Question of the Week # 431

431) A 25 year old G2P1L1 at 32 weeks gestation presents with right leg swelling and pain progressively increasing over the past two days. Her previous pregnancy was uneventful except for uncomplicated C-section and she has a 2 year old healthy male child. Past medical history is negative for any significant health issues. There is no family history of clots or cancer.  Physical examination is consistent with 32 week gestation. Right lower extremity is swollen about 3cm more in calf-circumference when compared to the left. There is tenderness in right calf. A Doppler ultrasound reveals thrombosis in superficial femoral vein. Factor V leiden mutation, Lupus anticoagulant, anti-cardioloipin antibodies, prothrombin gene mutation are negative. Anti-thombin III is within normal limits. She is scheduled for C-section in 6 weeks. Which of the following is the most appropriate Statement concerning her management?

A)     Since this is not deep vein thrombosis, start her on LMWH ( Low Molecular Weight Heparin) at prophylactic doses

B)      Start warfarin and continue for total 6 months

C)      Start LMWH, discontinue 2 days prior to C-section, start unfractionated heparin followed by discontinuation 4 hrs prior to C-section and then start LMWH 12 hrs after surgery followed by Warfarin for 6 months.

D)     Start LMWH, discontinue 2 days prior to C-section, start unfractionated heparin followed by discontinuation 4 hrs prior to C-section and then start LMWH 12 hrs after surgery followed by Warfarin for 6 weeks post-partum

E)      Start LMWH now through delivery followed by warfarin for 6 months post-partum.

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