Prenatal treatment of severe fetomaternal alloimmune thrombocytopenia

Prenatal treatment of fetomaternal alloimmune thrombocytopenia (FMAIT) in previously affected families is of great clinical importance. We report here our experience in the prenatal treatment of 15 severely thrombocytopenic fetuses. Thrombocytopenia was in 13 cases due to immunization to HPA-1a, in one case to HPA-5b, and in one case to HPA-6b. Thirteen fetuses received altogether 34 intrauterine platelet transfusions, seven of them in combination with maternal-administered intravenous gammaglobulin (IVIG) and two in combination with IVIG and prednisone. Six of the 13 fetuses had only one transfusion just prior to delivery. In our experience, IVIG seemed to be less effective than reported; only two fetuses of eight treated initially with weekly maternal-administered IVIG responded, and these were the mildest affected cases in the study. On the other hand, owing to the short survival time, weekly platelet transfusions could only partly maintain a safe platelet count in the four fetuses treated with serial intrauterine platelet transfusions. The number of transfusions needed to be limited because of the high cumulative risk associated with repeated procedures. Three of 34 intrauterine platelet transfusions were associated with near-loss of three different fetuses due to prolonged fetal bradycardia after the transfusion. In conclusion, overall neonatal outcome was good, with no mortality; among the study group there was no intracranial haemorrhage (evaluated by postnatal ultrasonography) compared with one case in their untreated siblings. However, the problem of the optimal treatment of FMAIT remains to be solved. For the moment, the treatment of choice is a combination of maternal IVIG and platelet transfusions in severely affected cases. Serial fetal blood samplings (FBS) are needed in order to monitor the fetus with sufficient care.