FRCPath Haem Part 1 EMQs-Haematosis 17 and 18

Theme: Obstetric APS

Options (Each option may be used once, more than once, or not at all)

A. Aspirin alone throughout pregnancy

B. Aspirin + prophylactic LMWH from positive pregnancy test

C. Therapeutic-dose LMWH throughout pregnancy

D. Switch from warfarin to LMWH immediately on confirmation of pregnancy

E. Continue warfarin until second trimester

F. Add hydroxychloroquine

G. Add prednisolone or IVIG

H. Refer to specialist obstetric–haematology centre

I. Continue LMWH for 6 weeks postpartum then reassess for long-term anticoagulation

J. Continue warfarin during breastfeeding

K. Arrange uterine artery Doppler at 20–24 weeks with serial growth scans

L. Long-term low-dose aspirin only after pregnancy

Scenario 1

A 30-year-old woman with a history of three consecutive miscarriages at 9–11 weeks gestation is found to have persistently positive lupus anticoagulant and anticardiolipin antibodies. She has no prior thrombosis.

She presents at 5 weeks of gestation following spontaneous conception. She is otherwise well. Answer:

Scenario 2

A 34-year-old woman with known thrombotic APS (previous unprovoked DVT) is anticoagulated with warfarin. She presents having just discovered she is 6 weeks pregnant.

Her INR is 2.6. She is concerned about fetal safety. Answer:

Scenario 3

A 28-year-old woman with known obstetric APS is currently 20 weeks pregnant and on aspirin and prophylactic LMWH. Her pregnancy has been uncomplicated so far.

You are reviewing her routine antenatal care plan. Answer:

Scenario 4

A 37-year-old woman with obstetric APS has been treated with aspirin and prophylactic LMWH in two previous pregnancies but had:

• One fetal loss at 24 weeks

• One pregnancy complicated by severe pre-eclampsia and IUGR

She is now pregnant again at 8 weeks. Answer:

Scenario 5

A 40-year-old woman with thrombotic APS (previous PE) is switched from warfarin to therapeutic LMWH at 6 weeks gestation.

She asks about duration of anticoagulation after delivery. Answer:

Scenario 6

A 32-year-old woman with obstetric APS is on aspirin and prophylactic LMWH. At 26 weeks gestation, she develops a proximal DVT. Answer:

Scenario 7

A 29-year-old woman with obstetric APS has a successful pregnancy on aspirin and LMWH. She has no history of thrombosis.

She asks about long-term management after pregnancy. Answer:

Scenario 8

A 36-year-old woman with APS has had recurrent pregnancy losses despite aspirin and LMWH. She is now under review for further management. Answer:

Scenario 9

A 33-year-old woman with thrombotic APS has delivered successfully. She is breastfeeding and requires ongoing anticoagulation. Answer:

Scenario 10

A 35-year-old woman with APS and complex previous pregnancy complications is being managed in a district hospital. The team feels uncertain about escalation beyond standard therapy. Answer: