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

Immune thrombocytopenia in pregnancy

Autoimmune thrombocytopenia (ITP)

1) The risks to mother and fetus have previously been overstated.

2) There is no maternal test which will accurately determine fetal thrombocytopenia.

3) The only reliable test for fetal thrombocytopenia is cordocentesis – this carries a higher morbidity than that of fetal intracerebral haemorrhage from ITP.

4) Contrary to received wisdom, there is no evidence that, even for the most severely thrombocytopenic infant, abdominal delivery protects against intracranial haemorrhage.

5) Management therefore involves keeping the maternal platelet count above 50 × 1091 and choosing the route of delivery on normal obstetric grounds.

Alloimmune thrombocytopenia

1) Alloimmune thrombocytopenia is commoner than hitherto believed (0.15% all neonates).

2) The fetal risks are considerable: intracranial haemorrhage occurs in 4% of cases antenatally and in 10% in labour. The risks are virtually confined to those with a platelet count of less than 30 × 109l−1.

3) Cordocentesis is justified for the ‘at risk’ fetus; fetal immunoglobulin or platelet therapy can be given.

4) When the fetal platelet count is below 50 × 109l−1, abdominal delivery should be planned.

5) A maternal screening test for neonatal alloimmune thrombocytopenia exists (lack of P1A1 antigen).

Outcome of pregnancy in women with idiopathic thrombocytopenic purpura

The obstetric management and haematological problems in 28 pregnancies of 23 mothers with idiopathic thrombocytopenic purpura (ITP) are analyzed. There was no maternal death and only 1 stillbirth occurred in the series. Ten infants were born by Caesarean section and 18 were delivered vaginally. Neonatal cord bloodplatelet counts showed thrombocytopenia in 12 infants, but in only 4 (14.3%) was the cord blood platelet count <50 x 10(9)/L. None of the 27 liveborn infants died, although 4 required supportive treatment with corticosteroids and IgG. No maternal characteristics could be used to predict the neonatal platelet count. These results are comparable with other studies reported in the literature. The rarity of poor neonatal outcome in mothers with ITP does not justify obstetric intervention solely on the basis of their platelet counts. The management of patients should be individualized and carefully planned.

Relationships between severe neonatal thrombocytopenia and maternal characteristics in pregnancies associated with autoimmune thrombocytopenia

In pregnant women with antecedents of autoimmune thrombocytopenia (AITP), no predictive factor for severe fetal thrombocytopenia has been identified. We evaluated the relationships between the course of the maternal disease before and during pregnancy and the risk of severe fetal thrombocytopenia, in 64 pregnant women with known chronic AITP antecedents, over a 12-year period. 28 pregnant women had undergone splenectomy before pregnancy and 17 experienced severe thrombocytopenia (< 50 x 10(9)/l) during pregnancy (monthly determination). Eight infants presented with severe thrombocytopenia at birth (12.5%), and four in the following days (6.25%). No severe haemorrhage was observed. Severe thrombocytopenia at birth was present in 57% (CI 95% 18-90%) of the infants born to mothers with severe pregnancy-associated thrombocytopenia and splenectomy antecedents, and in 0% (CI 95% 0-15%) of the infants born to mothers who presented none of these antecedents (P=0.001). In thrombocytopenic mothers the infant platelet counts at birth were positively correlated to the nadir maternal platelet count during the index pregnancy (r=0.42, P=0.0075). These results suggest that severe autoimmune disease is a risk factor for severe fetal thrombocytopenia, and that pregnant women with no antecedent of splenectomy nor severe thrombocytopenia during pregnancy have a very low risk of severe fetal thrombocytopenia.

Immune thrombocytopenia in pregnancy: autoimmune and alloimmune

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/microliter 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 (i.v.) gammaglobulin and/or platelet transfusions; and 7) treatment of the fetal platelet count can be accomplished in most instances by infusing the mother with i.v. gammaglobulin with or without steroids; platelet transfusions to the fetus is another option.

Platelet and hemorrhagic disorders associated with pregnancy: a review. Part I

Disorders of coagulation remain an important potential cause of maternal morbidity and mortality. Bleeding disorders in pregnancy, unlike disorders of hypercoagulability, most often can have little impact on the mother but devastating consequences for the fetus. Further complicating the issue is that not all disorders of coagulation are inherited. Some are due to maternal illnesses unique to pregnancy, others are due to drug ingestion, and yet others remain idiopathic. In still other instances, thrombocytopenia is a minor consequence of a more severe disorder and will resolve when the inciting agent is removed or treated. A basic understanding of the pathophysiology of various conditions that lead to bleeding diathesis in pregnancy is necessary in order to effectively manage these varied clinical disorders. In addition, knowledge of whether the major morbidity is fetal or maternal or both can impact management. This review is concerned with the etiology, pathophysiology, diagnosis, and general management of commonly encountered disorders in pregnancy that place the mother and fetus at increased morbidity and mortality because of the potential for hemorrhage. Acutely acquired disorders and the resultant maternal manifestation versus a chronic disease process that is altered by the state of pregnancy are distinguished. Where possible, the incidence and prognosis of the disorder are provided. Actual cases are included to illustrate how similar presentations of distinctly different disorders can confuse and complicate an accurate diagnosis that is essential for appropriate management.

Maternal thrombocytopenia in pregnancy: time for a reassessment

Antiplatelet autoantibodies in women with autoimmune thrombocytopenic purpura can cause fetal thrombocytopenia and serious bleeding problems. Obstetricians have used fetal scalp sampling, cordocentesis, and cesarean delivery in this disorder to avoid fetal complications such as intracranial hemorrhage. Accumulating evidence indicates that the fetal risk of intracranial hemorrhage is much lower than initially reported. Moreover, these invasive tests and treatments are costly, cause morbidity, and have little effect in preventing neonatal bleeding complications. Therefore we suggest these interventions should no longer be used in the management of maternal thrombocytopenia.

Low fetal morbidity in pregnancy associated with acute and chronic idiopathic thrombocytopenic purpura

Forty-six mothers with immune thrombocytopenic purpura (ITP) gave birth to 72 babies. Sixty-two babies were delivered vaginally and 10 babies by cesarean section. There was no mortality among mothers or babies. Eighteen infants were born thrombocytopenic (PLT < 100 x 10(9)/l). Eleven infants had a platelet count of less than 50 x 10(9)/l. All the severely thrombocytopenic babies (except 1) were born to post splenectomy thrombocytopenic mothers, regardless of steroid treatment during pregnancy. Five babies had clinical manifestations of bleeding; 3 had mild purpura, 1 severe gastrointestinal bleeding, and 1 intracranial bleeding. The latter 2 babies were born prematurely to the same mother who was severely thrombocytopenic despite splenectomy in childhood. In view of very low morbidity in babies of ITP mothers, we suggest that they be delivered vaginally. Cesarean delivery should be performed in selected cases where the mother is severely thrombocytopenic despite splenectomy or where prematurity or obstetrical complications are encountered.

Fetal platelet counts in thrombocytopenic pregnancy

Fetal platelet counts were assessed by percutaneous umbilical blood sampling in 64 pregnancies (62 women) with maternal thrombocytopenia. In 33 pregnancies associated with chronic immune thrombocytopenia, 11 of the fetuses had platelet counts below 150 x 10(9)/l and 4 were severely thrombocytopenic (less than 50 x 10(9)/l). In 31 pregnancies with symptomless maternal thrombocytopenia as an incidental finding, 4 fetuses were thrombocytopenic, 1 of them severely. Maternal indices, including antiplatelet antibodies, did not correlate with risk of fetal thrombocytopenia; and in those with repeat measurements there was no evidence of benefit from treatment with either corticosteroids (4 cases) or intravenous immunoglobulin (3 cases). Percutaneous umbilical blood sampling, a safe procedure in experienced hands, provides accurate platelet counts in thrombocytopenic pregnancy, as an aid to decisions on mode of delivery and to assessment of treatments.

Idiopathic thrombocytopenic purpura in pregnancy: a randomized trial on the effect of antenatal low dose corticosteroids on neonatal platelet count

OBJECTIVE

To determine the efficacy of antenatal low dose oral betamethasone in preventing neonatal thrombocytopenia and/or bleeding in infants of mothers with idiopathic thrombocytopenic purpura (ITP).

SETTING

Hospital department of obstetrics and gynaecology, referral centre.

PATIENTS

41 pregnancies in 38 women were randomized. The results of 13 pregnancies were considered non-assessable. The final analysis involved 14 in the betamethasone group and 14 in the non-treatment group. All fulfilled the criteria for ITP.

INTERVENTIONS

The treated group received 1.5 mg betamethasone orally per day, from day 259 till day 273 and 1 mg from day 273 till delivery.

MAIN OUTCOME MEASURES

Effects of treatment were assessed in terms of maternal platelet counts after the first trimester and neonatal platelet counts at birth and the first week of life and neonatal bleeding episodes.

RESULTS

There were no significant differences in neonatal platelet counts at birth. Two infants in the betamethasone group and one in the untreated group had a severe thrombocytopenia either at birth or during the first week of life (less than 50 x 10(9)/l). Seven infants in the betamethasone group and six in the non-treatment group had a mild thrombocytopenia. The overall frequency of neonatal thrombocytopenia was similar: 64% in the betamethasone group and 57% in the untreated group (95% CI of the true difference: -43.5% to +29.5%). There was also no significant difference in neonatal bleeding episodes.

CONCLUSIONS

Low-dose betamethasone in pregnant women with ITP does not prevent thrombocytopenia or bleeding in their newborn infants.

Estimation of the risk of thrombocytopenia in the offspring of pregnant women with presumed immune thrombocytopenic purpura

BACKGROUND AND METHODS

The optimal management of immune thrombocytopenic purpura during pregnancy remains controversial because the risk of severe neonatal thrombocytopenia remains uncertain. We studied the outcome of the index pregnancy in 162 women with a presumptive diagnosis of immune thrombocytopenic purpura to determine the frequency of neonatal thrombocytopenia and to determine whether neonatal risk could be predicted antenatally by history or platelet-antibody testing.

RESULTS

Two maternal characteristics were identified as predicting a low risk of severe neonatal thrombocytopenia: the absence of a history of immune thrombocytopenic purpura before pregnancy, and the absence of circulating platelet antibodies in the women who did have a history of the condition. Eighteen of 88 neonates (20 percent; 95 percent confidence interval, 13 to 30 percent) born to women with a history of immune thrombocytopenic purpura had severe thrombocytopenia (platelet count less than 50 x 10(9) per liter at birth), as compared with 0 of 74 (0 percent; 95 percent confidence interval, 0 to 5 percent) born to women first noted to have thrombocytopenia during pregnancy (P less than 0.0001). Among the women with a history of immune thrombocytopenic purpura, 18 of 70 neonates (26 percent; 95 percent confidence interval, 16 to 38 percent) born to those with circulating platelet antibodies had severe thrombocytopenia, as compared with 0 of 18 infants (0 percent; 95 percent confidence interval, 0 to 18.5 percent) born to those without circulating antibodies (P less than 0.02). Thus, the risk of severe neonatal thrombocytopenia in the offspring of women without a history of immune thrombocytopenic purpura before pregnancy and of women with a history of the condition in whom circulating platelet antibodies are not detected was 0 percent (95 percent confidence intervals, 0 to 5 and 0 to 18.5 percent, respectively).

CONCLUSIONS

The absence of a history of immune thrombocytopenic purpura or the presence of negative results on circulating-antibody testing in pregnant women indicates a minimal risk of severe neonatal thrombocytopenia in their offspring.

Perinatal diagnosis of passive ITP: use of percutaneous umbilical blood sampling (PUBS)

Fetal blood samples can be obtained in utero by direct sampling of the umbilical cord vessels, using an ultrasound guided technique termed percutaneous umbilical sampling (PUBS). This procedure is being used more frequently in high risk pregnancies to obtain direct fetal laboratory data. In specialized centers, with trained personnel, the technique can be used with a high degree of safety and efficiency. Direct access to the fetal circulation can also allow an accurate determination of the fetal platelet count in cases of suspected fetal thrombocytopenia. The technique may be used to plan appropriate clinical management of maternal ITP as well as to diagnose the presence of fetal alloimmune thrombocytopenia. A logical strategy for obstetric management and evaluation of fetal risk can be planned. The procedure also has the potential to allow direct fetal treatment as has been the case in the management of severe fetal anemia.

[Thrombocytopenia and pregnancy]

Over the past 20 years, 16 pregnancies with thrombocytopenia were observed. Fourteen of these cases were afflicted with immune thrombocytopenic purpura (ITP, M, Werlhof). Antenatal treatment of the mothers (e.g., with corticosteroids) varied and is discussed. The methods of delivery were spontaneous vaginal (nine) or cesarean section (five). Except for one neonatal death (28th week of gestation), no significant hemorrhagic morbidity occurred. On the basis of this experience and the literature, an individual management of delivery for parturient patients with ITP is proposed.

Prenatal diagnosis of platelet disorders

The antenatal diagnosis of platelet disorders represents real progress in the early detection of haemorrhagic diseases occurring in the fetus. However, the diagnosis is only possible in some cases during the first trimester of gestation, and not in the first weeks as is the case for other hereditary disorders such as abnormal haemoglobins. This delay can be reduced now that the molecular abnormalities responsible for some platelet disorders have been discovered. If the region of chromosome 17 and the DNA sequence coding for the glycoproteins GP IIb-IIIa were known, this would make possible the recognition of the gene defect responsible for Glanzmann's thrombasthenia. This could also permit the diagnosis of Glanzmann's thrombasthenia at the gene level, i.e. during the first weeks of gestation. However, the use of gene markers could be limited by the fact that a monomorphic clinical expression of Glanzmann's thrombasthenia could correspond to different genetic mutations which can all result in a defect in GP IIb-IIIa synthesis and assembly. If such diagnosis could be made very early, it would only represent real progress if a specific treatment could be applied. New therapeutic approaches to immune thrombocytopenia during pregnancy appear to be possible and can be applied when there is a risk to the fetus, they are still either experimental or anecdotal and there is a real need for a well-designed clinical trial. In all fetal platelet disorders, the risk of fetal death following fetal blood sampling must not be underestimated and very careful, intensive care is necessary after such an investigation. In the absence of a specific therapy, this antenatal diagnosis must be restricted to cases in which the risk of severe haemorrhagic complications are anticipated and where there is a well-documented family history. The patients must be properly informed of all the aspects of the investigation, including the possible risks. As has been the case for other haematological disorders, progress will be made, and we can anticipate that eventually in utero bone-marrow transplantation or gene correction be performed to cure the disease before birth.

The use of percutaneous umbilical blood sampling in immune thrombocytopenic purpura

Maternal immune thrombocytopenic purpura has been associated with profound fetal and neonatal thrombocytopenia. Percutaneous umbilical blood sampling offers a reliable method of determining the fetal platelet count antenatally and optimizing obstetric management. We present our experience with this technique in 19 gestations.

Does maternal platelet-associated or platelet-bindable IgG correlate with levels in umbilical cord blood or colostrum during normal pregnancy?

Existing data regarding the ability to predict neonatal thrombocytopenia during maternal immune thrombocytopenia are confusing. We studied normal pregnancies (n = 20) to define normal values and the correlation between maternal and umbilical cord platelet counts, platelet-associated immunoglobulin G (IgG), and platelet-bindable IgG. The postpartum serum platelet-bindable IgG level was measured to evaluate peripartum changes and the correlation with colostrum platelet-bindable IgG (n = 6). The mean maternal platelet count was 181,500 cells/cm3 mm and the mean umbilical cord platelet count was 293,500 cells/mm3. The median maternal platelet-associated IgG was 803 molecules per platelet, umbilical cord platelet-associated IgG was 791 molecules per platelet, maternal platelet-bindable IgG was 92 molecules per platelet, and umbilical cord platelet-bindable IgG was 256 molecules per platelet. The postpartum median maternal platelet-bindable IgG was 333 molecules per platelet and for colostrum it was 297 molecules per platelet. No clinically useful correlations for predicting the neonatal platelet count during normal pregnancy were found. Normal pregnancies may have high levels of maternal- or umbilical cord platelet-associated IgG, perhaps due to nonspecific binding.

Validity of intrapartum diagnosis of fetal thrombocytopenia

Performing a platelet count in fetal scalp blood was hitherto the only method to predict whether the infant of a mother with idiopathic thrombocytopenic purpura will be thrombocytopenic. Fifteen such cases are reported. Falsely low platelet counts were found in almost half of these fetal scalp samples. In two patients this could have altered the obstetric management.

Platelet-binding immunoglobulins in pregnancy-induced hypertension. II. Origin of circulating IgG and IgM antiplatelet antibodies in the umbilical cord serum

IgG and IgM have been identified on the surface of maternal platelets in both autoimmune thrombocytopenia (ATP) and pregnancy-induced hypertension (PIH). IgG is also found on the umbilical cord platelets of patients with ATP and PIH, whereas IgM is only found on the umbilical cord platelets of patients with PIH. The possible maternal or fetal origins of these umbilical cord blood immunoglobulins were investigated by immunoblot analysis of antibodies in paired maternal and umbilical cord blood sera of ATP and PIH patients. Maternal sera contained IgG and IgM antibodies which reacted with several platelet proteins, however, a large amount of patient-to-patient variation was observed in the specific antigens that were identified. Analysis of paired maternal and umbilical cord sera from patients with ATP or PIH showed identical patterns of antigen specificity, which suggested that the IgG antibodies in the fetal circulation were of maternal origin. Circulating IgM antibodies were not observed in the umbilical cord sera of ATP patients. The umbilical cord sera of PIH patients, however, contained IgM antibodies that reacted against a variety of platelet antigens. In addition, most umbilical cord sera from PIH patients had identical patterns and relative intensities of reactivity, which differed from the patterns observed in the paired maternal sera. Antiplatelet IgM in the umbilical cord blood of PIH patients, therefore, appears to be a product of the fetal immune system.

Platelet-binding immunoglobulins in pregnancy-induced hypertension. I. Platelet-associated IgM on fetal platelets: evidence of a fetal autoimmune reaction?

Pregnancy-induced hypertension (PIH) can be complicated by maternal or fetal thrombocytopenia, or both. In order to investigate possible immunologic causes of these thrombocytopenias, platelet-associated IgG (PAIgG) and IgM (PAIgM) were measured in mothers with PIH and in their infants and compared with those from patients with autoimmune thrombocytopenic purpura (ATP), a known immunodestructive platelet disorder. Many PIH patients (33.3%) and most ATP patients (68.1%) had elevated levels of maternal PAIgG. In both diseases, the amount of PAIgG was directly proportional with the degree of thrombocytopenia (r = 0.446 in PIH and r = 0.668 for ATP). But in neither disease did the degree of maternal thrombocytopenia correlate with the degree of neonatal thrombocytopenia (r = 0.153 for PIH and r = 0.175 for ATP). Umbilical cord samples from PIH patients contained PAIgG (53.3%) and PAIgM (53.8%), whereas the umbilical cord samples from ATP patients had elevated amounts of PAIgG but not PAIgM. PAIgM in the umbilical cord blood could not be accounted for by IgM rheumatoid factors, IgM-containing immune complexes, or non-specific adsorption because of elevated total IgM levels. The umbilical cord blood PAIgM was probably not of maternal origin because it was observed even when the maternal blood contained no PAIgM and maternal IgM is not normally transported transplacentally. Therefore, the PAIgM appears to be of fetal origin. These results suggest that both maternal and fetal immunologic mechanisms may be involved in PIH-induced thrombocytopenia; if so, this is one of the first reported examples of a possible fetal autoimmune response.

An epidemic of maternal thrombocytopenia associated with elevated antiplatelet antibody. Platelet count and antiplatelet antibody in 116 consecutive pregnancies: relationship to neonatal platelet count

Twenty-eight (24%) of 116 pregnant women studied prospectively during an 8-month period in 1983 had platelet counts of less than 150,000/mm3 at least once during pregnancy. Thirteen of these were thrombocytopenic in both the prenatal and the peripartum period. Eighteen were restudied 3 to 12 months after delivery. One woman, who was pregnant again, had a platelet count of 140,000/mm3. In the others, platelet counts were in the normal range. Platelet-associated immunoglobulin G and serum antiplatelet antibody levels were elevated in 79% and 61%, respectively, of these 28 women on at least one occasion. However, 59% of 73 pregnant nonthrombocytopenic women had increased platelet-associated immunoglobulin G levels and 59% had positive serum antiplatelet antibody test results. Twenty women who had increased platelet-associated immunoglobulin G levels and positive serum antiplatelet antibody test results were normal 6 to 10 months after delivery. Of 105 infants studied, 10 were thrombocytopenic. Neonatal thrombocytopenia was not predicted by maternal platelet count, platelet-associated immunoglobulin G, or serum antiplatelet antibody. By the fall of 1984, the incidence of thrombocytopenia had dropped to two in 280 consecutive pregnancies. We conclude that (1) epidemics of thrombocytopenia can occur in pregnant women and (2) if a women is found to be thrombocytopenic for the first time during pregnancy, she should not be subjected to the measures advocated for the management of pregnancy in women with autoimmune thrombocytopenic purpura.

Autoimmunity and pregnancy

The general effect of pregnancy on autoimmunity remains controversial. In the majority of cases, pregnancy may have no effect on the disease, while on other occasions, pregnancy induces exacerbations that may be especially pronounced in the immediate post-partum period. The reasons for this preponderance are still unclear. Another important aspect of autoimmune diseases during pregnancy entails the passive transfer of the disease into the fetal compartment. It seems that until the pathogenesis and a better specific therapy for autoimmune diseases are clearly defined, careful clinical and immunologic observation of each mother-infant pair will be invaluable.

Unsuccessful treatment of fetal immunologic thrombocytopenia with dexamethasone

Corticosteroid therapy near term for mothers with immunologic thrombocytopenia has recently been suggested as a clinically useful method to prevent neonatal thrombocytopenia. The unreliability of this approach is illustrated by the case of an infant with a low platelet count delivered after the maternal administration of dexamethasone.

Maternal azathioprine therapy and depressed haemopoiesis in the babies of renal allograft patients

Maternal immunosuppression with azathioprine during pregnancy can depress fetal haemopoiesis resulting in neonatal thrombocytopenia and leucopenia with the potential for serious sequelae. The effect on the infant of adjusting azathioprine dosage on the basis of maternal total leucocyte count has been studied in 10 pregnancies in eight renal allograft recipients. Throughout the first six pregnancies azathioprine dosage was unchanged and although the characteristic pregnancy leucocytosis was evident it was not maintained in four patients whose leucocyte counts by 32 weeks gestation were significantly less than our norm [10.3 (SD 1.7) X 10(9)/1] and who subsequently had babies with cord leucocyte counts less than or equal to 8.0 X 10(9)/l, again significantly less than our norm [13.7 (SD 3.9) X 10(9)/l]. A significant correlation existed between maternal leucocyte counts at 32 weeks gestation and at delivery and cord leucocyte count (r = 0.847; P less than 0.01 and r = 0.915; P less than 0.01 respectively). Three of these infants had platelet counts less than or equal to 100 X 10(9)/l but there was no correlation between maternal platelet counts at 32 weeks gestation or at delivery and cord platelet count. For the next four pregnancies policy changed: at 32 weeks gestation azathioprine dosage was halved if maternal leucocyte count was at or below the 1SD band (8.6 X 10(9)/l) for normal pregnancy. All of the infants were haemotologically normal and two patients whose first babies had leucopenia and thrombocytopenia had second babies without problems. Analysis of data from all 10 pregnancies still demonstrated a significant correlation between cord leucocyte count and maternal leucocyte count at delivery but no longer at 32 weeks gestation.(ABSTRACT TRUNCATED AT 250 WORDS)

Autoimmune thrombocytopenic purpura: current concepts and recommended practices

Autoimmune thrombocytopenic purpura is the most common autoimmune disorder encountered in the pregnant patient. It is potentially fatal for the mother and fetus yet treatable and potentially curable. Analysis of current perinatal literature reveals not only a great deal of interest and activity in the study of this syndrome and its special problems during pregnancy but also significant controversy. The disease can be acute or chronic and vary in time of onset and severity of manifestations. If not forewarned with an awareness of this disorder's pathogenesis and potential fetal effects particularly in the pregnant woman who has undergone splenectomy, the obstetrician cannot respond appropriately. The usefulness of platelet antibody determinations to facilitate obstetric management decisions is discussed. The importance of cooperative care among the obstetrician, hematologist, and neonatologist is emphasized. Recommendations for management of autoimmune thrombocytopenic purpura in pregnancy are derived from a review of current concepts of the disorder's pathogenesis, pathophysiology, criteria for diagnosis, and modes of therapy as well as special maternal/fetal considerations of antepartum, intrapartum, and postpartum care.

Route of delivery for patients with immune thrombocytopenic purpura

Over the past 15 years, we managed 19 pregnancies in 18 women afflicted with immune thrombocytopenic purpura. Our policy has been to treat the mother with corticosteroids if her platelet count was below 100 X 10(9)/L and to use cesarean section only for obstetric indications; 14 patients received corticosteroids. The perinatal outcomes were intrauterine fetal death (two), neonatal death (0), and live birth (17). The methods of delivery for the 17 live-born infants were spontaneous vaginal (seven), low forceps or midforceps (five), cesarean section (five). Although seven of the live-born infants (41%) were thrombocytopenic (less than 100 X 10(9)/L), only two received therapy, and none suffered significant hemorrhagic morbidity. Maternal treatment with corticosteroids did not affect the neonatal platelet count, nor was there a correlation between maternal and neonatal platelet counts. On the basis of our experience, we think that cesarean section is not routinely indicated as the method of delivery for parturient patients with immune thrombocytopenic purpura.