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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

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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

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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.

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• 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.

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• 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

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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

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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.

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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

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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

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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

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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).

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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