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Brenda Mertsock, PA-S Lock Haven University September 2008 Case Report DVT/PE

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Presenting Symptoms This is what we saw! Patient drove herself to the ER CC: Shortness of Breath Tightness in her chest X a few hours. VS: 148/95, 82, 20, 98.2 F HPI: Included rt. leg was swollen, warm to touch, and painful X 12 days. Pain was now a 3 out of 10, but it felt like a cutting, tight rope pressure behind the knee that was much more swollen and tender for the past 12 days.

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HPI Aug, 1 st, active doing yard work, felt pain behind the knee Aug, 2 nd, hauling logs, trimming trees, more physical activity, - swollen rt knee Aug 3 rd, knee so swollen, she reclined most of the day with it elevated, also noticed an exacerbation of low back pain Aug 4 th, her usual chiropractor out of town, went to someone new, showed him her leg and he agreed it was swollen and worked on her back Aug 6 th, her chiropractor back in town, he attributed her swollen leg to her back pain Aug 7 th, went to her primary care physician, he said her SI joint was out and that there was probably some pooling from that. No one ever made a measurement. By this time, she felt like her skin could not stretch anymore, she elevated it every night, but nothing helped. She continued to walk daily, work in her very busy professional business, and do household chores. Aug 9 th, her and her husband drove to North Carolina and then on Monday drove 10 hours back. On Tuesday the 12 th, she went to work and that evening was in the ER with SOB.

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Tests Ordered & PE CBC, BMP, D-Dimer, PT, PTT, cardiac enzymes, EKG, venous duplex of right lower extremity, and a CT chest with IV contrast. PE: no increased JVD or thyromegaly, lungs were CTA Bilat., RRR, S1 and S2 with no murmurs, + abd BS, soft, NT, no oganomegaly, no guarding or rigidity, portable chest x-ray was unremarkable. Lungs were well expanded, unremarkable heart, hila, and mediastinum. Right lower leg moderate to severe tenderness, swelling, and warmth to the post rt. knee, calf, and rt. popliteal. Tenderness to a cord-like structure along the great saphenous vein post. to the knee medially along the thigh.

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Recent Past Medical History Past 6 mo. new onset of hypothyroidism- taking 25mg daily of Levothyroxine Past 6 mo. New onset of menorrhagia- taking Solia.15/.03mg Past mo. skin rash- taking 5 mg prednisone Takes multivitamin and Oyster-D Allergic to Penicillin

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Differential Diagnosis DVT Acute deep vein thrombosis of the right leg popliteal vein, great saphenous vein thrombosis- underlying etiology of Oral contraceptives Chest pain ruling out PE or MI Hypothyroidism

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Test Results Pertinent lab results: White ct 12,700 Neutrophils- 90.4% Negative cardiac enzymes D-dimer- over 5000 ug/ml (0-300 ref range) Venous Doppler showed rt common femoral and femoral veins patent, Rt popliteal vein was occluded and contained thrombus with minimal flow, posterior tibial vein appeared to be patent. CT showed extensive pulmonary emboli through-out the pulmonary arteries bilaterally. This was so extensive there were only a few branches that were not involved.

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Treatment Admit to hospital with BRP only For 6 days Sub-Q Lovenox 100 mg/ml q 12 hr Use until therapeutic oral anticoagulation of Coumadin is established with a level between 2 and 3. Pt will be on anti-coagulant therapy for 9 mo to a year and monitor PT-INR. Pt was informed of risks and benefits of treatment. Pt will continue on thyroid med, vitamins, and discontinue OCP.

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Why did it Happen? Ethinyl estradiol and norgestrel Brand Names: Cryselle 28 Lo/Ovral- 28 Low-Ogestrel-28 Ogestrel-28 Patient had no previous history of any type of thrombolytic event. Pt had no complications with previous oral contraceptive use. Pt had no contributory family history. New onset of hypothyroidism and contributing symptom of menorrhagia? Maybe. Reinstated use of Oral contracptives? Maybe.

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Oral Contraceptive Use Solia Equivalent to: Desogen Ortho-cept Apri Reclipsen The pt. took Cryselle (2 nd generation OCP) from Feb to May, could not tolerate it. The pt. took Solia (3 rd generation OCP) from May to Aug. 2 nd an 3 rd generation OCPs contain different levels of progestin. 2 nd - Norgestrel 3 rd - Desogestrel

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What Happens? Desogestrel causes resistance to activated protein C (APC) Decreases total and free protein S Causes more pronounced APC resistance. When APC and protein S cannot perform their natural function of inhibiting coagulation, clots tend to form more easily. Increasing the risk of venous thrombosis. If a pre-existing pro-thrombotic condition exists, the risk increases 35-fold

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What Happens -600,000 episodes of PE in the US annually -100,000 200,000 deaths -Most not suspected or unrecognized -Common cause of death a week to ten days after a thrombosis formed. -Proximal lower extremity venous thrombosis has been reported to be the source of 90% of emboli. -Symptoms of a PE could include; chest pain, dyspnea, hemoptysis, JVD, fever, tricuspid regurgitation, increased pulmonic heart tone, tachycardia, tachypnea, and pleural effusion..

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Clinical Risk Factors for DVT/PE Age greater than 40 - Renal failure Previous DVT/PE - Nephrotic syndrome Surgery requiring anesthesia - Central venous catherization for more than 30 min. - COPD Prolonged immobilization - Long distance travel Stroke - Genetic or acquired thrombophilia Heart failure -Inflammatory bowel disease Malignancy - Estsrogen therapy Fractures of long bones or pelvis Spinal cord injury Obesity Smoking Pregnancy

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Discussion At this time there is a petition to the US Food and Drug Administration to ban third generation oral contraceptives containing desogestrel. There have been documented case of women of all ages experiencing DVTs from taking OCPs that contain desogestrel. Pro-thrombotic blood tests are not routinely checked, so prior knowledge is often unknown to the patient. Need to consider history, physical, and risks, when prescribing OCPs.

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References Demaria, Andrew (2001, February 5). Deep vein thrombosis explained. Retrieved September 4, 2008, from CNN.com Web site: http://archives.cnn.com/2001/WORLD/asiapcf/01/24/dvt.medical/ http://archives.cnn.com/2001/WORLD/asiapcf/01/24/dvt.medical/ Drug Information Online. Retrieved September 5, 2008, from Drugs.com Web site: http://www.drugs.com/drug_interactions.php?action=allinteractions&drugid=d03780&grugname=http://www.drugs.com/drug_interactions.php?action=allinteractions&drugid=d03780&grugname desogestrel Parkinson, MD, MPH, Jay, Park, MD, MPH, Sylvia, Wolfe, MD, Sidney M., & Rosendaal, MD, Frits (2007). Petition to the FDA to Ban Third Generation Oral Contraceptives Containing Desogestrel due to Increased Risk of Venous Thrombosis (HRG Publication # 1799). Protecting Health, Safety & Democracy, Retrieved Sept, 1, 2008, from http://www.citizen.org/publications/release.cfm?ID=7503.http://www.citizen.org/publications/release.cfm?ID=7503 Savelli, MD, Stephanie L., Kerliln, MD, Bryce A., Springer, MS, CGC, Michelle A., Monda, BSN, RN, Kay L., Thornton, BSN, RN, Jennifer D., & Blanchong, MD, Carol A. (2006). Recommendations for screening for thrombophilic tendencies in teenage females prior to contraceptive initiation. Journal of Pediatric and Adolescent Gynecology 19, 1-8 Test, MD, FCCP, Victor J. (2008). Pulmonary Embolism. In Rakel & Bope: Conn's Current Therapy 2008, 60th ed. [Web]. Saunders, An Imprint of Elsevier. Retrieved Sept 1, 2008, from http://www.mdconsult.com/das/book/body/10388708-ttp://www.mdconsult.com/das/book/body/10388708- 2 /0/1621/155.html?tocnode=54634409&fromURL=155.html#4-u1.0-B978-1-4160-4435-2..50081-9_1072 (2008, July 3). Cryselle 28. Retrieved September 5, 2008, from Consumer Drug Information Web site: http://www.drugs.com/mtm/cryselle-28.html http://www.drugs.com/mtm/cryselle-28.html