A 26-year-old woman comes to the emergency complaining of 2 day of worsening right leg pain and swelling. She drove in a car 8 hours back from a hiking trip 2 days ago and then noticed some pain in the leg. At first she thought it was due to exeion, but it has worsened over the day. Her past medical history is related to difficulty getting pregnant, with two prior spontaneous aboions. Her physical examination is notable for normal vital signs, hea, and lung examination. Her right leg is swollen from the mid-thigh down and is tender. Doppler studies demonstrate a large deep venous thrombosis in the femoral and ileac veins extending into the pelvis. Laboratory studies show normal electrolytes, normal WBC and platelet counts, normal PT, and an aPTT 3x normal. Her pregnancy test is negative. Low-molecular-weight heparin therapy is initiated in the emergency depament. Subsequent therapy should include which of the following?
This patient has a typical presentation of antiphospholipid syndrome (APS) with a deep venous thrombosis, history of spontaneous aboion, and isolated elevated aPTT due to a lupus anticoagulant. Clinical Feature: Recurrent aerial and venous thromboembolism Recurrent Foetal loss Stroke, Seizures, Cerebral venous thrombosis Pulmonary aerial hypeension Livedo reticularis Myocardial infarction Gangrene in fingers After diagnosis of a thrombotic event due to APS, patients should receive warfarin for life with a goal international normalized ratio (INR) of 2.5- 3.5 alone or in combination with daily aspirin. Treatment: -During pregnancy, patients should receive heparin plus aspirin. -Patients who develop recurrent thrombosis while on effective anticoagulation may benefit from a 5-day infusion of IV g-globulin or 4 weeks of rituximab therapy. -Warfarin for 3 months with INR goal of 2.0-3.0 is recommended therapy for deep vein thrombosis (DVT) with a known reversible precipitating event. Warfarin for 6-12 months with an INR goal of 2.0-3.0 is recommended therapy for first episode of idiopathic DVT.
Rituximab 375 mg/m2 per week for 4 weeks
Warfarin with international normalized ratio (INR) goal of 2.0-3.0 for 3 months
Warfarin with INR goal of 2.0-3.0 for 12 months
Warfarin with INR goal of 2.5-3.5 for life
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