Correspondence
Fetal and Maternal Thrombocytopenia
N Engl J Med 1994; 330:940-941March 31, 1994
- Article
To the Editor:
The study of Burrows and Kelton (Nov. 11 issue)1 focuses on moderate neonatal thrombocytopenia (platelet count, 20,000 to 50,000 per cubic millimeter) and severe neonatal thrombocytopenia (<20,000 per cubic millimeter) at the time of delivery and on the relation of neonatal thrombocytopenia to maternal thrombocytopenia (<150,000 per cubic millimeter) and various maternal diseases. This is of particular interest to obstetricians, who are concerned with prenatal management and the mode of delivery2,3.
The authors state that many of the women with idiopathic thrombocytopenic purpura had been treated with corticosteroids or intravenous immune globulin, but they give no further information about this treatment. It is therefore not possible to draw any conclusions about the risk of neonatal thrombocytopenia at the time of delivery. This treatment might also explain the authors' finding of an absence of mortality and morbidity among the neonates born to mothers with idiopathic thrombocytopenic purpura, in contrast to the findings of other investigators3,4. Another explanation may be the lack of follow-up data on the neonates in the study. As mentioned in the Discussion, the platelet count reaches its nadir several days after delivery3. Therefore, it would be of interest to know how many neonates subsequently had worse thrombocytopenia. The same problems also apply to neonates with alloimmune thrombocytopenia. As stated in the Discussion, aggressive intravenous immune globulin therapy has been used routinely for alloimmune thrombocytopenia, but no further information about this treatment is given. This treatment could also account for the good outcome in these neonates3,5.
We conclude that the data presented by Burrows and Kelton do not provide obstetricians and neonatologists with a reliable estimate of mortality and morbidity among neonates with potential or manifest immunologic thrombocytopenia.
5 ReferencesJurgen Fischer, M.D.
Johannes Dietl, M.D.
Rangmar Goelz, M.D.
University of Tubingen, 72076 Tubingen, Germany1
Burrows RF ,Kelton JG . Fetal thrombocytopenia and its relation to maternal thrombocytopenia. N Engl J Med 1993;329:1463-1466
Full Text | Web of Science | Medline2
Marzusch K ,Fischer J ,Dietl J ,Wiest E ,Volklein K ,Schnaidt M . Difficulties in the antenatal assessment of neonatal alloimmune thrombocytopenia. Acta Obstet Gynecol Scand 1993;72:583-585
CrossRef | Web of Science | Medline3
Bussel J, Kaplan C, McFarland J, Working Party on Neonatal Immune Thrombocytopenia of the Neonatal Hemostasis Subcommittee of the Scientific and Standardization Committee of the ISTH
Web of Science | Medline4
Samuels P ,Bussel JB ,Braitman LE , et al. Estimation of the risk of thrombocytopenia in the offspring of pregnant women with presumed immune thrombocytopenic purpura. N Engl J Med 1990;323:229-235
Full Text | Web of Science | Medline5
Lynch L ,Bussel JB ,McFarland JG ,Chitkara U ,Berkowitz RL . Antenatal treatment of alloimmune thrombocytopenia. Obstet Gynecol 1992;80:67-71
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Clinical impressions of the risk of idiopathic thrombocytopenic purpura among infants and mothers during pregnancy have changed dramatically during the past decade. Our experience1 suggested that severe adverse outcomes were rare, but recognizing that personal experience was just that, we recently reviewed the relevant literature of the past decade2,3. After analyzing the information according to the likelihood of reliability, with emphasis on larger studies in which neonatal platelet counts were made in blood obtained by cordocentesis or by scalp or cord sampling, we have several observations.
First, the platelet count continues to fall for several days after delivery4. Severe thrombocytopenia three to five days after delivery may require treatment with intravenous immune globulin, but it has little effect on the optimal mode of delivery. Second, most descriptions of adverse outcomes in these babies have come from small series of cases; although these reports alert physicians to the possibility of such events, they provide no information about their frequency2. In larger series, severe thrombocytopenia (platelet count, <20,000 per cubic millimeter) was uncommon, occurring in only 4 percent. Minor bleeding was similarly uncommon, occurring in 3 percent. None of the infants had intracranial hemorrhage or died.
Given the very low risk of severe thrombocytopenia in an infant whose mother has idiopathic thrombocytopenic purpura, we are unaware of any intervention that has been proved effective in the fetus. We do not, therefore, recommend any intervention in the mother to raise the platelet count in her infant. Our use of corticosteroids and intravenous immune globulin is directed at raising the platelet count of the mother to ensure safe delivery.
The situation of platelet alloimmunization during pregnancy is quite different. Specifically, alloimmunization against platelet antigens, not idiopathic thrombocytopenic purpura in the mother, is the cause of thrombocytopenia most often associated with serious morbidity in the fetus.
4 ReferencesRobert F. Burrows, M.D.
John G. Kelton, M.D.
McMaster University Medical Centre, Hamilton, ON L8N 3Z5, Canada1
Burrows RF ,Kelton JG . Low fetal risks in pregnancies associated with idiopathic thrombocytopenic purpura. Am J Obstet Gynecol 1990;163:1147-1150
Web of Science | Medline2
Burrows RF ,Kelton JG . Pregnancy in patients with idiopathic thrombocytopenic purpura: assessing the risks for the infant at delivery. Obstet Gynecol Surv 1993;48:781-788
CrossRef | Medline3
Burrows RF ,Kelton JG . Plateletes and pregnancy. Curr Obstet Med 1993;2:83-1064
Kelton JG . Management of the pregnant patient with idiopathic thrombocytopenic purpura. Ann Intern Med 1983;99:796-800
Web of Science | Medline
