The process of megakaryocyte generation in the bone marrow and subsequent differentiation leading to platelet production is little understood. Known as megakaryo-poiesis, it involves a number of unique biological features, including an increase in the nuclear DNA content (endoreplication) and partitioning of cytoplasm and membranes into platelets. Abnormalities of thrombosis and hemostasis can occur as a result of alterations in the number of platelets generated and maintained in the circulation or through aberrations in the functional behavior of the platelet itself. Although some of these abnormalities are most likely indirect in their etiology (for example, immune thrombocytopenias), many are directly linked to an inherited or acquired genetic effect operating at some point during megakaryopoiesis. Inherited mutations affecting megakaryocytes and platelets are relatively rare, although there is increasing interest in the association between genetic polymorphisms in platelet proteins that have no profound phenotype but may be linked to an increased thrombotic risk. Specific genetic changes leading to deregulation of proliferation and/or differentiation at some point during megakaryopoiesis are also implicated in several acquired conditions, including leukemias, preleukemic states, and dysplasias.