Around 1 in 10 pregnant women will develop thrombocytopenia during an otherwise unremarkable pregnancy. While the most frequent cause is gestational thrombocytopenia, a benign clinical entity which typically induces a mild platelet fall in late pregnancy, a number of important pregnancy-specific causes must be excluded, particularly pre-eclampsia and its severe form hemolysis with elevated liver enzymes and low platelets (HELLP). For women who do not have an identifiable pregnancy-related cause of thrombocytopenia, an underlying medical condition should be considered. The most common of these is immune thrombocytopenia (ITP). Management of ITP in pregnancy can prove particularly challenging. First-line treatment options are limited to intravenous immunoglobulin or corticosteroids; with a higher rate of adverse effects and a lower likelihood of response than in the non-pregnant population. The safety data for commonly employed second-line treatment options is scarce, and there is no international consensus on the optimal second-line treatment in pregnancy. Management of ITP is further complicated by the desire to attain higher platelet thresholds to facilitate the safe administration of neuraxial anesthesia and minimize the risk of postpartum hemorrhage. Finally, the risk of neonatal thrombocytopenia must be considered and appropriate precautions taken at the time of delivery.