ITP in Pregnancy

See also ITP main page or Immune thrombocytopenic purpura (peds) for pediatric patients.

Background

• Marked diff between maternal and fetal platelet counts
• No antenatal measures predict fetal status
• Maternal response to medicine does not guarantee a favorable outcome for baby
• Only previous neonatal outcomes provide predictor of neonatal platelet counts.

Clinical Features

Petechiae in a patient with ITP.

Petechiae on the tongue in a patient with ITP.

Petechiae on the lower leg in a patient with ITP.

Unprovoked gingival bleeding as a presenting symptom in ITP.

• Thrombocytopenia during pregnancy
  • Petechiae
  • Epistaxis
  • Gingival bleeding
  • Vaginal Bleeding
  • GI bleeding
  • Intracranial hemorrhage

Differential Diagnosis

Thrombocytopenia

Decreased production

• Marrow infiltration (tumor or infection)
• Viral infections (rubella, HIV)
• Marrow suppression (commonly chemotherapy or radiation)
• Congenital thrombocytopenia
  • Fanconi anemia
  • Alport syndrome
  • Bernand Soulier
• Vitamin B12 and/or folate deficiency

Increased platelet destruction or use

• Idiopathic thrombocytopenic purpura
• Thrombotic Thrombocytopenic Purpura (TTP)
• Hemolytic Uremic Syndrome (HUS)
• Disseminated Intravascular Coagulation (DIC)
• Viral infections (HIV, mumps, varicella, EBV)
• Drugs (heparin, protamine)
• Postransfusion or Posttransplantation
• Autoimmune destruction (SLE or Sarcoidosis)
• Mechanical destruction
  • Artificial valves
  • ECMO
• HELLP syndrome
• Excessive hemorrhage
• Hemodialysis, extracorporeal circulation
• Splenic Sequestration
  • Occurs in Sickle cell disease and Cirrhosis

Drug Induced

• sulfa antibiotics, ETOH, ASA, thiazide diuretics/furosemide

Comparison by Etiology

	ITP	TTP	HUS	HIT	DIC
↓ PLT	Yes	Yes	Yes	Yes	Yes
↑PT/INR	No	No	No	+/-	Yes
MAHA	No	Yes	Yes	No	Yes
↓ Fibrinogen	No	No	No	No	Yes
Ok to give PLT	Yes	No	No	No	Yes

Evaluation

• Usually mild thrombocytopenia (>70k)
  • Platelet count normalizes after delivery

Management

• Balance risk of thrombocytopenia (for mother and fetus/baby) vs potential teratogenesis from therapy
• Treatment indicated if:
  • Platelets <10,000
  • Platelets <30,000 and bleeding or in 2nd or 3rd trimester
• Risk of prednisone or IVIG outweighed by benefits in above situations
• Infant has slightly increased risk of ICH with v low risk of ICH- but higher of normal baby
  • role of cesarean in preventing ICH controversial
• If baby has platelets <30k; IVIG and or prednisone
• No contraindication to breastfeeding.

See Also

• ITP
• Pregnancy (Main)