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Pregnancy Does Not Increase Risk of Severe Bleeding in ITP

October 20, 2022

November 2022

There was no increased risk of severe bleeding during pregnancy among women with immune thrombocytopenia (ITP), according to a prospective, observational cohort study published in Blood. Pregnant women with ITP had similar rates of severe bleeding as women with ITP who were not pregnant, a useful finding for counseling women with ITP, according to a study conducted by researcher Bertrand Godeau, MD, of Université Paris Est Créteil in France, and colleagues.

“Pregnancy can be a source of anxiety and presents a challenge for women with ITP and for their physicians,” Dr. Godeau said. “Current guidelines for pregnant women with ITP are mostly based on expert opinion and results of retrospective studies.”

To assess whether pregnancy was associated with worsened ITP or the incidence of neonatal ITP (NITP), Dr. Godeau and colleagues prospectively studied 131 pregnant women with ITP matched with 131 non-pregnant women with ITP. The women were matched by history of splenectomy, ITP status, and duration.

There was no significant worsening of ITP during pregnancy in the study group, and the first occurrence of worsened ITP was similar among pregnant and non-pregnant women at 53.4 per 100 person-years (95% CI 40.8-69.9) versus 37.1 (27.5-50.0), respectively (hazard ratio [HR] = 1.35, 95% CI 0.89-2.03; p=0.16). Recurrence of severe bleeding was also similar between the groups.

The researchers noted they “cannot exclude a potential confounder of gestational thrombocytopenia because in healthy women, pregnancy shifts the normal bell-shaped distribution of platelet counts downward by 25 to 50 × 109/L at the time of pregnancy. However, it is unlikely that gestational thrombocytopenia can explain the occurrence of severe thrombocytopenia below 30 G/L.”

Women who were pregnant were more than twice as likely as those who were not pregnant to have recurrence of severe thrombocytopenia and treatment modification (HR=2.71, 95% CI 1.41-5.23; p=0.003 and HR=2.01, 95% CI 1.14-3.57; p=0.017).

Among the 171 pregnant women followed until delivery, 39.2% received treatment in preparation for delivery, but there was no other ITP treatment during pregnancy for 28.4%. Administered treatments were mostly based on corticosteroids and IVIg.

Fourteen percent of the neonates showed NITP and 9.6% had severe NITP. The researchers found that moderate or severe NITP was independently associated with previous offspring with NITP (adjusted odds ratio [aOR] = 5.55, 95% CI 1.72-17.89; p=0.0004) and maternal platelet count below 50 × 109/L within three months of delivery (aOR=4.07; 95% CI 1.41-11.73; p=0.009).

Based on this finding, researchers wrote that “severity of ITP in the mother with a platelet count less than 50 × 109/L in the third trimester should be considered a risk factor for severe NITP.”

There were several possible limitations to the study. First, the study was designed to enroll 150 women in each group but only matched 131 women. Second, the study used a composite endpoint that combines objective criteria: bleeding events, severe thrombocytopenia, and criteria depending on clinician practice as treatment intervention.

According to the researchers, “To allow a full assessment of the complexity of ITP worsening, it seems important not to limit our evaluation to bleeding event even though it was the more relevant clinical event for physicians.”

Finally, the study did not assess for an association between the presence of anti-platelet antibodies and risk of NITP.

“Our study demonstrates that the severity of ITP during pregnancy should now also be considered a risk factor,” Dr. Godeau and colleagues wrote. “Nevertheless, women with ITP should not be discouraged if they want to become pregnant because the prognosis for the newborn is reassuring when therapeutic measures proposed in the international guidelines are observed.”

Any conflicts of interest declared by the authors can be found in the original article.


Guillet S, Loustau V, Boutin E, et al. Immune thrombocytopenia and pregnancy: an exposed/non-exposed study [published online ahead of print, 2022 Sept 2]. Blood. doi: 10.1182/blood.2022017277.


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