Pulmonary embolism associated with oral contraceptive use – Case report

Abstract

A 25-year-old female patient with a history of oral contraceptive use was admitted to hospital because of exertional dyspnoea, palpitations, chest discomfort and weakness. Since the clinical presentation was suggestive of some heart disease the patient underwent echocardiography which revealed indirect signs of acute pulmonary embolism. The diagnosis was confirmed with multisliced computed tomography of the pulmonary arteries. Blood test results raised suspicion of antithrombin III deficiency. Enoxaparin and warfarin were used as treatment regimen with good effect and the patient was discharged home without significant symptoms, signs, and with normal echocardiography. CASE REPORT A 25-year-old female patient was admitted to hospital because of exertional dyspnoea, palpitations, chest discomfort and weakness. The symptoms had started about three weeks prior to hospital admission. The patient’s medical history was negative for significant disorders but the patient declared prolonged use of oral contraceptives. On physical examination, increased resting heart rate of about 140 per minute was found. ECG revealed sinus tachycardia without other abnormalities. The patient fainted and became pale in the face when trying to move from the bed. Since the clinical presentation was suggestive of some heart disease the patient underwent bedside echocardiography, and blood samples were taken for laboratory tests, including troponin T, N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) and D-dimer level. On echocardiography, indirect signs of acute pulmonary embolism were found including McConnell’s sign, dilatation of the right ventricle, shortening of pulmonary artery acceleration time with a typical notch on the spectrum, tricuspid regurgitation with TRVPG (tricuspid regurgitation peak gradient) about 70 mmHg. D-dimer level and NT-proBNP level were elevated. Troponin T level remained within normal range. Laboratory findings are shown in Table 1. The patient was sent for multisliced computed tomography of the pulmonary arteries and large clots were found within both branches of the main pulmonary artery (Fig. 1). Based on imaging, blood test results and clinical presentation, intermediate-risk pulmonary embolism was diagnosed in the patient. Pulmonary embolism is a rare disorder in young individuals without known risk factors for venous thromboembolism. Therefore, a blood sample was also taken for diagnosis of possible thrombophilia, including evaluation of antithrombin III, mutation of factor V Leiden, prothrombin, protein C, protein S and factor VIII. The level of antithrombin III was slightly lowered to about 77% of normal value. Since the patient was stable without signs or symptoms of haemodynamic compromise, low molecular weight heparin – enoxaparin – at a weight-adjusted dose of 1 mg/kg was administered subcutaneously twice daily. The patient’s state improved significantly within two days. After five days, the patient was administered orally the anticoagulant warfarin. No recurrent dyspnoea, fainting or bleeding as a side-effect of the treatment were observed. Echocardiographic measures as well as laboratory findings of heart failure returned to normal. The patient was discharged home safely with recommendation to keep taking warfarin for at least six months and to repeat antithrombin III level evaluation after the treatment. This was because the low values observed in the acute stage of the disease could be the result of ongoing thrombosis.