Namavar Jahromi et al. medical team from low PCs and its probable compli- cations during delivery. According to the clinical practice guidelines PC>20,000 during pregnancy and PC>50 000 near term and PC>80,000 for epidural anesthesia is targeted. However, counts may drop un- predictably and major bleeding has been reported rarely even with platelet counts that seem appropri- ate.25 Furthermore obstetric hemorrhage may happen due to placental abruption or previa, uterine atonia or uncontrollable genital lacerations even in a normal co- agulating condition. In this study, there were two cases that had platelet counts above the targeted values but developed bleeding complications. The first case de- veloped severe vaginal bleeding after normal delivery with PC=41,000/µL and the second case had severe hemorrhage in abdominal incision site with PC=70,000/µL. However, the final maternal and neo- natal outcome was good. We believe that hypercoagu- able state of pregnancy may somehow protect the mothers with ITP to develop fewer bleeding complica- tions compared to non-pregnant conditions. This study had several limitations. The first is its retrospective nature and absence of some data in the charts. The second is the possibility of misdiagnoses. References 1 2 3 4 5 434 Cunningham FG, Lenovo KJ, Bloom SL, Haut JC, Rouse DJ, Spong CY. Preterm birth. In: Williams Obstet- rics, 23rd Ed. New York: MC Graw- Hill; 2010; pp. 1079-1103. Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther MA; American Society of Hematolo- gy. The American Society of Hema- tology 2011 evidence-based prac- tice guideline for immune thrombo- cytopenia. Blood 2011;117: 4190- 207. [21325604] [doi.org/10. 1182/blood-2010-08-302984] Karim R, Sacher RA. Thrombocyto- penia in pregnancy. Curr Hematol Rep 2004;3:128-33. [14965489] Clinical practice guidelines August 2006 MOH/p/pak/115.06 (GU). Management of immune thrombocy- topenic purpura. Ministry of Health Malaysia, Academy of Medicine. George JN, Woolf SH, Raskob GE, Wasser JS, Aledort LM, Ballem PJ, Blanchette VS, Bussel JB, Cines DB, Kelton JG, Lichtin AE, McMillian R, Okerbloom JA, Regan DH, Warrier I. Idiopathic thrombocytopeaenic purpu- ra a practice guideline developed by explicit methods for the 6 7 8 American Society of Hematology. Blood 1996;88:3-40. [8704187] British Committee for Standards in Haematology General Haematology Task Force. Guidelines for the in- vestigation and management of idi- opathic thrombocytopenia in adults, Children and in pregnancy. Br J Haematol 2003;120:574-96. [12 588344] [doi.org/10.1046/j.1365- 2141.2003.04131.x] Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM, Bussel JB, Cines DB, Chong BH, Cooper N, Godeau B, Lechner K, Mazzucconi MG, McMillan R, Sanz MA, Imbach P, Blanchette V, Kühne T, Ruggeri M, George JN. Standardi- zation of terminology, definitions and outcome criteria in immune throm- bocytopenic purpura of adults and children: report from an international working group. Blood 2009;113:2386-93. [19005 182] [doi.org/10.1182/blood-2008-07- 162503] Gernsheimer T, McCare KR. Im- mune thrombocytopenic purpura in pregnancy. Curr Opin Hematol 2007;14:574-80. [17934366] [doi.org/ If thrombocytopenia was diagnosed for the first time during pregnancy, the case was included only if PC was less than 80,000/µL. There is the possibility that some real cases of mild ITP had not been included or some cases of gestational thrombocytopenia had been included in error. The third limitation is that we were not able to follow the neonatal PCs after delivery and other late neonatal outcomes were not studied. Maternal and neonatal outcomes of pregnancies complicated by ITP are generally good. All of the cases should be carefully managed by a team of hematologist, neonatologist, anesthesiologist and obstetrician for the best results. However, fetal well being evaluations are more strongly recommended for the chronic cases. Acknowledgement The present article was partly extracted from the thesis written by Zahra Shiravani and was financially supported by Shiraz University of Medical Sciences grant number 87-4268. Conflict of interest: None declared. 10.1097/MOH.0b013e3282bf6dc2] 9 ACOG Committee on Practice Bul- letins--Obstetrics. ACOG practice bulletin. Diagnosis and manage- ment of preeclampsia and eclamp- sia. Number 33, January 2002. Ob- stet Gyneco. 2002;99:159-67. [16175681] 10 Cunningham FG, Lenovo KJ, Bloom SL, Haut JC, Rouse DJ, Spong CY. Diabetes. In: Williams Obstetrics. New York: MC Graw-Hill, 2010: pp. 1104-1125. 11 ACOG Committee on Practice Bul- letins--Obstetrics. ACOG practice bulletin. Management of preterm la- bor. Number 43, May 2003. Int J Gynaecol Obstet 2003;82:127-35. [12834934] [doi.org/10.1016/S0020- 7292(03)00247-9] 12 Gill KK, Kelton JG. Management of idiopathic thrombocytopenic purpura in pregnancy. Semin Hematol 2000; 37:275-89. [10942222] 13 Webert KE, Mittal R, Sigouin C, Heddle NM, Kelton JG. A retrospec- tive 11-year analysis of obstetric pa- tients with idiopathic thrombocytope- nic purpura. Blood 2003; 102:4306-11. [12947011] [doi. WWW.ircmj.com Vol 14 July 2012