Where delivery is planned, either by elective caesarean section or induction of labour, LMWH maintenance therapy should be discontinued 24 hours prior to planned delivery.

Regional anaesthetic or analgesic techniques should not be undertaken until at least 24 hours
after the last dose of therapeutic LMWH.
LMWH should not be given for 4 hours after the use of spinal anaesthesia or after the epidural catheter has been removed, and the epidural catheter should not be removed within 12 hours of the most recent injection.

Regarding 'Prophylactic dose'-Regional techniques should be avoided if possible until at least 12 hours after the previous
prophylactic dose of LMWH.
LMWH should not be given for 4 hours after use of spinal anaesthesia or after the epidural catheter has been removed and the catheter should not be removed within 12 hours of the most recent injection.

The contraindications/Cautions are-

• Known bleeding disorder (e.g. haemophilia, von Willebrand’s disease or acquired coagulopathy)
• Active antenatal or postpartum bleeding
  - Women considered at increased risk of major haemorrhage (e.g. placenta praevia)
  - Thrombocytopenia (platelet count < 75 × 109/l)
  - Acute stroke in previous 4 weeks (haemorrhagic or ischaemic)
  - Severe renal disease (glomerular filtration rate [GFR] < 30 ml/minute/1.73m2)
  - Severe liver disease (prothrombin time above normal range or known varices)
  - Uncontrolled hypertension (blood pressure > 200 mmHg systolic or > 120 mmHg diastolic)
•  ( In case of any doubt, a haematologist review should be sought)

• Warfarin use in pregnancy is restricted to the few situations where heparin is considered unsuitable,e.g. some women with mechanical heart valves.
• Women with previous VTE associated with antithrombin deficiency (who will often be on long-term
  oral anticoagulation) should be offered thromboprophylaxis with higher dose LMWH (either 50%,
  75% or full treatment dose)
• Danaparoid is a heparinoid that is mostly used in patients intolerant of heparin, either because of HIT or a skin allergy to heparins

Cryoprecipitate should be used for fibrinogen replacement.

Fibrinogen loss can be replaced by cryoprecipitate or fibrinogen concentrate .

But fibrinogen concentrate is not licensed for acquired hypofibrinogenaemia in the UK.

- For pregnancies at more than 16 weeks of gestation the term low-lying placenta should be used when the placental edge is less than 20 mm from the internal os on transabdominal or transvaginal scanning (TVS).

• The term placenta praevia should be used when the placenta lies directly over the internal os.

The algorithm suggested by RCOG for low lying placenta can be accessed HERE