For women who want to conceive, the pregnancy process is both a time of excitement and a time of profound adjustment. A woman’s body undergoes tremendous biological and physiological changes as the pregnancy progresses, and it is important that special care is afforded to them during this delicate time.
The standard of care in the obstetrics and gynecology field is very high, as it should be. For example, there are stringent measures in place in the event that a pregnancy-related illness arises prepartum, such as preeclampsia and gestational diabetes. In modern obstetrics and gynecology, physicians are expected to have a full understanding of the mother’s medical situation; tentative due dates are issued, and careful consideration is given in the decision whether the patient should proceed with a normal vaginal delivery or whether a cesarean-section is required.
Read more about immune thrombocytopenia etiology
In the Malaysian hospital I worked at, obstetricians work towards a 0% rate of pregnancy-related maternal deaths. This is because more than 1 life is involved, so the utmost care should be offered to pregnant mothers, supporting them throughout the pregnancy and the delivery process.
Understanding the Extent of the Disease
A great irony in medicine involving pregnant women is that the quality of evidence for this group of individuals leaves much to be desired; this is because clinical trials are always conducted first on healthy young men before recruiting women with a childbearing capacity. Once again, because of the delicate situation in which more than 1 life is affected by any clinical decision, scientists generally shy away from including pregnant women in clinical studies, even when the therapy has undergone rounds of tests and is found to be relatively safe.
Let’s bring our focus to immune thrombocytopenia in pregnancy. The main worry with pregnant women with this disorder is that an insufficient platelet count may present hemostatic challenges to the delivery process. Physicians usually want to have a good handle on the severity of any morbidities in pregnant individuals, meaning that extensive tests are typically conducted (even repeated) in pregnant women.
“Knowledge of the expected platelet count trend during pregnancy is important to distinguish benign from life-threatening etiologies,” Pishko and Marshall wrote in Hematology.
Patients with thrombocytopenia may experience the benign phenomenon in which their platelet count steadily drops throughout pregnancy but is spontaneously restored once the baby has been delivered. This is termed gestational thrombocytopenia.
Trimesters are important to quantify because they provide obstetricians and gynecologists a framework to work towards; if, for example, a low platelet count is detected in the first trimester, immune thrombocytopenia is likely to be the culprit (although other disorders such as von Willebrand disease are also likely).
“Most patients who can maintain a platelet count ≥30 × 109/L during pregnancy do not require treatment until near delivery,” Pishko and Marshall wrote.
The first-line treatment for immune thrombocytopenia in pregnancy is corticosteroids and intravenous immunoglobulin. These first-line medications are effective in an overwhelming number of patients, but should they fail, second-line therapies may be used, although their objective efficacy remains a subject of debate. These may include splenectomy or prescription of the drug rituximab.
Severity of Immune Thrombocytopenia in Pregnancy
A large team of experts led by Guillet published an exposed, nonexposed cohort study of pregnant women with immune thrombocytopenia in Blood. Their findings complement those reported by Pishko and Marshall above.
When comparing pregnant and non-pregnant women with immune thrombocytopenia, the research team reported that pregnant women diagnosed with immune thrombocytopenia were more likely to have severe thrombocytopenia recurrence and the need for treatment adjustment.
“However, recurrence of severe bleeding events was not different between both groups,” Guillet et al wrote.
What about the babies delivered? Scientists report that mothers who were diagnosed with immune thrombocytopenia during the pregnancy period were most likely to pass on the disease to their offspring.
Overall, the findings by Guillet and colleagues suggest that immune thrombocytopenia in pregnant women should not be excessively feared; many patients go on to have normal, healthy deliveries. It is, of course, the exception to the rule—cases in which immune thrombocytopenia negatively affects the health of both mother and baby—that keeps physicians up at night.
One of the most important and overlooked tools in our clinical arsenal is education. Women with a preexisting diagnosis of immune thrombocytopenia who wish to get pregnant should be advised about the risks of being pregnant with the disorder but also reassured about the therapies currently available to prevent serious deterioration. The results from the study by Guillet et al should offer some comfort: women with immune thrombocytopenia generally do not have a risk of severe bleeding during pregnancy compared to nonpregnant women with this disorder.
Read more about immune thrombocytopenia treatment
Ultimately, obstetricians and gynecologists treat rare comorbidities in pregnant women with great seriousness, understanding that the diligent carrying out of their prenatal responsibilities will lower the risk of any untoward incident during childbirth. By arming would-be mothers with evidence-based information regarding their condition during pregnancy and closely monitoring them throughout the pregnancy process, physicians maximize the chance of a normal, healthy delivery, bringing along the joy that so often comes with it.
References
Pishko AM, Marshall AL. Thrombocytopenia in pregnancy. Hematology Am Soc Hematol Educ Program. Published online December 9, 2022. doi:10.1182/hematology.2022000375
Guillet S, Loustau V, Boutin E, et al. Immune thrombocytopenia and pregnancy: an exposed/nonexposed cohort study. Blood. Published online January 5, 2023. doi:10.1182/blood.2022017277
