THE DETERMINANTS IN THE MANAGEMENT OF PREGNANCIES COMPLICATED WITH IMMUNE THROMBOCYTOPENIA

Abstract

Objective: This study aims to determine the hematologic and obstetric factors that would affect the management of immune thrombocytopenia (ITP) during pregnancy. Material and Method: This is a retrospective review of 54 pregnancies that were complicated by ITP at a single tertiary center. All of the patients were followed-up and delivered at the same center. Subgroup analysis for obstetric outcomes was made according to the platelet counts at the time of delivery (<50x103/mm3 or ≥50x103 /mm3 ), the time of diagnosis (before or during pregnancy) and neonatal platelet counts (≤100x103 /mm3 or >100x103 /mm3 ). Result: Transfusion of blood products, steroid administration per se, or in combination with intravenous immunoglobulins (IVIG), were significantly more often administered in those with platelet counts <50x103 /mm3 at the time of delivery (p=0.020, p=0.020, and p=0.004, respectively). The patients who were first diagnosed with ITP during pregnancy had higher rates of transfusion of blood products (p=0.041), higher rates of vaginal deliveries (p=0.048), and lower rates of preterm delivery (p=0.044) when compared to the patients who had ITP diagnosed before the on set of pregnancy. Gestational age at birth (p=0.020), birth weight (p=0.002) and neonatal platelet count (p=0.002) were significantly higher in those who were diagnosed during the pregnancy. History of maternal splenectomy, intensive care unit admission, IVIG administration, and blood transfusion were significantly more frequent in neonates with platelet counts ≤100x103 /mm3 (p=0.028, p=0.001, p=0.001, and p=0.025, respectively). Conclusion: The women diagnosed with ITP before the pregnancy and those who were diagnosed during the pregnancy had comparable rates of postpartum bleeding. However, there was a tendency towards overtreatment of the women who developed ITP during pregnancy.

Keywords

• Immune thrombocytopenia
• pregnancy
• bleeding

İMMÜN TROMBOSİTOPENİYLE KOMPLİKE GEBELİKLERİN YÖNETİMİNDE BELİRLEYİCİLER

Abstract

Amaç: Bu çalışma, gebelikte immün trombositopeni (İTP) yönetimini etkileyecek hematolojik ve obstetrik faktörleri belirlemeyi amaçlamaktadır. Gereç ve Yöntem: İTP nedeniyle hastanemizde tedavi edilen ve doğumu hastanemizde yaptırılan İTP ile komplike olmuş 54 gebelik retrospektif olarak incelenmiştir. Obstetrik sonuçlar için alt grup analizi, doğum anındaki (<50x103 /mm3 veya ≥50x103 /mm3 ) ve tanı anındaki (gebelik öncesi veya gebelik sırasında) trombosit sayısı ve neonatal trombosit sayısına (≤100x103 /mm3 veya >100x103 /mm3 ) göre yapılmıştır. Bulgular: Doğumda trombosit sayısı <50x103 /mm3 olan gebeliklerde steroid uygulaması, intravenöz immünoglobulinler (İVİG) ile birlikte steroid kullanımı ve kan ürünleri transfüzyonu anlamlı olarak daha yüksek saptanmıştır (sırasıyla, p=0,020, p=0,020, p=0,004). Gebelik öncesi İTP tanısı alan hastalara göre gebelikte İTP tanısı alan hastalarda, gebelik esnasında transfüzyon ve vajinal doğum oranının anlamlı olarak daha yüksek, erken doğum oranının anlamlı olarak daha düşük olduğu ve doğum anındaki gebelik yaşı, doğum ağırlığı ve neonatal trombosit sayısının anlamlı olarak daha yüksek olduğu belirlenmiştir (sırasıyla, p=0,041, p=0,048, p=0,044, p=0,020, p=0,002 ve p=0,002). Trombosit sayısı ≤100x103 /mm3 olan yenidoğanlarda maternal splenektomi öyküsü, yoğun bakım gereksinimi, IVIG tedavisi ve kan transfüzyon gereksinimi anlamlı olarak daha yüksek bulunmuştur (sırasıyla p=0,028, p=0,001, p=0,001 ve p=0,025). Sonuç: Gebelik öncesi İTP tanısı alan kadınlar ve gebelik sırasında İTP tanısı konulan kadınlar, postpartum kanama bakımından benzerdir. Buna karşılık, gebelik sırasında İTP gelişen kadınların gereğinden fazla tedavi edilmesine yönelik bir eğilim söz konusudur.

Keywords

• İmmun trombositopeni
• gebelik
• kanama

References

1. 1. Cines DB, Levine LD. Thrombocytopenia in pregnancy. Blood 2017;130(21):2271-7. [CrossRef] google scholar
2. 2. Fogerty AE. Thrombocytopenia in pregnancy: Mechanisms and management. Transfus Med Rev 2018;32(4):225-9. [CrossRef] google scholar
3. 3. Kohli R, Chaturvedi S. Epidemiology and clinical manifestations of immune thrombocytopenia. Hamostaseologie 2019;39(3):238-49. [CrossRef] google scholar
4. 4. Sankaran S, Robinson SE. Immune thrombocytopenia and pregnancy. Obstet Med 2011;4(4):140-6. [CrossRef] google scholar
5. 5. LoustauV, Debouverie O, Canoui-Poitrine F, Baili L, Khellaf M, Touboul C, et al. Effect of pregnancy on the course of immune thrombocytopenia: a retrospective study of 118 pregnancies in 82 women. Br J Haematol 2014;166(6):929-35. [CrossRef] google scholar
6. 6. Rodeghiero F, Marranconi E. Management of immune thrombocytopenia in women: current standards and special considerations. Expert Rev Hematol 2020;13(2):175-85. [CrossRef] google scholar
7. 7. Feudjo-Tepie MA, Robinson NJ, Bennett D. Prevalence of diagnosed chronic immune thrombocytopenic purpura in the US: analysis of a large US claim database: a rebuttal. J Thromb Haemost 2008; 6(4):711-3. [CrossRef] google scholar
8. 8. Care A, Pavord S, Knight M, Alfirevic Z. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG 2018;125(5):604-12. [CrossRef] google scholar

9. 9. Wyszynski DF, Carman WJ, Cantor AB, Graham JM Jr, Kunz LH, Slavotinek AM, et al. Pregnancy and birth outcomes among women with idiopathic thrombocytopenic purpura. J Pregnancy 2016;2016:8297407. [CrossRef] google scholar
10. 10. Gilmore KS, McLintock C. Maternal and fetal outcomes of primary immune thrombocytopenia during pregnancy: A retrospective study. Obstet Med 2018;11(1):12-6. [CrossRef] google scholar
11. 11. Onisâi M, Vlâdâreanu AM, Spînu A, Gaman M, Bumbea H. Idiopathic thrombocytopenic purpura (ITP) - new era for an old disease. Rom J Intern Med 2019;57(4):273-83. [CrossRef] google scholar
12. 12. Cooper N, Ghanima W. Immune thrombocytopenia. N Engl J Med 2019;381(10):945-55. [CrossRef] google scholar
13. 13. Neunert C, Terrell DR, Arnold DM, Buchanan G, Cines DB, Cooper N, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv 2019;3(23):3829-66. [CrossRef] google scholar
14. 14. Sun D, Shehata N, Ye XY, Gregorovich S, France BD, Arnold DM, et al. Corticosteroids compared with intravenous immunoglobulin for the treatment of immune thrombocytopenia in pregnancy. Blood 2016;128(10):1329-35. [CrossRef] google scholar
15. 15. Webert KE, Mittal R, Sigouin C, Heddle NM, Kelton JG. A retrospective 11 year analysis of obstetric patients with idiopathic thrombocytopenic purpura. Blood 2003;102(13):4306-11. [CrossRef] google scholar
16. 16. James AH. Paving the way for improved management of severe immune thrombocytopenia purpura in pregnancy. BJOG 2018;125(5):613. [CrossRef] google scholar
17. 17. Samuels P, Bussel JB, Braitman LE, Tomaski A, Druzin ML, Mennuti MT, et al. Estimation of the risk of thrombocytopenia in the offspring of pregnant women with presumed immune thrombocytopenic purpura. N Engl J Med 1990;323(4):229-35. [CrossRef] google scholar
18. 18. Kawaguchi K, Matsubara K, Takafuta T, Shinzato I, Tanaka Y, Iwata A, et al. Factors predictive of neonatal thrombocytopenia in pregnant women with immune thrombocytopenia. Int J Hematol 2014;99(5):570-6. [CrossRef] google scholar
19. 19. Payne SD, Resnik R, Moore TR, Hedriana HL, Kelly TF. Maternal characteristics and risk of severe neonatal thrombocytopenia and intracranial hemorrhage in pregnancies complicated by autoimmune thrombocytopenia. Am J Obstet Gynecol 1997;177(1):149-55. [CrossRef] google scholar
20. 20. Koyama S, Tomimatsu T, Kanagawa T, Kumasawa K, Tsutsui T, Kimura T. Reliable predictors of neonatal immune thrombocytopenia in pregnant women with idiopathic thrombocytopenic purpura. Am J Hematol 2012;87(1):15-21. [CrossRef] google scholar
21. 21. Yuce T, Acar D, Kalafat E, Alkilic A, Cetindag E, Soylemez F. Thrombocytopenia in pregnancy: Do the time of diagnosis and delivery route affect pregnancy outcome in parturients with idiopathic thrombocytopenic purpura? Int J Haematol 2014;100(6):540-4. [CrossRef] google scholar
22. 22. Belkin A, Levy A, Sheiner E. Perinatal outcomes and complications of pregnancy in women with immune thrombocytopenic purpura. J Matern Fetal Neonatal Med 2009;22(11):1081-5. [CrossRef] google scholar
23. 23. Subbaiah M, Kumar S, Roy KK, Sharma JB, Singh N. Pregnancy outcome in patients with idiopathic thrombocytopenic purpura. Arch Gynecol Obstet 2014;289(2):269-73. [CrossRef] google scholar
24. 24. Won YW, Moon W, Yun YS, Oh HS, Choi JH, Lee YY, et al. Clinical aspects of pregnancy and delivery in patients with chronic idiopathic thrombocytopenic purpura (ITP). Korean J Intern Med 2005;20(2):129-34. [CrossRef] google scholar