A 32-year old woman is brought to the emergency room with an acute onset of shortness of breath and pleuritic chest pain that occurred while she was shopping. She has never been sick before and takes no medications, except contraceptives. Her respiratory rate is 26/min and pulse is 107/min. Auscultation is clear, and the rest of the examination is normal. Her ABG shows evidence of mild hypoxia (7.52/70/25/93%). Chest X-ray is normal.



She is started on hepatin (LMWH) on arrival (for being high risk of PTE). A contrast enhanced CT was done and Pulmonary thromboembolism was confirmed.

On day 3, warfarin was started with heparin.

On day 4 the patient developed SOB with cough.. A spiral CT was done confirming the presence of another attack of PTE. Doppler U/S of the lower limb was –ve (excluding an embolic dislodgment).



How would u explain this second attack and how would be the management?

first of all , thanks ahmed for your cases

warfarin dose must be increased and / or change the contraceptive method because contraceptive steroids lead to
1/ increase the coagulation
AND MOST IMP.
2/ has adverse interaction with warfarin by decrease its effect due to enzyme induction
Management: check the INR and aim to make it 2-3.

waiting for yours and others' reply

Dear Luay,

thanks for ur nice reply but i think the patient is already on heparin and free of symptoms and second, warfarin takes about 3 days to work..(am i right??)

So, it's right that OCP interfere with warfarin but warfarin hasn't worked yet and the patient is still on heparin...

Thanks again for ur reply..

hello ahmed, is it Malignancy, coz i know that i causes thromboses......

hello every body and congrajulations for your graduation hoping all the best for u in your practical life
i'm interested in this case but i have no answer hoping u will find one soon

hello ahmed
first of all congr. for ur graduation ,i hope everything will go so good and smooth with you.

about the case,its interesting but what i will suggest is that the thrombi is coming from the side effects of the OCP,as we all know one of its side effects is clot formation and thrombi ,so i will go for this answer.
about the MX ,she should be warned not to go on OCP again and we will try to control the thrombi by adjusting the heparin dose .

thank for ur case
tc