Clinical study
Immune thrombocytopenia in pregnancy: autoimmune and alloimmune

https://doi.org/10.1016/S0165-0378(97)00072-7Get rights and content

Abstract

Auto- and alloimmune thrombocytopenias in pregnancy may seriously impact on both mother and fetus. Autoimmune thrombocytopenia (ITP) affects both mothers and fetuses but is considered to be quite benign for both groups. The ‘facts’ are that: 1) ITP occurs commonly in pregnancy; 2) there has been no reported maternal mortality in more than 20 years; 3) management, except at delivery, is similar to management in the non-pregnant state; 4) splenectomy is virtually never required during pregnancy; 5) significant neonatal thrombocytopenia occurs in approximately 10% of cases and intra-cranial hemorrhage (ICH) 1%; 6) the course of the first sibling predicts that of the next sibling; and 7) the fetal platelet count can be successfully determined (if desired) by either fetal blood sampling (FBS) or by fetal scalp sampling. Many other important considerations remain undetermined: 1) non-invasive prediction of severe fetal thrombocytopenia; 2) the appropriate mode of delivery for a thrombocytopenic fetus; 3) the role of anti-platelet antibody testing; and 4) the effects on the fetal platelet count of maternal therapy. Alloimmune thrombocytopenia (AIT) is easier to outline because it is a far more serious fetal disorder: 1) neonatal platelet counts < 20 000/μl are common in AIT; 2) there is a 10–30% ICH rate in first affected newborns, some of which occur antenatally; 3) there is no universal prenatal screening although this would be scientifically feasible; 4) testing is complex and requires an experienced laboratory that can test at least five platelet antigens and has sufficient typed controls to confirm the specificity of any anti-platelet antibodies detected; 5) the second affected sibling in a family is usually more severely affected than the first; 6) treatment of the thrombocytopenic neonate can be accomplished with intravenous (IV) gammaglobulin and/or platelet transfusions; and 7) treatment of the fetal platelet count can be accomplished in most instances by infusing the mother with IV gammaglobulin with or without steroids; platelet transfusions to the fetus is another option.

References (50)

  • J.G. McFarland et al.

    Prenatal diagnosis of neonatal alloimmune thrombocytopenia using allele-specific oligonucleotide probes

    Blood

    (1991)
  • S. McIntosh et al.

    Neonatal isoimmunue purpura: response to platelet infusions

    J. Pediatr.

    (1973)
  • M.J. Paidas et al.

    Alloimmune thrombcytopenia: Fetal and neonatal losses related to cordocentesis

    Am. J. Obstet. Gynecol.

    (1995)
  • A. Scaradavou et al.

    Intravenous ANTI-D treatment of immune thrombocytopenic purpura: experience in 272 patients

    Blood

    (1997)
  • A.L. Scioscia et al.

    The use of percutaneous umbilical blood sampling in immune thrombocytopenic purpura

    Am. J. Obstet. Gynecol.

    (1988)
  • J.R. Scott et al.

    Fetal platelet counts in the obstetric management of immunologic thrombocytopenic purpura

    Am. J. Obstet. Gynecol.

    (1980)
  • J.R. Scott et al.

    Antiplatelet antibodies and platelet counts in pregnanacies complicated by autoimmune thrombocytopenic purpura

    Am. J. Obstet. Gynecol.

    (1983)
  • R.M. Silver et al.

    Maternal thrombocytopenia in pregnancy: time for a reassessment

    Am. J. Obstet. Gynecol.

    (1995)
  • D.M. Adams et al.

    Accurate intrapartum estimation of fetal platelet count by fetal scalp sample smear

    Am. J. Perin.

    (1994)
  • M.A. Baumann et al.

    Urgent treatment of idiopathic thrombocytopenic purpura with single-dose gammaglobulin infusion followed by platelt transfusion

    Ann. Int. Med.

    (1986)
  • K. Bjoro et al.

    Hepatitis C infection in patients with primary hypogammaglobulinia after treatment with contaminated immune globulin

    New Engl. J. Med.

    (1994)
  • V.S. Blanchette et al.

    Alloimmunization to the PLA1 platelet antigen: results of a prospective study

    Br. J. Hematol.

    (1990)
  • R.F. Burrows et al.

    Incidentally detected thrombocytopenia in healthy mothers and their infants

    New Engl. J. Med.

    (1988)
  • R.F. Burrows et al.

    Fetal thrombocytopenia and its related to maternal thrombocytopenia

    New Engl. J. Med.

    (1993)
  • J.B. Bussel et al.

    Antenatal treatment of neonatal alloimmune thrombocytopenia

    New Engl. J. Med.

    (1988)
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      It is currently unknown whether this novel Fc-independent platelet clearance pathway also occurs in fetuses and contributes to FNAIT. Expecting mothers with pre-existing ITP have been less well studied and as such the effect of the disease on neonates is controversial.91,92 Neonatal thrombocytopenia in mothers with ITP cannot be predicted by history or platelet count, however an affected older sibling is a reliable risk factor in subsequent pregnancies.93

    • Neonatal thrombocytopenia

      2008, Seminars in Fetal and Neonatal Medicine
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      Around 10% of infants of affected mothers develop thrombocytopenia. It is a less common cause of NT than NAITP, affecting 1–5 in 10,000 pregnancies.42,43 Thrombocytopenia is usually mild and ICH is rare (<1% of at-risk babies).

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      2008, Blood Reviews
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      Transplacental passage of maternal auto-antibodies in this setting is much less of a clinical problem than NAIT. Thrombocytopenia only occurs in ∼10% of neonates whose mothers have autoantibodies and the incidence of ICH is 1% or less.47 Therefore fetal blood sampling or cesarean delivery in mothers with autoimmune thrombocytopenia is not normally necessary irrespective of the platelet count during pregnancy.44,48

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    Paper presented by invitation at the first International Conference on Experimental and Clinical Reproductive Immunobiology, Charlottesville, VA, USA, October, 1997.

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