Post on 11-Sep-2020
2/18/2015
1
Impact of Familial Clotting Disorders in Prescribing Contraceptive Therapy
Carla Turner, DNP, CRNP, ACNP-BC Instructor, UAB School of Nursing
Disclosure Statement
• Nothing to disclose.
Objectives
• Participant will be able to describe the prevalence of venous thromboembolism
• Participant will be able to describe risk factors associated with venous thromboembolism and at risk population
• Participant will be able to describe the prevalence of oral contraception use
• Participant will be able to describe Virchow’s Triad, familial clotting disorders and use as a concept to identify populations at risk for venous thromboembolism
• Participant will be able to identify the importance of performing a comprehensive History and Physical and family history as a guide to prescribing contraceptive methods
2/18/2015
2
Case Study 1
• A 58 year-old G1P1002 • Past Medical History : Adult onset asthma
GERD Urinary Incontinence
Right knee pain
• Past Surgical History: Adenoidectomy and tonsillectomy- childhood
Right meniscus orthoscopic repair
Case Study 1, cont.
• Family History: – Father currently living with history of early
Myocardial infarction age 45 with PTCA and subsequent Stent Implantation.
Myasthenia Gravis – Mother currently living with history of colon
cancer at age 78 Ovarian cancer at age 75 – Siblings healthy
Case Study 1, cont.
• Gynecology History : Twins via vaginal delivery
Bilateral Tubal ligation at age 33 • Social History : Lifelong Nonsmoker Alcohol occasional Exercise occasional Works full time as a Nurse
2/18/2015
3
Case Study 1, cont. • Current Medications:
– LoOvral one tablet daily as directed
–Voltaren 50 mg by mouth BID
–Aspirin 81mg daily
–Pulmicort 180 mcg, 2 puffs daily
–Albuterol MDI 2 puffs every 4 hours as needed for shortness of breath/wheezing
• Underwent same day orthoscopic repair of right meniscus from injury 6 months prior to surgery.
• Preoperative medication instructions:
– Discontinue Voltaren 3 days before surgery
– Discontinue Aspirin 3 days before surgery
– Continue LoOvral
Case Study 1, cont.
• Postoperative medication instructions:
– LoOvral 1 tablet daily as directed
–Voltaren 50 mg BID
–Aspirin 81mg daily
–Pulmicort 180 mcg 2 puffs daily
–Albuterol MDI 2 puffs every 4 hours as needed for shortness of breath/wheezing
Case Study 1, cont.
2/18/2015
4
• Postop Day #7:
Follow-up appointment no abnormalities
Ambulate with aide crutches for 1 week
• Postop Day #12:
Returned to work and co-workers mentioned right leg appeared swollen
• Postop Day#25:
Developed acute onset of right calf pain and progressively worsening swelling.
Case Study 1, cont.
• Postop Day#28: Right calf pain and leg swelling worse Called Orthopedic service suggested ED visit to evaluate possible strained muscle Denied chest pain/discomfort and no shortness of breath. • Postop Day #28: Presented to ED elevated D-dimer Venous doppler indicated extensive DVT of right leg extended from right ankle to right femoral
Case Study 1, cont.
• Management of embolic event
– Weight based loading dose of Lovenox subcutaneously in the ED
– Discharge from the ER with Lovenox weight based subq every 12 hours for 7 days then daily with a bridge of Coumadin.
– Discontinued LoOvral
– Placed on strict bed rest for one month
• Completed a 6 month course of anticoagulation with Coumadin therapy.
• Occasional right lower extremity swelling
• No further embolic events
• Eventually required right knee replacement without complications
Case Study 1, cont.
2/18/2015
5
• A 23 year-old G0P0 • Past Medical History : Seasonal allergies • Past Surgical History: None • Family History: –Father : Hypertension, T2DM –Mother : Asthma, GERD, DVT, Urinary
Incontinence –Siblings: Healthy
Case Study 2
• Gynecology History :
–Labial cysts
• Social History :
Lifelong Nonsmoker
Alcohol occasional
Exercise occasional
Pharmacy Technician/College Student
Case Study 2, cont.
Case Study 2, cont.
• Medications:
–Ortho-Cyclen one tablet daily
2/18/2015
6
Case Study 2, cont.
• Very active and enjoys staying busy.
• One hot Alabama Summer she helped her boyfriend repair his roof.
• She remained in a stooping position for an extended period of time and could not drink enough water to relieve her thirst.
Case Study 2, cont.
• 2 days later she complained of right leg pain with swelling.
• She thought maybe she had sprained her ankle.
• 1 week later symptoms progressively worst
• Instructed by Neighbor who is an orthopedic surgeon to go to ED for evaluation of possible DVT.
• No complaints of chest pain/discomfort or shortness of breath.
Case Study 2, cont.
• Presented to ED elevated d-Dimer
• Underwent a venous Doppler positive Deep Vein Thrombosis popliteal vein.
• Admitted to hospital as 23 hour observation
• Management of embolic event
• Started on Lovenox bridged to Coumadin
• Discontinued Ortho-Cyclen
2/18/2015
7
Case Study 2, cont.
• During hospitalization blood collected for evaluation of
hereditary thrombophilia
• Referred to hematologists Protein C Deficiency
• Completed a 9 month course of Coumadin therapy
• No further embolic events
• Current method of oral contraceptive therapy Depo-
Provera
What is Venous Thromboembolism (VTE)
• Deep Vein Thrombosis (DVT)-blood clot forms in the
deep veins of lower leg, thigh, pelvis, or arms.
• Pulmonary Embolism (PTE)- most often caused by a
blood clot that travels to the lungs from legs, thigh, pelvis, or heart.
Why?
– Each year 350,000 to 900,000 Americans develop first DVT.
– Estimated that 60,000 – 100,000 Americans die of DVT/PE annually.
– 10 to 30% will die within one month of being diagnosed.
– One-third (33%) of those with a DVT/PE will have recurrence within 10 years.
– Approximately 5 to 8% of the U.S. population has inherited thrombophilia.
– One-half of those who develops a DVT/PE will have long-term complications.
2/18/2015
8
At Risk Population
– Over age 65 (increase risk after age 40) – Overweight BMI >30 – Family history of blood clots – Pregnancy or recent delivery – Oral contraception – Hormone replacement therapy – Extended immobility or sitting
longer than 4 hours during travel – Previous VTE – Thrombophilia – Active Cancer
Risk Factors for VTE
Genetic Acquired Transient Acquired
Family history Advanced Age Pregnancy
Factor V Leiden
Thrombophilia
Antiphospholipid
antibodies
Oral contraceptive
Prothrombin G20210A
Cancer Hormone therapy
Protein C deficiency Chronic Disease Hospitalization
Protein S deficiency Obesity Surgery
Antithrombin deficiency
---------------- Trauma
Sickle cell trait ---------------- Immobilization
Thrombophilia
2/18/2015
9
When?
• Venous Stasis
• Hypercoagulability
• Endothelial Damage
Virchow’s Triad
VTE and Estrogen
• Estrogen facilitates increased levels of Procoagulant factors:
–Fibrinogen
–Factors VII
–Factors VIII
–Factor X
2/18/2015
10
VTE and Estrogen
• Estrogen facilitates a decrease in coagulation inhibitors:
–Antithrombin
–Protein S
–Protein C resistance
Resulting in a hypercoagulable state and increase risk VTE
Contraceptive Use Among American Women
Contraceptive Use Among American Women
2/18/2015
11
Contraceptive Use Among American Women
Oral Contraception Agents and VTE
• VTE risk varies among combined oral contraceptive therapy considering the type of Progestin and the dose of Estradiol.
• Activated protein C resistance appears to be higher among users of Desogestrel (DSG), Drospirenone (DRSP), and Cyproterone acetate (CPA).
2/18/2015
12
History and Physical
• Women should be screened for contraindications to specific contraceptive therapies.
• A comprehensive H&P can facilitate identifying contraindications to Combined Hormonal Contraceptive Therapy
• Identifying co-morbid conditions: Hypertension, DM, CHF, Obesity.
Lessons Learned
• The best contraceptive strategy is to use the safest therapy considering risk for VTE, past medical history, and family history.
• Goal of a detailed H&P is to match patients with the most appropriate contraceptive method with the lowest risk for complications.
• Preoperative considerations of discontinuing contraceptive therapy.
Questions