2-5 days) intravenous
immunoglobulin (IVIg) is an effective means
of raising the platelet count rapidly
 Splenectomy may be considered as another
option for patients who fail to adequately
respond to corticosteroids or IVIg
 In patients who develop severe ITP refractory
to steroids and IVIG, and who are beyond the
optimal second trimester window for
splenectomy, intravenous anti-D has been
used successfully.
 cytotoxic and immunosuppressive agents,
not used in pregnancy
Management of parturition: fetal and maternal
considerations

 the primary consideration is achieving a

platelet count sufficient to minimize maternal
hemorrhage
 Maternal platelet count of 50,000/μl is
sufficient for vaginal delivery as well as
cesarean section.
 The most feared consequence of fetal
thrombocytopenia is the risk of intracranial
hemorrhage,
 There was no correlation between platelet
counts or the ITP status of the mothers and
the development of neonatal
thrombocytopenia
 no association of intracranial hemorrhage
with the mode of delivery
 cesarean section be performed solely for
maternal indications.
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