Fetal and neonatal alloimmune thrombocytopenia (FNAIT): From reactive transfusion to proactive prevention.

Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a major cause of severe thrombocytopenia, intracranial hemorrhage, and long-term neurological impairment in otherwise healthy neonates. Current management strategies are largely reactive, relying on maternal intravenous immunoglobulin (IVIG), intrauterine platelet transfusions, and postnatal supportive care. Although these interventions can be lifesaving, they are associated with considerable risks, inconsistent efficacy, and significant maternal and healthcare burdens, underscoring the need for a paradigm shift toward prevention. Recent advances in screening, including human platelet antigen genotyping, maternal antibody testing, and the development of non-invasive prenatal testing (NIPT), offer promising opportunities for earlier and safer identification of at-risk pregnancies. At the same time, therapeutic innovation is reshaping the field: monoclonal antibodies targeting Fcγ receptors or FcRn-mediated pathways, strategies to optimize IVIG dosing through pharmacokinetic refinement and biomarker guidance, and experimental tolerogenic approaches collectively illustrate the transition from reactive to proactive care. Looking ahead, the integration of point-of-care diagnostics, artificial intelligence-driven risk prediction, and randomized trials of monoclonal antibody-based prophylaxis may enable population-wide prevention and improve maternal-neonatal outcomes. Together, these developments signal a fundamental transformation in the management of FNAIT, from responding to clinical crises after fetal injury has occurred to preventing disease before it manifests.