A pregnant woman at 36 weeks of gestation with a prosthetic valve replacement for mitral stenosis is on warfarin therapy. Her INR is 3. What is the appropriate next step in management?

Options

1. Stop warfarin and start LMWH
2. Stop warfarin and start heparin
3. Continue warfarin
4. Stop warfarin, start LMWH and aspirin

Correct Answer

Stop warfarin and start LMWH

Explanation

Warfarin is contraindicated near term due to risk of fetal and maternal hemorrhage during delivery. At 36 weeks (near term), warfarin should be stopped and switched to LMWH (Low Molecular Weight Heparin) or unfractionated heparin. LMWH does not cross the placenta and can be discontinued closer to delivery time to minimize bleeding risk.

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