Pulmonary embolism and deep vein thrombosis related to oral contraceptive use
A 24-year-old woman (gravida 0) visited our clinic due to left inguinal pain on every step and edema of left leg four months after taking Yasmin (Bayer HealthCare, New York, NY, USA). This pain and edema were started a week ago and aggravated three days ago. Her weight was 69 kg, and height 170 cm. She was a non-smoker. Her job was a company worker. The patient and family members had not suffered prior VTE. She received pelviscopic ovarian cystectomy of 5 cm sized left ovarian endometrioma at another clinic a year ago. Two weeks after operation, she was injected gonadotropin releasing hormone (GnRH) per four weeks for six months continuously. A month after sixth GnRH injection, she had started taking Yasmin 21-tablet continuously without seven-day discontinuation period for four months to prevent recurrence of endometriosis. During taking the fifth pack of Yasmin, she felt left inguinal pain on ambulation, and edema of left leg. So, she admitted our clinic. Her vital signs were as stable. Body temperature 120/80 mm Hg, pulse rate 72/min, respiratory rate 20/min, body temperature 36.5℃. She had no chest discomfort, breathing difficulties and skin color change of left leg. The circumference of her left thigh was proximal 64 cm, distal 48 cm, and right proximal 57 cm, distal 43 cm, respectively. Her left radial artery and dorsalis pedis artery were palpable well. Laboratory findings were below. Complete blood count, chemistry profile, and urine analysis were all normal range. Prothrombin time 11.6 sec (normal, 9.8 to 12.4 sec), partial thromboplastin time 96.6% (normal, 80% to 135%). Anti-cardiolipin antibody IgG/IgM, Lupus anticoagulant, Factor V Leiden (FV, Q506) were all negative. Protein C activity was 109% (normal, 70% to 130%), and protein S activity 99% (normal, 65% to 140%). D-dimer was elevated to 2.68 µg/mL (normal, 0 to 0.5 µg/mL). Chest posterial-anterial and electrocardiogram were normal findings. Chest pulmonary angiography computed tomography (CT) (contrast enhanced) showed pulmonary thromboembolism in BLLs' basal pulmonary arteries and 32-mm sized consolidation in right lower lobe posterior segment as considering pulmonary infarction (). Lower extremity venogram CT (contrast enhanced) showed thrombosis in inferior vena cava (IVC) and diffuse DVT below the level of left external iliac vein (). We injected low molecular weight heparin (LMWH) 60 mg per 12 hours subcutaneously for seven days and overlapped heparin with 4 mg warfarin five days. After five days of combined therapy, we changed to 4 mg warfarin per oral. We determined the proper dose of warfarin by a blood test reported as the international normalized ratio. She discharged with warfarin. She had taken warfarin for six months thereafter. She had normal menstrual cycles and no recurrence of PE and DVT during 12-month follow-up.