Современные подходы к лечению рефрактерной иммунной тромбоцитопении при беременности (на английском языке)

Рефрактерная иммунная тромбоцитопения (ИТП) является редким заболеванием и может быть «случайной находкой» во время беременности, но геморрагические осложнения несут угрозу для матери и для плода. Лечение рефрактерной ИТП должно осуществляться согласно Международным рекомендациям с использованием всех доступных препаратов.

Положительного результата лечения ИТП во время беременности удалось добиться благодаря использования правильной тактики родоразрешения и профилактике кровотечения. Включающей в себя 4T стратегию и адекватные дозы транексамовой кислоты (Сангера) и рекомбинантный тромбопоэтин (Емаплаг). Это был первый опыт применения рекомбинантного тромбопоэтина человека у рожениц с рефрактерной ИТП в Украине.

MODERN APPROACHES FOR MANAGEMENT OF REFRACTORY THROMBOCYTOPENIA IN PREGNANCY

Davydova Iulia, Limanskaya Alice, Klimenko Sergiy, Mokrik Alexandra, Butenko Ludmila, Ogorodnyk Artem.
SI “Institute of Pediatrics, Obstetrics and Gynecology National Academy of Medical Sciences of Ukraine”.

Thrombocytopenia is one of the hematological diseases, which demands the repeated thrombocytes infusion. The last tendencies in the management of this disease show the enhanced amount of the necessary thrombocytes doses for treatment and the worldwide trend for the declining of donors.

Considerably to these facts the new approaches for the thrombocytopenia treatment have been organized within last two decades. One of them is the finding of the safe, appropriate and effective growth factor for platelets, which could significantly improve the level of thrombocytes.

The thrombopoietin (TPO), the c-Mpl ligand, the primary natural regulator for megakaryocyte and platelets development was purified in 1994, and since that two recombinant forms rh(TPO) and pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF) have passed through the clinical investigation.

The efficacy of both of them have been proved in different hematological protocols, but showed no benefit in stem cells transplantation and in leukemia chemotherapy.

There are some serious cautions for platelet infusion therapy (PIT) in pregnancy. We do consider two main protocols for PIT in gestation and postpartum period: acute (after bleedings, PPH, postoperative blood loss) and repeated (in patients with comorbidities- leukemia, SLE, ITP, TTP, HUS etc.). In the second situation we have to consider the possible refractoriness and alloimmunization and in both situations we have to assume the possibility of the transmission of the infectious agents (viruses of hepatitis B,C, HIV) and, of course, the transfusion reactions. There is one more important factor for the limitation of platelet infusion – the limited supply of the products and significantly high cost of them. The main consequent approaches for ITP management in pregnancy are represented in the table 1.

In the table 2 we represent the data concerning the PIT and rhTPO usage in pregnancy and postpartum.

Table 1

The main consequent approaches for ITP management in pregnancy

Table 2

Platelet infusion therapy and rhTPO use in treatment of thrombocytopenia during pregnancy

The case of refactory ITP management in pregnancy.

Patient Ch., 25 years of age, diagnosed for ITP at 26 weeks of gestation, the platelet number at the time of diagnostics 20000. The other bone marrow disorders excluded by bone marrow biopsy. The in-patient of the High Risk Pregnancy Department (Obstetric Issues of the Extragenital Pathology) from the 28 weeks of pregnancy. The therapy on the regional level started by oral corticosteroids. The therapy details and platelet response are represented in the Table 3.

Table 3

The management of refractory ITP in pregnancy

Conclusions.
The refractory ITP is a rare disease and could be occasionally seen during pregnancy, but the hemorrhagic complications could be extremely harmful for both mother and child and demand the preterm pregnancy termination. The management of refractory ITP during pregnancy should be performed according to the International recommendations for the thrombocytopenia treatment with all the reserve of the medications. The positive result of the ITP management and perinatal and obstetric outcomes has been achieved through the use of the entire arsenal of drugs, correct tactics of delivery with hemorrhage prevention be using the 4 T strategy and the adequate doses of the tranexamic acid (Sangera) and rhTPO (Emaplug) (Yuriya-Pharm, Ukraine). It was the first implementation of the subcutaneous rhTPO in parturient with refractory ITP in Ukraine.

References

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