Ans. is b i.e. To take Warfarin after delivery Friends venous thromboembolism in pregnancy, is one of those topics which we donot study in detail during undergraduation. So, I am giving in brief, all the impoant points you need to remember : Venous thromboembolism in pregnnacy : Venous thromboembolism is the leading cause of maternal deaths in developed countries. Pregnancy increases the risk of thromboembolism 6 times as all components of virchow's triad are increased.deg A. Deep vein thrombosis : Left sided DVT is more common than Right sided DVT. Clinical features : swelling / redness / pain and calf muscle tenderness and oedema. Investigations - Recommended method during pregnancy : Doppler ultrasound - Gold standard (in conditions other than pregnancy) : venography Mangement : Therapeutic The treatment should be staed on clinical grounds if confirmatory tests are not available. Drug of choice - Heparin (as it doesnot cross the placenta) Initially intravenous Heparin is given with the aim to prolong APTT (activated paial thromboplastic time) by 1.5 to 2 times the control followed by subcutaneous Heparin. Monitoring is done by APTT and platelet count (as Heparin causes Thrombocytopenia). Oral anticoagulants like Warfarin cross the placenta and cause teratogenesis therefore should be avoided in pregnancy. Treatment is continued for 6 weeks following which prophylactic subcutaneous heparin is given throughout pregnancy. Heparin is stopped just before delivery. Regional anaesthesia should be avoided at the time of delivery in patients on heparin due to the risk of hematoma formation. Heparin is restaed about 6 - 8 hours after delivery as the puerperium is the time of greatest risk for VTE. Warfarin is commenced simultaneously and thereafter monitoring is done by prothrombin time (PT). Once the prothrombin time INR is between 2 and 3, heparin can be discontinued. Usually warfarin is continued for 6 to 18 weeks and is safe for breast feeding mothers. Thromboprophylaxis : Thromboprophylaxis is considered for women who are at increased risk of thromboembolism (TE). Risk category Risk factors High risk Recurrent TE Previous TE with thrombophilia Previous TE with family history TE in current pregnancy Low risk One episode of previous TE without thrombophiiia or family history Thrombophilia without previous thrombosis Additional risk Cesarean section, obesity, grand multiparity, age above 35, pre-eclampsia, prolonged immobilization etc. High risk patients need antepaum heparin, intrapaum heparin and postpaum prophylaxis for 6 weeks. Low risk patient require intrapaum and postpaum low dose prophylaxis for 6 weeks. Well, now that you have a detailed knowledge of thromboembolism, lets have a look at the question. It says : a female with previous history of embolism becomes pregnant,what medical management should be given to her? Option 'a. i.e. Compulsory prophylaxis with warfarin at 10 weeks. It is absolutely wrong as warfarin is not given during pregnancy. Option 'b Le to take warfarin after delivery - According to William obs. 22/e, p 1077 table 47-3, 23/e, p 1028 - table 47.6 In case of prior VTE associated with a non recurring risk factor and no known thrombophilia? During pregnancy : Only surveillance is required as per American college of chest physicians. Prophylaxis with low molecular weight heparin is required as per American college of obs & gynaecology (which also explains option 'd is paly correct). Postpaum : warfarin is given for 6 weeks. So, option 'b' is absolutely correct i.e. warfarin should be given in the post paum period for six weeks.