<prompt> 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:Aspirin aloneAspirin and heparinLMWHWarfarin for 6 months  <response>: Ans: B Aspirin and heparin Ref: Maternal-Fetal Medicine edited by Mary E. DAlton. pg: 10-14 and DC Duttas 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: Duttas 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. 