Venous thromboembolism risk with non-oral hormonal contraceptives

By Suhair Shawar, PharmD, PGY2 EM Pharmacy Resident // Edited by Liz Rozycki, PharmD, Specialty Practice Pharmacist, EM

A 32 year-old female patient presented to the emergency department (ED) with shortness of breath and chest pain. Patient’s work up included ruling out pulmonary embolism (PE).  Otherwise healthy, the patient is currently on etonogestrel implant (Nexplanon®) for contraception. The clinical pharmacist in the ED was asked to help with literature search regarding thromboembolic risk associated with etonogestrel implant and other non-oral, hormonal contraceptive therapies

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Does D-dimer rule out PE? YES, but…

Written by Zach Adams, OSU EM resident // Edited by Michael Barrie EM Assistant Professor.

Bottom line: D-dimer reliably excludes PE in low/moderate risk patients, however use clinical history/exam to guide pursuing advanced imaging.

An otherwise healthy 23 year-old presents with worsening shortness of breath for the past 7 days.  Shortness of breath began suddenly while at rest, has been continuous, and with associated reduced exercise tolerance.  Five days ago she was seen in the ED with a negative d-dimer and CXR and discharged with return precautions.  Since then, she states that the symptoms have progressed. She says she cannot lie flat.  ROS reveals a history of antecedent URI 10 days ago.  She is a non-smoker, takes no birth control pills, does not have a personal or family history of DVT or PE, and denies recent prolonged travel.  She appears uncomfortable and takes deep inspirations every 3-5 seconds.  Her physical exam reveals tachypnea with otherwise normal exam.  ECG shows normal sinus rhythm.  CXR is normal and repeat d-dimer is negative.

The patient has bounced back with worsening symptoms.  I struggled with this clinical question: should we obtain a CT PE to rule out PE despite a negative d-dimer in this low risk patient?

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