Romiplostim during pregnancy in refractory primary immune thrombocytopenia: Literature review and case series

Primary immune thrombocytopenia (ITP) in pregnancy presents significant therapeutic challenges, particularly when refractory to standard treatments such as corticosteroids, intravenous immunoglobulin, and immunosuppressants. Data on thrombopoietin receptor agonists (TPO-RAs) during pregnancy remain scarce. This study reports four pregnancies in three women with refractory ITP who received Romiplostim during gestation. All cases were retrospectively analyzed, with detailed documentation of treatment courses, platelet trajectories, and maternal and neonatal outcomes. Romiplostim was introduced in the second or third trimester at doses ranging from 3.1 to 6.25 µg/kg/week, following inadequate response to conventional therapy. All patients demonstrated hematologic improvement, often within one to two weeks of initiation, enabling corticosteroid tapering and preparation for delivery. Delivery outcomes were favorable, including four term vaginal deliveries without major hemorrhagic or thromboembolic complications. Neonatal outcomes were reassuring, with all infants born healthy, exhibiting platelet counts between 73,000 and 233,000/µL and no evidence of bleeding or congenital anomalies. One patient experienced transient postpartum thrombocytosis managed with low-molecular-weight heparin prophylaxis. No maternal or neonatal adverse events were attributed to Romiplostim exposure. These findings are consistent with previous limited reports suggesting that Romiplostim may be a viable rescue therapy for severe, refractory ITP in pregnancy. The favorable hematologic responses and reassuring neonatal outcomes observed in this series highlight the potential role of Romiplostim as an alternative treatment in carefully selected cases, provided that therapy is conducted under close multidisciplinary supervision.