Int J Hematol (2014) 99:570576

DOI 10.1007/s12185-014-1562-6

ORIGINAL ARTICLE

Factors predictive of neonatal thrombocytopenia in pregnant

women with immune thrombocytopenia
Koji Kawaguchi Kousaku Matsubara Toshiro Takafuta
Isaku Shinzato Yasuhiro Tanaka Aya Iwata
Hiroyuki Nigami Yasuhito Takeuchi Takashi Fukaya

Received: 19 December 2013 / Revised: 21 February 2014 / Accepted: 23 February 2014 / Published online: 13 March 2014
The Japanese Society of Hematology 2014

Abstract To determine predictive factors for neonatal

thrombocytopenia in deliveries with immune thrombocytopenia (ITP), we conducted a retrospective study at a
tertiary hospital between 1997 and 2013. During this period, 30 women with ITP delivered 44 children. Neonatal
thrombocytopenia (\100 9 109/L) at birth was observed in
seven neonates; four of these cases were severe
(\50 9 109/L). No cases were complicated by intracranial
hemorrhage, and there was no neonatal mortality. Platelet
counts at birth of neonates born to mothers, who had first
been diagnosed with ITP during pregnancy were significantly higher than those born to mothers diagnosed with
ITP before pregnancy. There were significant correlations
between neonatal platelet counts in the first and second
siblings at birth (P = 0.015) and at nadir (P = 0.035).
Platelet counts of neonates born vaginally were significantly more likely to decline after birth than those delivered by cesarean section (13/16 vs. 10/23, P = 0.024). In
conclusion, diagnosis of ITP before pregnancy was significantly associated with neonatal thrombocytopenia, and
the platelet count of an older sibling is a strong predictor
for that of the next baby. The delivery mode may be an
indicator of the timing of platelet count nadir after birth.
K. Kawaguchi (&)
K. Matsubara
A. Iwata
H. Nigami

T. Fukaya
Department of Pediatrics, Nishi-Kobe Medical Center,
5-7-1 Kojidai, Nishi-ku, Kobe 651-2273, Japan
e-mail: mlc01602@nifty.com
T. Takafuta
I. Shinzato
Y. Tanaka
Department of Hematology and Clinical Immunology,
Nishi-Kobe Medical Center, Kobe, Japan
Y. Takeuchi
Department of Obstetrics and Gynecology, Nishi-Kobe Medical
Center, Kobe, Japan

123

Keywords Immune thrombocytopenia
Pregnancy

Neonatal thrombocytopenia
Predictive factor
Abbreviations
CBC
Complete blood count
emCS Emergency cesarean section
ITP
Immune thrombocytopenia
IVIG
Intravenous immunoglobulin
mPSL Methylprednisolone
plCS
Planned cesarean section
PSL
Prednisolone

Introduction
Immune thrombocytopenia (ITP) is a common hemorrhagic disorder characterized by low platelet counts and the
involvement of platelet autoantibodies, which is clinically
manifested as mucocutaneous bleeding tendencies. It is
estimated that ITP occurs in 12 of every 1000 pregnancies, accounting for *3 % of women, who have thrombocytopenia at the time of delivery [1, 2]. During the past
three decades, our understanding of the management of
pregnant women with ITP has advanced. Several risk factors to predict severe neonatal thrombocytopenia have been
explored. Most consistent is an older sibling with thrombocytopenia [1, 2]. Other factors, such as maternal history
of splenectomy for therapy-resistant ITP and the presence
of detectable antiplatelet antibodies in maternal serum
showed mixed results [1].
The prediction of postnatal platelet counts is also crucial
for neonatal management. Some neonates born to women
with ITP who have a normal platelet count at birth
may subsequently develop severe thrombocytopenia of

Neonatal thrombocytopenia in pregnant ITP women

\50 9 109/L [3]. Asymptomatic intracranial hemorrhage

may be a complication in such neonates [46]. Recently, a
new hypothesis was proposed that there is a significant
correlation between the mode of delivery and the timing of
the nadir of platelet count; the nadir of platelet count in
neonates born by cesarean section tends to occur just at
birth and that in vaginally born neonates is likely to
develop several days after birth [7]. Confirmation of this
hypothesis is important because neonates who are at risk
for progressive thrombocytopenia could be selected.
To determine the predictive factors of neonatal thrombocytopenia and the postnatal course of platelet count, we
conducted a retrospective study of 44 consecutive deliveries at a tertiary hospital between 1997 and 2013.

Materials and methods

A retrospective review was performed for obstetric patients
with ITP who were treated and delivered at our hospital
from April 1997 to October 2013. Patients were eligible for
the study if they met the criteria of ITP during their
pregnancy, or pregnancy with a previous history of chronic
ITP. It is difficult to differentiate between gestational
thrombocytopenia and ITP for the first time during pregnancy. The latter diagnosis was confirmed only for those
who developed thrombocytopenia at early gestation and
had no history of thrombocytopenia due to other causes,
and their platelet counts did not return to normal more than
3 months after delivery.
The following information was extracted from the
medical records for each eligible patient: age at delivery,
age at diagnosis of ITP, minimum platelet count during
pregnancy, platelet count at delivery, treatments for ITP
before and during pregnancy, gestational age at delivery,
type of delivery (vaginal or cesarean section), and complications during delivery. Information collected for each
infant included platelet count at birth and at nadir, the
timing of nadir, birth weight, complications at birth and
treatment received. Complete blood count (CBC) was
examined principally at birth from umbilical cord blood
(on day 0), on days 2 and 45 (screening period for
inherited metabolic disorders), and in addition, in periods
of follow-up when newborns showed thrombocytopenia. If
thrombocytopenia (\100 9 109/L) was observed in
umbilical cord blood, it was confirmed using peripheral
blood on the same day. Neonatal platelet count was defined
as stabilized when a count over 150 9 109/L was observed
twice over more than a 1-week interval. In 3 of 19 vaginal
deliveries and 2 of 25 cesarean deliveries, CBC was
examined only once because the platelet count was normal
(more than 150 9 109/L) at birth. These 5 cases were
excluded from the analyses of nadir platelet count.

571

Statistical comparisons of parameters between two

groups were performed using Students t test. Differences
in the proportions of two groups were examined using
Fishers exact test. The association of platelet counts
between neonates and mothers, and the association of
platelet counts among siblings were examined using
Pearsons correlation coefficient. Significance was established at P \ 0.05.

Results
Maternal characteristics
During the 16-year study period, 30 women with ITP
delivered 44 children. Table 1 summarizes the maternal
and neonatal characteristics. Laboratory and therapeutic
findings on motherneonate pairs of 44 pregnancies are
summarized in Table 2. There was no delivery of twins.
The mean age of the women at delivery was
30.7 4.4 years. Twenty-one women (70 %) were diagnosed with ITP before pregnancy, and the remaining 9
(30 %) were identified during pregnancy. Three (10 %) of
30 women had undergone splenectomy before pregnancy.
Of 44 pregnancies, 25 (57 %) and 19 (43 %) were
cesarean sections and vaginal deliveries, respectively.
Cesarean section was performed for almost all cases based
on obstetric indications. Of the 25 cesarean deliveries, 19
and 6 were planned and emergency cesarean sections,
respectively. Indications for planned cesarean section
included repeated sections (n = 10), unstable maternal
thrombocytopenia during the third trimester (n = 3),
cephalopelvic disproportions, breech presentation (2 each),
maternal renal failure, and intrauterine growth retardation
(one each). Indications for emergency cesarean section
included prolonged labor with failure of fetal descent, fetal
distress (2 each), placental abruption, and premature rupture of membrane (one each). The mean platelet counts at
delivery and at nadir were 105.8 40.3 9 109/L and
71.3 35.0 9 109/L, respectively. Only one woman had a
platelet count lower than 50 9 109/L at delivery. There
was one maternal death, in which the patient was complicated by uterine cervical laceration with massive bleeding
of over 10 L, and died of multiple organ failure and disseminated intravascular coagulation (case 26). In this case,
the platelet count at delivery was 109 9 109/L, and the
thrombocytopenia did not necessarily contribute to the fatal
outcome.
Neonatal characteristics (Tables 1, 2)
Neonatal thrombocytopenia (\100 9 109/L) at birth was
observed in 7 neonates (16 %), and in 4 (9 %) it was severe

123

572

K. Kawaguchi et al.

Table 1 Maternal and neonatal characteristics in a total of 44

pregnancies
Characteristics

Mean SD (range)
or number (%)

Maternal characteristics
Maternal age at delivery (years) (n = 44)

30.7 4.4 (2141)

Diagnosis of ITP before pregnancy (n = 30)

21 (70 %)

Diagnosis of ITP during pregnancy (n = 30)

9 (30 %)

Number of pregnancies per mother (n = 30)

1 time

19 (63 %)

2 times

8 (27 %)

3 times

3 (10 %)

Platelet count (n = 44)

At nadir (9109/L)

71.3 35.0 (13161)

At delivery (9 109/L)

105.8 40.3
(38248)

Treatment for maternal ITP

Before pregnancy (n = 30)
Splenectomy

3 (10 %)

PSL

2 (7 %)

During pregnancy (n = 44)

PSL or mPSL

9 (20 %)

IVIG

1 (2 %)

PSL ? IVIG ? platelet transfusion

1 (2 %)

Mode of delivery (n = 44)

Cesarean section

25 (57 %)

Vaginal

19 (43 %)

(less than 50 9 109/L). Administration of high-dose

c-globulin was performed in all 7 babies with thrombocytopenia. Administration of steroids was performed in 3
babies with severe thrombocytopenia (cases 15, 29a, and
29b). Platelet transfusion was performed in one case with
prolonged severe thrombocytopenia of \10 9 109/L (case
15). No cases were complicated by intracranial hemorrhage, and there was no neonatal mortality. Petechiae were
found in 4 cases (9 %). Neonatal asphyxia was observed in
one case (2 %). In this study, CBC was examined principally at birth from umbilical cord blood (on day 0), on days
2 and 45, and in addition, in periods of follow-up when
newborns showed thrombocytopenia. In 39 cases, the
timing of the nadir of platelet counts could be determined.
The mean platelet count at nadir was 157.7 88.1 9 109/
L (range 4351 9 109/L). The timing of the nadir of
platelet counts widely varied, ranging from days 0 to 47,
and the median time was at 2 days after birth. Most
patients with mild thrombocytopenia spontaneously
recovered by day 5, but thrombocytopenia in 3 patients,
who had a nadir of \30 9 109/L was not stabilized until
days 3185 (cases 5, 15, and 29a). One infant required 4
courses of intravenous immunoglobulin in combination
with steroids and platelet transfusion until stabilization for
more than 2 months (case 15) [8].
Prediction of neonatal thrombocytopenia

Neonatal characteristics (n = 44, unless otherwise mentioned)

Gestational age at birth (weeks)

38.2 1.6 (3341)

Premature delivery (\37 weeks of gestation)

3 (7 %)

Birth weight (g)

2938 439
(16683706)

Low-birth-weight infant (\2500 g)

6 (14 %)

Neonatal platelet count at birth (9 109/L)

192.5 85.5 (4399)

C150 9 109/L

36 (82 %)

100149 9 109/L

1 (2 %)

5099 9 109/L

3 (7 %)

2049 9 109/L

2 (5 %)

\20 9 109/L

2 (5 %)

Neonatal platelet count at nadir (9 109/L)

(n = 39)

157.7 88.1 (4351)

C150 9 109/L

21 (54 %)

100149 9 109/L

8 (20 %)

5099 9 109/L

3 (8 %)

2049 9 109/L

4 (10 %)

\20 9 109/L

3 (8 %)

Treatment for neonatal thrombocytopenia

IVIG

4 (9 %)

PSL or mPSL ? IVIG

2 (4 %)

PSL ? mPSL ? IVIG ? platelet

transfusion

1 (2 %)

ITP immune thrombocytopenia, IVIG intravenous immunoglobulin, PSL

prednisolone, mPSL methylprednisolone

123

Neonatal platelet counts at birth were compared with

maternal platelet counts at nadir during pregnancy or at
delivery. A correlation was not found between neonatal
platelet counts at birth and maternal platelet counts at nadir
during pregnancy or those at delivery. We assessed the
effect of maternal treatment for ITP during pregnancy.
Mean neonatal platelet counts with any medical treatment
for ITP during pregnancy were 208.5 79.1 9 109/L at
birth and 174.7 81.5 9 109/L at nadir after birth, while
those without treatment were 187.2 88.0 9 109/L at
birth and 163.8 91.5 9 109/L at nadir. There was no
significant difference between neonatal platelet counts with
and without maternal treatment (P = 0.48 at birth,
P = 0.73 at nadir by Students t test). In addition, there
was no association between a maternal history of splenectomy and neonatal platelet counts at birth. The platelet
counts of neonates at birth born to mothers who had first
been diagnosed with ITP during pregnancy were significantly higher than those born to mothers diagnosed with
ITP before pregnancy (244.7 103.5 9 109/L vs.
179.1 76.3 9 109/L, P = 0.039).
We compared platelet counts between the first and
second siblings. There was a strong positive correlation
between individual neonatal platelet counts both at birth

Neonatal thrombocytopenia in pregnant ITP women

Table 2 Laboratory and
therapeutic findings on mother
neonate pairs of 44 pregnancies
with ITP

Case

First pregnancy

Second pregnancy

Third pregnancy

Birth date is defined as day 0

Maternal
platelet count
(9 109/L)

Treatment

At
nadir

Before
pregnancy

During
pregnancy

Splenectomy

At
delivery

Type of
delivery

Neonatal
platelet count
(9 109/L)
At
birth

At
nadir

Timing
of nadird

#1a

13

81

PSL, IVIG,
platelet
transfusion

plCS

225

225

#1b

48

111

IVIG

plCS

256

251

#2

88

121

plCS

190

190

#3b

161

248

plCS

149

149

#4b

154

172

plCS

230

230

#5
#6

109
63

145
63

plCS
plCS

88
173

23
173

28
0

#7a

64

98

plCS

251

251

#7b

67

102

plCS

231

231

#7c

83

124

plCS

262

262

#8a

59

80

mPSL

plCS

52

23

#8b

85

88

plCS

42

38

#9

118

137

plCS

216

216

#10

116

196

plCS

57

38

#11

56

67

plCS

281

NA

NA

#12

64

81

plCS

292

232

#13b

90

92

plCS

183

181

#13c

80

87

plCS

217

217

#14

52

79

plCS

157

NA

NA

#15

64

84

emCS

#2a
#3a

47
15

66
70

PSL

emCS
emCS

#16

ITP immune thrombocytopenia,

IVIG intravenous
immunoglobulin, mPSL
methylprednisolone, NA not
assessed, PSL prednisolone,
plCS planned cesarean section,
emCS emergency cesarean
section

573

220
310

220
310

0
0

41

80

PSL

PSL

emCS

207

119

#13

59

71

PSL, mPSL

emCS

224

224

#14b

38

38

emCS

207

138

#4a

65

88

PSL

PSL

Vaginal

158

96

#17

39

51

PSL

Vaginal

180

142

#18a

52

121

Vaginal

191

103

#18b

33

127

Vaginal

163

83

#18

73

102

Vaginal

216

101

#19

52

123

PSL

Vaginal

161

130

#20

135

153

Vaginal

217

217

#21a

110

110

Vaginal

240

NA

NA

#21b

110

146

Vaginal

182

182

#22

95

107

Vaginal

163

117

#23

56

82

Vaginal

166

73

#24
#25

110
88

175
110

Vaginal
Vaginal

202
199

187
NA

2
NA

#26

33

109

PSL, mPSL

Vaginal

268

213

#27

42

77

Vaginal

399

351

#28

75

76

Vaginal

301

NA

NA

#29a

42

141

Vaginal

29

13

47

#29b

80

95

Vaginal

#30

13

83

PSL

Vaginal

298

188

123

574

K. Kawaguchi et al.

Fig. 1 Associations between

platelet counts of the first
sibling and those of the second
sibling both at birth and at nadir
after birth showing significant
positive correlations with
Pearsons correlation
coefficients of 0.706
(P = 0.015) at birth and 0.703
(P = 0.035) at nadir after birth

At birth
350

300

300

250
200
150
100
50

250
200
150
100
50

0
First sibling

Second sibling Third sibling

and at nadir after birth in the first and second siblings, with
Pearsons correlation coefficients of 0.706 (P = 0.015) at
birth and 0.703 (P = 0.035) at nadir (Fig. 1). This study
included 3 sets of 3 siblings. Despite the small number of
cases, platelet counts of the third siblings were well correlated with those in their first and second siblings both at
birth and at nadir (Fig. 2).
We investigated a newly proposed hypothesis of a significant correlation between the mode of delivery and the
timing of the nadir of neonatal platelet counts; the nadir of
platelet counts in neonates born by cesarean section tended
to occur just at birth and that in vaginally born neonates
was likely to develop several days after birth [7]. In vaginal
deliveries, 13 of 16 cases (81 %) showed a decline of
platelet counts after birth. Nadir was observed between
days 0 and 47. On the other hand, in deliveries by cesarean
section, 13 of 23 cases (57 %) showed the lowest platelet
counts at birth. A decline of neonatal platelet count after
birth showed a significant association with vaginal delivery
(P = 0.024).

Discussion
Many studies have revealed that the occurrence of severe
thrombocytopenia in a previous neonate is the most useful

123

At nadir

350

Platelet count ( 109/L)

Platelet count ( 109/L)

Fig. 2 Associations between

platelet counts of siblings,
including the third sibling both
at birth and at nadir after birth.
Symbols are connected with a
straight line between siblings

First sibling

Second sibling Third sibling

parameter for predicting the occurrence of neonatal

thrombocytopenia [3, 4, 7, 911]. Christiaens et al. [9]
demonstrated the platelet count correlations between siblings, with correlation coefficients of 0.73 at birth and 0.76
at nadir using Fishers Z transformation. We also found
strong positive correlations between individual neonatal
platelet counts both at birth and at nadir after birth in the
first and second siblings (Fig. 1). There are few reports
referring to the third sibling [3, 7, 11]. Our study revealed
that the platelet count of third siblings is also well correlated to the platelet count of both the first and the second
siblings (Fig. 2).
In this survey, ITP identified for the first time during
pregnancy was confirmed only for those who developed
thrombocytopenia at early gestation and had no history of
thrombocytopenia due to other causes, and their platelet
counts did not return to normal more than 3 months after
delivery. The platelet counts of neonates at birth born to
mothers who had been diagnosed with ITP for the first time
during pregnancy were significantly higher than those born
to mothers diagnosed with ITP before pregnancy. Samuels
et al. [12] have also shown that only women with a history
of pregestational ITP are likely to have fetuses with severe
thrombocytopenia. However, this finding has not been
replicated in several studies [7, 13]. There are few reports
about the effect of the absence of a history of ITP before

Neonatal thrombocytopenia in pregnant ITP women

pregnancy on neonatal thrombocytopenia. Further study

using strict criteria for a diagnosis of ITP during pregnancy
is needed.
The severity of neonatal thrombocytopenia is often most
marked a few days after birth. Recently, Koyama et al. [7]
proposed the hypothesis of a correlation between the pattern of neonatal thrombocytopenia and the mode of delivery. However, in their study [7], the proportion of postnatal
decline of platelet counts did not significantly differ
between vaginal (10/13) and cesarean section (4/7) deliveries. In contrast, our data showed that a decline of neonatal platelet count after birth was significantly associated
with vaginal delivery when compared with cesarean section (P = 0.024), confirming this hypothesis for the first
time. Koyama et al. [7] speculate that uterine contraction
facilitates a trans-placental transfer of maternal IgG antiplatelet autoantibodies. Maternal IgG transport to the fetus
may contribute to the decline of neonatal platelet count
after vaginal birth. A recent study showed that 2 of 20
neonates, who developed severe thrombocytopenia of
\50 9 109/L had a normal platelet count at birth [3]. In
such cases, asymptomatic intracranial hemorrhage may
occur [46]. Therefore, it is important to estimate the risk
of postnatal thrombocytopenia. Thus, in the case of vaginal
delivery, careful attention should be paid to the decline of
platelet counts after birth, as well as thrombocytopenia at
birth.
In this study, 8 neonates (18 %) had platelet counts of
\150 9 109/L, 7 neonates (16 %) had platelet counts of
\100 9 109/L, and 4 neonates (9 %) had severe neonatal
thrombocytopenia (\50 9 109/L) at birth (Table 1). These
findings are similar to those in prior studies [4, 1418].
There were no neonatal deaths and none of the infants had
serious hemorrhagic complications. However, in three of
our cases, thrombocytopenia was not stabilized until days
3185. Therefore, careful observation should be undertaken until the platelet counts normalize. Indeed, genetic
abnormality of glycoprotein IIb/IIIa was recently identified
as a cause of sustained thrombocytopenia over 3 months
after birth in our hospital [19]. In this case, the mother had
been diagnosed with ITP before pregnancy. Owing to the
possibility of congenital abnormalities of platelet production, the etiology of prolonged neonatal thrombocytopenia
should be investigated.
Although the platelet count often drops in pregnant ITP
patients, serious morbidity or mortality is uncommon for
the mothers [14]. According to the guidelines of therapy for
pregnant patients [15, 20, 21], medical intervention should
be considered whenever the platelet counts show
\2030 9 109/L or the patients have symptoms. Because
neonatal mortality is estimated to be low [12, 16, 17], and
there is no evidence that cesarean section is safer for
thrombocytopenic neonates than uncomplicated vaginal

575

delivery, the mode of delivery is currently based almost

entirely on obstetric considerations [6, 15, 20, 21]. In this
study, cesarean section was performed for almost all cases
based on obstetric indications. There was one maternal
death in our cases. The main cause of this was uterine
cervical laceration with massive bleeding rather than
maternal ITP. Our data also support the rarity of maternal
morbidity or mortality in pregnant ITP patients.
Several limitations were identified in this study.
Although the fact that this study was performed at a single
center ensures consistency, the number of cases was relatively small. Because of this, the effects of several
parameters, such as splenectomy on neonatal thrombocytopenia might not have been fully examined.
In conclusion, pregnant patients with ITP have generally
good maternal and perinatal outcomes. There is very strong
correlation between the platelet counts between siblings.
The pattern of platelet count in an older sibling is a good
predictor of that in the next sibling. In this study, diagnosis
of ITP before pregnancy was associated with the development of neonatal thrombocytopenia, when compared
with the diagnosis during pregnancy. Platelet counts of
neonates born vaginally are more likely to decline after
birth than those delivered by cesarean section. Another
cohort, including more patients should be studied to evaluate these values.
Acknowledgment This work was supported by a research grant
from the Japanese Ministry of Health, Labour and Welfare.
Conflict of interest
of interest.

The authors declare that they have no conflict

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