Overview

Immune thrombocytopenia (ITP) is an autoimmune condition causing isolated thrombocytopenia. Most women maintain safe platelet counts during pregnancy, but treatment is recommended when:^[1–6]

• Platelets < 30,000/µL
• Bleeding symptoms regardless of count
• Platelets < 50,000/µL near delivery or for neuraxial anesthesia planning

First-Line Therapy

1. Corticosteroids

Prednisone is preferred due to lower fetal exposure compared with dexamethasone.^[1–6]

• Initial dose: Prednisone 10–20 mg orally daily (titrate to response)
• Alternative: Prednisone 0.5–1 mg/kg/day for severe thrombocytopenia or bleeding
• Goal: Platelets > 30,000/µL (early pregnancy) or > 50,000/µL (delivery)

2. Intravenous Immune Globulin (IVIG)

• Dose: 1 g/kg/day for 1–2 days or 0.4 g/kg/day for 5 days^[1–7]
• Response typically within 24–48 hours.
• Useful near delivery or when steroids contraindicated or ineffective.

Second-Line Therapies

Anti-D Immune Globulin (RhIG)

Only for Rh-positive, nonsplenectomized patients.^[4–7]

• Dose: 50–75 µg/kg IV once
• Risks: Hemolysis; avoid when anemia or risk of DIC present.

Thrombopoietin Receptor Agonists (TPO-RAs)

Increasingly used for refractory ITP. Limited pregnancy data but case series support cautious use when benefits outweigh risks.^[8–12]

Rescue Therapy (Severe Thrombocytopenia or Bleeding)

• IVIG 1 g/kg/day × 1–2 days
• Methylprednisolone 500–1000 mg IV daily × 1–3 days
• Platelet transfusion (short-lived effect; combine with IVIG or steroids)

Delivery Planning

• Vaginal delivery safe when platelets ≥ 50,000/µL.
• Neuraxial anesthesia: Often targeted to ≥ 70,000–80,000/µL depending on local policy.^[1–3]
• Cesarean delivery: Hemostatic threshold ~ 50,000/µL (higher if additional risk factors).