Therapies for immune thrombocytopenia and considerations in pregnancy
| . | Dosing . | Pregnancy-specific notes . |
|---|---|---|
| First line | ||
| Prednisone | 0.25-1 mg/kg* | Maternal—increased risk for gestational diabetes, mood lability Fetal—increased risk of cleft palate in early pregnancy |
| IVIG | 0.5-2 g/kg IV in divided dosing over 1-5 days (maximum 1 g/kg/24 hours) | Maternal—thrombotic risk in general population studies, hemolysis Fetal—hemolysis |
| Second line† | ||
| Splenectomy | NA | Maternal—safety reported up to the second trimester; impaired future immune response to encapsulated organisms, requires vaccinations to decrease risk |
| Azathioprine | 1-2 mg/kg PO once per day (maximum 150 mg/d) | Maternal—reports of use in rheumatologic/transplant indications in pregnancy |
| Cyclosporine | 5-6 mg/kg/d PO divided into 2 doses (titrate to blood levels of 100-200 ng/mL) | Maternal—reports of use in rheumatologic/transplant indications in pregnancy |
| Rituximab | 375 mg/m2 IV once per week × 4 weeks | Maternal—increased susceptibility to viral infections, reactivation of hepatitis B infection Fetal—risk to neonate of B-cell lymphopenia |
| TPO-R agonists‡ Romiplostim Eltrombopag | 1-10 µg/kg subq weekly 25-75 mg PO daily | Maternal/fetal—data limited to mostly retrospective data/case series |
| Rho(D) immune globulin | HgB ≥10 g/dL: 50 µg as a single injection or separate days HgB 8 to <10 g/dL: 25 to 40 µg as a single injection or can be given as 2 divided doses on separate days HgB <8 g/dL: use not recommended | Maternal—risk of severe intravascular hemolysis Fetal—possible hemolysis |
| . | Dosing . | Pregnancy-specific notes . |
|---|---|---|
| First line | ||
| Prednisone | 0.25-1 mg/kg* | Maternal—increased risk for gestational diabetes, mood lability Fetal—increased risk of cleft palate in early pregnancy |
| IVIG | 0.5-2 g/kg IV in divided dosing over 1-5 days (maximum 1 g/kg/24 hours) | Maternal—thrombotic risk in general population studies, hemolysis Fetal—hemolysis |
| Second line† | ||
| Splenectomy | NA | Maternal—safety reported up to the second trimester; impaired future immune response to encapsulated organisms, requires vaccinations to decrease risk |
| Azathioprine | 1-2 mg/kg PO once per day (maximum 150 mg/d) | Maternal—reports of use in rheumatologic/transplant indications in pregnancy |
| Cyclosporine | 5-6 mg/kg/d PO divided into 2 doses (titrate to blood levels of 100-200 ng/mL) | Maternal—reports of use in rheumatologic/transplant indications in pregnancy |
| Rituximab | 375 mg/m2 IV once per week × 4 weeks | Maternal—increased susceptibility to viral infections, reactivation of hepatitis B infection Fetal—risk to neonate of B-cell lymphopenia |
| TPO-R agonists‡ Romiplostim Eltrombopag | 1-10 µg/kg subq weekly 25-75 mg PO daily | Maternal/fetal—data limited to mostly retrospective data/case series |
| Rho(D) immune globulin | HgB ≥10 g/dL: 50 µg as a single injection or separate days HgB 8 to <10 g/dL: 25 to 40 µg as a single injection or can be given as 2 divided doses on separate days HgB <8 g/dL: use not recommended | Maternal—risk of severe intravascular hemolysis Fetal—possible hemolysis |
Reprinted from Blood Reviews, Pishko et al., Thrombocytopenia in pregnancy: Diagnosis and approach to management, 40: 100638. Copyright (2019), with permission from Elsevier.
Typical dosing for ITP 1 mg/kg; some experts suggest trialing lower doses in pregnancy.
Inadequate data to support an order to second-line approach.
Off-label use in pregnancy.
HgB, hemoglobin; IV, intravenous; NA, not applicable; PO, per os.