What is the recommended management of immune thrombocytopenia (ITP) in pregnant women?
Bertrand Godeau, MD, PhD: It is a very important question because in my experience it is clear that a lot of pregnant women with ITP are overtreated, with a very high number of side effects of treatment.
The first message is that the important period is delivery, but before delivery, throughout the duration of pregnancy, there is no higher risk of bleeding in pregnant women compared with nonpregnant women. My main message is that during pregnancy you must absolutely avoid overtreating your patients. It is perfectly possible to keep pregnant women with low platelet counts such as platelet counts of 20,000, 25,000, or 30,000 cells per mm3 without treatment. The main criteria to treat is the presence of bleeding. If you have a pregnant woman without purpura or bleeding, it is not necessary to give steroids, it is not necessary to give several courses of intravenous immunoglobulin (IVIG)—you survey. It is the policy for the duration of pregnancy.
In contrast, at the time of delivery it is necessary to transiently increase the platelet counts with a short course of steroids, and if the patient is refractory to steroids, you can add IVIG 1, 2, or 3 weeks before the end of pregnancy.
For the delivery, it is not necessary to perform cesarean delivery. In our experience in >80% of pregnant women it is possible to have vaginal delivery and not to perform cesarean delivery.
The last point is that you must systematically check the platelet count in the newborn, because there is a risk of thrombocytopenia in the newborn at the time of delivery but [also] between 3 and 5 days after delivery. So it is necessary to control the platelet count in the newborn at birth but also between days 3 and 5 [after delivery].
With this rule, clearly our experience and experience of colleagues reported in the literature is that it is very rare to have a very severe complication in a woman and it is very rare to have a complication in a newborn. So you should avoid overtreating your patients.