VTE in Pregnancy

Option List:
A. Thrombophilia screen 
B. Stop heparin
C. Offer termination of pregnancy 
D. Low molecular weight heparin for 7 days post-partum
E. Low molecular weight heparin for now and 10 days post-partum 
F. Screen for antiphospholipid antibodies
G. Close observation for additional risk factors 
H. Close observation for additional risk factors + low molecular weight heparin for 7 days post-partum
I. Close observation for additional risk factors + low molecular weight heparin for 6 weeks post-partum 
J. Graduated elastic compression stockings
K. Low molecular weight heparin 10 days post-partum 
L. Low molecular weight heparin antenatally + 7 days post-partum 
M. Warfarin from 12 weeks
For each scenario described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all. 

1. A 33 year old woman with BMI =32, attends the antenatal clinic at 32 weeks gestation. She is known to be smoker and has uncontrolled high blood pressure. She is being admitted. Regarding her thromboprophylaxis, you are required to give your opinion?

2. A 30 year old woman para 3, only one living, has BMI=30 and undergoes c- section for breech. Blood loss of 1100 ml. advice for thromboprophylaxis?

Option List:
A. Stop LMWH and Commence intravenous prophylactic unfractionated heparin  
B. Change to theraputic intravenous unfractionated heparin  
C. Change to heparinoid (danaparaoid sodium)
D. Commence to UFH re-bolus of 40 units and mantainence dose to be maintained at rate of 20 units/kg/hr
E. Commence low molecular weight heparin
F. Commence dalteparin   
G. Monitor anti-Xa levels   
H. Commence to UFH re-bolus of 40 units and mantainence dose to be maintained at rate of 18 units/kg/hr
I. Remove catheter 8 hours after giving the last dose of heparin 
J. Remove catheter 12 hours after giving the last dose of heparin
K. Remove catheter 24 hours after giving the last dose of heparin 
L. Withhold heparin for 12 hours before giving spinal anaesthesia 
M. Withhold heparin for 24 hours before giving spinal anaesthesia 
N. Withhold heparin for 6  hours before giving epidural anaesthesia 
O. Withhold heparin for 12 hours before giving epidural anaesthesia 
P. Check APS and Commence low molecular weight heparin
For each scenario described below, choose the single most appropriate antenatal management from the above list of options. Each option may be used once, more than once, or not at all.

3. A 43-year-old woman, para 3, presents to the EPAU at 32 weeks of gestation with severe chest pain. Investigations are done diagnosed with pulmonary embolism. She is started on bolus dose of unfractioned heparin and APTT monitoring done. She is receiving UFH at rate of 18units/kg/hour as mantainence dose. Her APTT level after 6hours 1.2-1.5. what is the further management in this case?

4. A 40-year-old woman, para 2, presents to the obstetric day assessment unit at 28 weeks of gestation with reduced fetal movements (normal cardiotocograph [CTG]. Her notes indicate that she had DVT at 20 weeks of gestation during her current pregnancy and is on 80 mg LMWH twice daily. Her booking blood results were normal. However, her recent blood test reveals a platelet count of 60 x 109/L.