MATERNAL TREATMENT FOR ITP :
No treatment is necessary if platelet counts remain above 50,000/mcL and the patient is asymptomatic. However, many physicians will treat for asymptomatic platelet counts of less than 50,000/mcL, abnormal bleeding, or prior to invasive procedures such as cesarean delivery or regional anesthesia.
Below are recommended treatments for maternal thrombopenia due to ITP. While they all improve maternal platelet counts, none have been shown to adequately prevent or treat fetal/neonatal thrombocytopenia.
1. Steroids (eg, prednisone)
Response time is 3-7 days; maximum effect occurs by 2-3 weeks.
Approximately 70% of patients will respond, and 25% will enter complete remission.
Risks include hyperglycemia, fluid retention, and bone calcium loss.
2. Intravenous immune globulin (IVIG)
IVIG works by binding to platelets, blocking the attachment of antiplatelet antibodies.
IVIG is ideal when time is inadequate for steroids to take effect (prior to surgery or low platelet counts with bleeding).
Response time is 6-72 hours.
Approximately 70% of patients will return to pretreatment levels within 30 days.
3. Anti-D immunoglobulin in Rh-positive, nonsplenectomized women
Anti-D immunoglobulin binds to maternal red blood cells and results in Fc receptor blockade. The spleen directs its phagocytotic activity to the coated red cells rather than to antibody-coated platelets.
It is not useful in Rh-negative or splenectomized women.
Response time of anti-D immunoglobulin is 1-2 days, peak effect in 7-14 days, average duration 30 days.
Little data are available on the use of anti-D immunoglobulin in pregnant women; risk-benefit ratios need to be considered prior to its usage.
4. Splenectomy
Splenectomy removes the organ responsible for the destruction of IgG-coated platelets.
In nonpregnant women, splenectomy is used for patients who are unresponsive to IVIG.
Splenectomy usually is avoided during pregnancy for technical reasons, although it remains an option in the first and second trimesters when ITP is severe (counts <10,000/mcL) and the patient does not respond to steroids or IVIG
Complete remission occurs in two thirds of cases.
Splenectomy does not have an impact on circulating antibodies that may still cross the placenta and cause neonatal thrombocytopenia.
5. Platelet transfusion
This is a temporary measure, which should be administered for life-threatening hemorrhage and should be available prior to surgery for patients with severe thrombocytopenia.
Six to 10 units of platelets are usually administered at one time.
Platelet counts normally rise by 10,000/mcL for each unit of platelets transfused, but in ITP the rise is less pronounced due to destruction of donor platelets.