A 32-year-old primi gravida presents with DVT. There is history of 2 episodes of DVT in the past and was diagnosed to have antiphospoholipid antibody. Next step in management is:
Ans: B (Aspirin and heparin) Ref: Maternal-Fetal Medicine edited by Mary E. D'Alton. pg: 10-14 and DC Dutta's Textbook of Obstetrics. 7th edition, pg: 343 Explanation: "ACOG 2005 guidelines recommends low dos aspirin t5-80 mg orally per day along with unfractionated heparin 5000 unit subcutaneously twice daily. The therapy is begun with diagnosis of pregnancy and continued till delivery." Ref: The American Congress of Obstetricians and Gynecologists (ACOG) Guidelines 'Therapy for patients with positive antiphospholipid antibodies and with thrombophilias is low dose aspirin (50 mg a day). When there is history of previous thrombotic event heparin (5000IU, sc twice daily) is the drug of choice. Low molecular weight heparin in also effective."Ref: Dutta's Obstetries ANTI PHOSPHOLIPID ANTIBODY SYNDROME Autoimmune disorder characterized by circulating antibodies against membrane phospholipid. Antiphospholipid Antibodies o Abs against Cardioitpin - aCL. o Abs against beta 2 glycoprotein 1 - B2GP1. o Lupus anticoagulant - LAC. o Abs against phospholipids and cholesterol. Clinical Features o Recurrent pregnancy loss, o Coombs positive hemolytic anemia and thrombocytopenia. o Pre-eclampsia, o IUGR. o Recurrent Thrombosis (Superficial and deep vein thrombosis; Cerebral venous thrombosis; Retinal vein thrombosis). o Raised intracranial tension, o Livedo retiuclaris. o Libman sacks endocarditis. o Premature atherosclerosis. Diagnosis: o Lupus anticoagulant is an unidentified antibody causing increase of phospholipid dependent coagulation tests { aPTT, Russel viper venom test) by binding to prothrombin activator complex. o In vivo, LAC causes thrombosis. o Specific antiphospholipid antibodies measured by ELISA, o It is associated with anticoagulatnt activity in-vitro and procoagulant activity in-vivo. Differential Diagnosis o SLE. o 10 - 30% women with SLE have APLA antibodies, o 60 - 90% women with APS have ANA antibodies. Complications: * Maternal o Recurrent pregnancy loss o Thrombosis o Thrombocytopenia o PROM o Preeclampsia Drug side-effects: (Aspirin, Heparin and Prednisolone) o Hemorrhage o Osteoporosis o Fractures o Cataracts o Infection o Adrenal suppression. Fetal o Prematurity o Placental abruption o IUGR o Stillbirth Treatment General Measures o Low dose aspirin (60-100 mg) + Prophylactic Heparin - Current treatment of choice. Alternative Options o Low dose Aspirin + Prednisolone (40 - 60 mg daily), o Heparin and Prednisolone should not be given together due to increased risk of osteoporosis, c Treatment should be initiated early in pregnancy and continued to delivery. o Regular fetal testing for growth. o Elective delivery at 39 - 40 weeks. o WARFARIN contraindicated in pregnancy.
Aspirin alone
Aspirin and heparin
LMWH
Warfarin for 6 months