ITP Treatment in Pregnancy

James Bussel, MD: We all know about steroids and IVIG [intravenous immunoglobulin] in ITP [immune thrombocytopenia] and pregnancy. With steroids, the general recommendations are to start with a lower dose and let a patient’s platelets be in the 20,000 per μL or anything over 30,000 per μL as long as they’re not having bleeding until it comes to the time of delivery. Recently, there have been 3 sets of studies on TPO [thrombopoietin] agents in pregnancy. One from China, published in Blood in 2017, looked at 33 pregnancies, 31 patients, using their TPO agent, which is not well licensed outside of China. Marc Michel, MD,’s study, published in Blood in September 2020, had about 7 patients with romiplostim and 7 with eltrombopag. Then I had the pleasure to present at ASH [American Society of Hematology annual meeting], and at least the abstract is published, on the general safety from looking at a registry of romiplostim use during pregnancy. Personally, I would go earlier to romiplostim in a pregnant patient, especially in the third trimester. Do either of you disagree with that or want to say more about it?

Craig Kessler, MD: I’m a little hesitant to do that yet, Jim. Since IVIG is so effective in the end of pregnancy prior to making a decision about the approach to delivery, my inclination right now is to remain with IVIG toward the end. Also, we know this will help with the child’s propensity to be thrombocytopenic. I know that the Michel study suggests that the newborn may have less of a chance of being thrombocytopenic. Nonetheless, I’m still a little nervous about using a TPO mimetic yet because the TPO mimetics also have stem cell stimulation properties. I’m a little nervous about that in newborns. I don’t think we have enough data yet, but I’m certainly interested in trying to see what the results would be with a TPO receptor agonist.

Transcript Edited for Clarity