Contraverted questions of management of pregnancy with immune thrombocytopenia
DOI:
https://doi.org/10.15574/PP.2021.88.52Keywords:
immune thrombocytopenia, pregnancy, fetal-neonatal alloimmune thrombocytopenia, gestational thrombocytopeniaAbstract
Among autoimmune cytopenias during pregnancy, immune thrombocytopenia (ITP) occurs most often. Thrombocytopenia (TP), a decrease in platelet count less than 150x109/l, occurs in 5 to 12% of pregnancies. Immune thrombocytopenia is a diagnosis of exclusion and requires differential diagnosis primarily with gestational TP. Preconception counseling is extremely important in ITP to develop an individual pregnancy management plan. Prediction and calculation of antero-, perinatal and obstetric risks for the fetus and pregnant woman should be performed repeatedly during pregnancy. The choice of the time of initiation of therapy and the type of medication is not clear due to the specificity of the drugs and the possible impact on the fetus. The issue of neonatal severe thrombocytopenia and hemorrhagic complications that may occur at the antenatal stage in some cases is not explained by maternal immune thrombocytopenia, and fetal3neonatal alloimmune thrombocytopenia (FNAT). An unambiguous guide to the prevention and management of cases with FNAT has not been developed at present. We have highlighted current global trends on this issue. Pregnant women with severe TP are a group of high perinatal risk, pregnancy and childbirth should take place in a maternity hospital of III level with the involvement of a multidisciplinary team and an individual plan of pregnancy management, development of delivery and management of postpartum and neonatal periods.
The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies.
No conflict of interest was declared by the authors.
References
ACOG. (2019). ACOG Practice Bulletin No. 207: Thrombocytopenia in Pregnancy. Obstet Gynecol. 133: 181. https://doi.org/10.1097/AOG.0000000000003100
Aronson JK, Ferner RE. (2017, Dec). Unlicensed and off-label uses of medicines: definitions and clarification of terminology. Br J Clin Pharmacol. 83(12): 2615-2625. Epub 2017 Sep 26. https://doi.org/10.1111/bcp.13394; PMid:28779556 PMCid:PMC5698582
Bussel JB, Berkowitz RL, Hung C, Kolb EA, Wissert M, Primiani A et al. (2010). Intracranial hemorrhage in alloimmune thrombocytopenia: stratified management to prevent recurrence in the subsequent affected fetus. Am J Obstet Gynecol. 203 (135): e1-14. https://doi.org/10.1016/j.ajog.2010.03.011; PMid:20494333
Dresser R, Frader J. (2009). Off$label prescribing: a call for heightened professional and government oversight. J Law Med Ethics. 37 (3): 476-486, 396. https://doi.org/10.1111/j.1748-720X.2009.00408.x; PMid:19723258 PMCid:PMC2836889
Fadiloglu E, Unal C, Tanacan A, Portakal O, Beksac MS. (2020). 5 Years? Experience of a Tertiary Center with Thrombocytopenic Pregnancies: Gestational Thrombocytopenia, Idiopathic Thrombocytopenic Purpura and Hypertensive Disorders of Pregnancy. Geburtsh Frauenheilk. 80: 76-83. URL: https://doi.org/10.1055/a-0865-4442. https://doi.org/10.1055/a-0865-4442; PMid:31949322 PMCid:PMC6957351
Fujimura K, Harada Y, Fujimoto T, Kuramoto A, Ikeda Y, Akatsuka J, Dan K, Omine M, Mizoguchi H. (2002, May). Nationwide study of idiopathic thrombocytopenic purpura in pregnant women and the clinical influence on neonates. Int J Hematol. 75 (4): 426-433. https://doi.org/10.1007/BF02982137; PMid:12041677
Gabbe SG, Niebyl JR, Simpson JL, Landon MB, Galan HL. (2017). Obstetrics: Normal and Problem Pregnancies. 7th Edition. Elsevier.
George JN, McIntosh JJ. (2020, Apr). Thrombocytopenia in pregnancy. UpToDate.
Ghevaert C, Herbert N, Hawkins L, Grehan N, Cookson P, Garner SF et al. (2013). Recombinant HPA$1a antibody therapy for treatment of fetomaternal alloimmune thrombocytopenia: proof of principle in human volunteers. Blood. 122: 313-320. https://doi.org/10.1182/blood-2013-02-481887; PMid:23656729 PMCid:PMC3716198
Herring C, McManus A, Weeks A. (2010, Aug). Off$label prescribing during pregnancy in the UK: an analysis of 18,000 prescriptions in Liverpool Women's Hospital. Int J Pharm Pract. 18 (4): 226-229. doi: 10.1211/ijpp.18.04.0007.
Holt GR. (2019, Dec 9). Ethical Considerations in Off$Label Drug Prescribing ENTToday. URL: https://www.enttoday.org/article/ethical-considerationsin-off-label-drug-prescribing/.
Kaye DK. (2019). The moral imperative to approve pregnant women's participation in randomized clinical trials for pregnancy and newborn complications. Philos Ethics Humanit Med. 14: 11. https://doi.org/10.1186/s13010-019-0081-8; PMid:31492178 PMCid:PMC6731584
Pacheco LD, Berkowitz RL, Moise KJ Jr, Bussel JB, McFarland JG, Saade GR. (2011). Fetal and neonatal alloimmune thrombocytopenia: a management algorithm based on risk stratification. Obstet Gynecol. 118: 1157-1163. https://doi.org/10.1097/AOG.0b013e31823403f4; PMid:22015886
Parnas M, Sheiner E, Shoham$Vardi I, Burstein E, Yermiahu T, Levi I, Holcberg G, Yerushalmi R. (2006). Moderate to severe thrombocytopenia during pregnancy. Eur J Obstet Gynecol Reprod Biol. 128 (1-2): 163-168. https://doi.org/10.1016/j.ejogrb.2005.12.031; PMid:16533554
Pavord S, Hunt B. (2010). The Obstetric Hematology Manual. Cambridge University Press.
https://doi.org/10.1017/CBO9780511676451
Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N et al. (2019). Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 3 (22): 3780-3817. https://doi.org/10.1182/bloodadvances.2019000812; PMid:31770441 PMCid:PMC6880896
Rajasekhar A, Gernsheimer T, Stasi R, James AH. (2013). 2013 Clinical Practice Guide on Thrombocytopenia in Pregnancy. Washington, DC: American Society of Hematology.
Regan F, Lees CC, Jones B, Nicolaides KH, Wimalasundera RC, Mijovic A, on behalf of the Royal College of Obstetricians and Gynaecologists. (2019). Prenatal Management of Pregnancies at Risk of Fetal Neonatal Alloimmune Thrombocytopenia (FNAIT). Scientific Impact Paper No. 61. BJOG. 126: e173-185. https://doi.org/10.1111/1471-0528.15642; PMid:30968555
Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D et al. (2009, Mar 12). Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 113 (11): 2386-2393. https://doi.org/10.1182/blood-2008-07-162503; PMid:19005182
Sankaran S, Robinson SE. (2011). Immune thrombocytopenia and pregnancy. Obstet Med. 4 (4): 140-146. https://doi.org/10.1258/om.2011.110025; PMid:27579112 PMCid:PMC4989643
Webert KE, Mittal R, Sigouin C, Heddle NM, Kelton JG. (2003). A retrospective 11$year analysis of obstetric patients with idiopathic thrombocytopenic purpura. Blood. 102: 4306-4311. https://doi.org/10.1182/blood-2002-10-3317; PMid:12947011
Wienzek-Lischka S, Sawazki A, Ehrhardt H, Sachs UJ, Axt-Fliedner R, Bein G. (2020). Non-invasive risk-assessment and bleeding prophylaxis with IVIG in pregnant women with a history of fetal and neonatal alloimmune thrombocytopenia: management to minimize adverse events. Arch Gynecol Obstet. 302 (2): 355-363. https://doi.org/10.1007/s00404-020-05618-y; PMid:32495019 PMCid:PMC7321899
Winkelhorst D, Murphy MF, Greinacher A, Shehata N, Bakchoul T, Massey E, Baker J, Lieberman L, Tanael S, Hume H, Arnold DM, Baidya S, Bertrand G, Bussel J, Kjaer M, Kaplan C, Kjeldsen-Kragh J, Oepkes D, Ryan G. (2017, Mar 16). Antenatal management in fetal and neonatal alloimmune thrombocytopenia: a systematic review. Blood. 129 (11): 1538-1547. Epub 2017 Jan 27. https://doi.org/10.1182/blood-2016-10-739656; PMid:28130210
Yavasoglu I, Turgutkaya A. (2020). Pregnancy and immune thrombocytopenia: New trends. J Turk Ger Gynecol Assoc. 21 (2): 136-137. https://doi.org/10.4274/jtgga.galenos.2019.2019.0142; PMid:31927816 PMCid:PMC7294828
Downloads
Published
Issue
Section
License
Copyright (c) 2022 Ukrainian journal of Perinatology and Pediatrics
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The policy of the Journal “Ukrainian Journal of Perinatology and Pediatrics” is compatible with the vast majority of funders' of open access and self-archiving policies. The journal provides immediate open access route being convinced that everyone – not only scientists - can benefit from research results, and publishes articles exclusively under open access distribution, with a Creative Commons Attribution-Noncommercial 4.0 international license(СС BY-NC).
Authors transfer the copyright to the Journal “MODERN PEDIATRICS. UKRAINE” when the manuscript is accepted for publication. Authors declare that this manuscript has not been published nor is under simultaneous consideration for publication elsewhere. After publication, the articles become freely available on-line to the public.
Readers have the right to use, distribute, and reproduce articles in any medium, provided the articles and the journal are properly cited.
The use of published materials for commercial purposes is strongly prohibited.
