Therapeutic options and considerations for treatment of ITP during pregnancy and lactation
| Treatment . | Dosing . | Response rates (%) . | Time to response . | Maternal considerations . | Fetal considerations . | Lactation xonsiderations . |
|---|---|---|---|---|---|---|
| FIRST LINE | ||||||
| Prednisone | 20-60 mg/d | 40-70 | 3-14 days | HTN, diabetes, premature delivery, insomnia, mood lability, fluid overload | Hypoglycemia, prematurity, risk for cleft palate when exposed in first trimester | Low risk |
| IVIG | 0.4 g/kg up to 5 days or 1 g/kg for 1-2 days | 40-80 | 1-3 days | Headache, fluid overload, HTN, aseptic meningitis, myalgias, hemolysis | Hemolysis | Low risk |
| SECOND LINE (Minimal data available. No uniform recommendations exist regarding optimal agent.) | ||||||
| Not recommended in pregnancy, but use described | ||||||
| Romiplostim | 1-10 µg/kg/wk | 70-80 | 7-14 days | Headache, myalgia | Thrombocytosis | Limited data, thus not advised Detected in breast milk50,51 |
| Eltrombopag | 25-75 mg/d | 70-80 | 7-14 days | Elevated LFTs, headache | Thrombocytosis | Limited data, thus not advised |
| Cyclosporine | 3-5 mg/kg of body weight/d | Insufficient data on ITP in pregnancy to calculate | 4-12 weeks | Renal injury, HTN, tremor | IUGR | Present in breast milk Monitor for neonate infection |
| Rituximab | 375 mg/m2 weekly × 4 | 40-60 | 1-8 weeks | Infusion reaction, hypogammaglobulinemia, infection, curtailed vaccine response | Hypogammaglobulinemia, reduced B cells | Minimal concentrations, low risk |
| Azathioprine | 50-75 mg/d | Insufficient data on ITP in pregnancy to calculate | 8-16 weeks | Transaminitis, neutropenia, infection | Case reports of use in renal transplant recipients with congenital anomalies, heme toxicity, and IUGR | Neonate neutropenia has been reported. Avoidance or neonate CBC monitoring advised |
| Generally contraindicated in pregnancy, but use described | ||||||
| Dapsone | 100 mg/d | 40-50 | 7-14 days | Hemolysis | Anemia, prematurity | Hemolytic anemia reported (check G6PD level and monitor CBC) |
| RhD immune globulin | 50 µg/kg of body weight | 70 | 4-5 days | *Limit use to nonsplenectomized patients Hemolysis, renal failure, infusion reaction | Anemia, jaundice | Low risk |
| Splenectomy | Optimal timing is early second trimester or before pregnancy | 50-80 | 1-60 days | Bleeding, infection, thrombosis risk, preterm labor | Prematurity | Minimal risk |
| CONTRAINDICATED IN PREGNANCY | ||||||
| Vinca alkaloids Cyclophosphamide Mycophenolate mofetil Danazol Fostamatinib | ||||||
| Treatment . | Dosing . | Response rates (%) . | Time to response . | Maternal considerations . | Fetal considerations . | Lactation xonsiderations . |
|---|---|---|---|---|---|---|
| FIRST LINE | ||||||
| Prednisone | 20-60 mg/d | 40-70 | 3-14 days | HTN, diabetes, premature delivery, insomnia, mood lability, fluid overload | Hypoglycemia, prematurity, risk for cleft palate when exposed in first trimester | Low risk |
| IVIG | 0.4 g/kg up to 5 days or 1 g/kg for 1-2 days | 40-80 | 1-3 days | Headache, fluid overload, HTN, aseptic meningitis, myalgias, hemolysis | Hemolysis | Low risk |
| SECOND LINE (Minimal data available. No uniform recommendations exist regarding optimal agent.) | ||||||
| Not recommended in pregnancy, but use described | ||||||
| Romiplostim | 1-10 µg/kg/wk | 70-80 | 7-14 days | Headache, myalgia | Thrombocytosis | Limited data, thus not advised Detected in breast milk50,51 |
| Eltrombopag | 25-75 mg/d | 70-80 | 7-14 days | Elevated LFTs, headache | Thrombocytosis | Limited data, thus not advised |
| Cyclosporine | 3-5 mg/kg of body weight/d | Insufficient data on ITP in pregnancy to calculate | 4-12 weeks | Renal injury, HTN, tremor | IUGR | Present in breast milk Monitor for neonate infection |
| Rituximab | 375 mg/m2 weekly × 4 | 40-60 | 1-8 weeks | Infusion reaction, hypogammaglobulinemia, infection, curtailed vaccine response | Hypogammaglobulinemia, reduced B cells | Minimal concentrations, low risk |
| Azathioprine | 50-75 mg/d | Insufficient data on ITP in pregnancy to calculate | 8-16 weeks | Transaminitis, neutropenia, infection | Case reports of use in renal transplant recipients with congenital anomalies, heme toxicity, and IUGR | Neonate neutropenia has been reported. Avoidance or neonate CBC monitoring advised |
| Generally contraindicated in pregnancy, but use described | ||||||
| Dapsone | 100 mg/d | 40-50 | 7-14 days | Hemolysis | Anemia, prematurity | Hemolytic anemia reported (check G6PD level and monitor CBC) |
| RhD immune globulin | 50 µg/kg of body weight | 70 | 4-5 days | *Limit use to nonsplenectomized patients Hemolysis, renal failure, infusion reaction | Anemia, jaundice | Low risk |
| Splenectomy | Optimal timing is early second trimester or before pregnancy | 50-80 | 1-60 days | Bleeding, infection, thrombosis risk, preterm labor | Prematurity | Minimal risk |
| CONTRAINDICATED IN PREGNANCY | ||||||
| Vinca alkaloids Cyclophosphamide Mycophenolate mofetil Danazol Fostamatinib | ||||||
G6PD, glucose-6-phosphate dehydrogenase; HTN, hypertension; IUGR, intrauterine growth retardation; LFTs, liver function tests;.