Idiopathic thrombocytopenic purpura (ITP) is more common in women between 20 and 40 years of age of childbearing age and does not affect reproductive function, so ITP is more common in combination with pregnancy.
ITP is the most common cause of thrombocytopenia in the first trimester of pregnancy, accounting for 011% of pregnancies and 510% of thrombocytopenia during pregnancy. According to the pathogenesis of ITP, patients have antibodies against their own platelets (PAIgG),
These antibodies not only destroy the patient’s own platelets and reduce them, but also enter the fetus through the placenta, damaging fetal platelets and causing fetal thrombocytopenia. Therefore, the treatment of ITP
The treatment of ITP in combination with pregnancy must deal with both patients, i.e. the mother and the fetus. Treatment of the mother in the case of ITP combined with pregnancy Once a woman with ITP becomes pregnant, her platelets will drop further and her symptoms will worsen. Therefore, in principle, it is better to avoid pregnancy in women with ITP, especially in severe ITP (platelets < 20
Therefore, in principle, it is better to avoid pregnancy in women with ITP, especially in patients with severe ITP (platelets < 20 × 109/L), because in addition to further worsening of the disease after pregnancy, treatment is also more difficult because many treatments not only increase pregnancy complications, but also may have an impact on the fetus,
As a result, many medications cannot be used in the same way as in non-pregnancy and are often limited. Treatment varies depending on the degree of thrombocytopenia in the mother and is described below. Treatment of mild ITP (platelets > 50 × 109/L, no clinical manifestations of bleeding) Patients can usually have a normal pregnancy without special treatment, and can be treated with oral amineptine 1g, 3 times/d,
Long-term use has no side effects. However, attention should be paid to avoid colds and trauma, regular life and close observation of the bleeding tendency of the whole body, and regular (once a month or so) platelet count check,
In case of aggravation, treatment can be given as follows. Treatment of moderate ITP [platelets (20-50) × 109/ L] Patients usually have varying degrees of bleeding, and the preferred treatment is controversial. Glucocorticoids are preferred in non-pregnant women, but their use after pregnancy can have many side effects,
Although the teratogenic effect on the fetus is uncertain, the use of glucocorticoids in the first three months of pregnancy is generally not recommended.
Although the teratogenic effect on the fetus is certain, it is generally not recommended in the first trimester of pregnancy, and should be used with caution when available or not in the fourth to sixth trimester of pregnancy. This drug is more effective, easy to apply, and inexpensive, and the application method and dosage are the same as for non-pregnant patients,
The dose and method of application are the same as for non-pregnant patients, except that the weight is not calculated according to the weight at the time of pregnancy, but according to the weight before pregnancy, and the dose should be reduced to the lowest effective maintenance dose when it becomes effective. Currently, for ITP
The best treatment for ITP with pregnancy and the least side effects is intravenous high-dose gammaglobulin, which should be used if bleeding symptoms are significant, even if the platelet count is not too low (possibly combined with abnormal platelet function),
If bleeding symptoms are significant, although the platelet count is not too low (possibly combined with abnormal platelet function), it is necessary to administer the same dose as in non-pregnancy, except that the weight is calculated according to the pre-pregnancy weight.
The biggest disadvantage of this drug is that it is too expensive. The biggest disadvantage of this drug is that it is too expensive,
It should be preferred if available. Other drugs that can be used in non-pregnant patients, such as vincristine, cyclophosphamide and danazol, are contraindicated because of their side effects such as causing fetal malformation. Other general management is the same as for patients with mild ITP. Treatment of severe ITP (platelets < 20 × 109/ L) In general, patients with severe ITP should not be pregnant. If pregnancy occurs accidentally, abortion should be performed as soon as possible,
Before abortion, dexamethasone should be given intravenously 10-20 mg daily for 3 days, and on the third day, 1 unit of platelets should be transfused to make platelets > 50 × 109/L. After abortion, the patient should be treated according to the usual treatment protocol for ITP. If the patient insists to continue the pregnancy, it is more dangerous and difficult to manage, so she should be treated in the hematology unit.
In the first 3 months of pregnancy, only high-dose intravenous gammaglobulin should be administered as above; in the 4th-6th months, glucocorticoids should be added in the same way and dosage as above, but side effects should be closely monitored.
If the treatment is not effective after more than 1 month, splenectomy can be carefully considered after weighing the advantages and disadvantages. The entire pregnancy should be observed and treated in the obstetrics and gynecology department and the hematology department. Management at delivery Patients with moderate to severe ITP who still have low platelets should be admitted to the obstetrical ward about half a month before the expected delivery date to continue treatment to raise platelets and reduce bleeding,
The obstetrician should choose the appropriate delivery method according to the patient’s specific condition to help the mother and the fetus to be safe. The emergency measure to raise platelets before delivery is a triple therapy: (1) glucocorticoids:
(1) glucocorticoids: dexamethasone is usually given intravenously 3-5 days before delivery, 10-20 mg/d; (2) intravenous platelet concentrate: 1 unit of platelets (platelets ≥250 × 109/L) is transfused on the day of delivery, and 1 unit of platelets is prepared.
(2) Intravenous platelet concentrate: 1 unit of platelets (platelets ≥ 250 × 109/L) on the day of delivery, and 1 unit of platelets during or after delivery; (3) Intravenous gammaglobulin, 20g/d, for 5 days, preferably one week before delivery, if economic conditions allow.
for 5 days. After delivery, the treatment should be done according to the ITP routine. Neonatal thrombocytopenia and its management Newborns delivered by pregnant women with ITP are prone to thrombocytopenia.
The percentage of newborns with platelets ≤50 × 109/L is about 10% and ≤20 × 109/L is about 5%. It is difficult to detect fetal platelets before delivery or to predict the number of platelets, but the degree of fetal thrombocytopenia may be related to the following factors: (1) maternal PAIgG concentration:
(2) Fetal megakaryocyte proliferation: those with good proliferation may have less thrombocytopenia;
(3) The ability of fetal mononuclear macrophage system to clear platelets: Generally, the fetal mononuclear macrophage system is very poor before delivery, so the thrombocytopenia is generally low and not too severe when the fetus is in the mother’s body,
(4) Pregnant women who have delivered a thrombocytopenic infant,
The fetus is often thrombocytopenic in the second pregnancy. Because fetal thrombocytopenia is usually self-limiting and can recover on its own within a short period of time, treatment is usually not necessary,
If platelets are < 20 × 109/L or bleeding, intravenous gammaglobulin can be given at 1 g kg-1 d-1 for 1-5 days, depending on the thrombocytopenia and bleeding, and glucocorticoids are generally not used because of their slow action and their tendency to cause infection,
If necessary, platelet concentrate can be given intravenously.