Double bad luck: pulmonary embolism and vaginal bleeding - a case report

Abstract

Abstract Background: Pulmonary embolism is a common and potentially fatal condition. Exogenous estrogens in contraceptives are associated with an increased risk of venous thrombo-embolism. However, discontinuation of a combined oral contraceptive can lead to severe withdrawal bleeding in an anticoagulated patient. Case presentation: We report a case of a 47-year-old female who presented to the emergency room with a two-day history of worsening shortness of breath and chest pain. Her chronic medication included a combined oral contraceptive pill. Transthoracic echocardiogram showed pulmonary hypertension and right ventricular dilatation. Computerized tomography scan revealed bilateral pulmonary embolism. She received thrombolysis with alteplase and was started on rivaroxaban. Five days after discharge, however, she was readmitted with severe vaginal bleeding. Discussion and conclusion: We describe a case of submassive pulmonary embolism, treated with thrombolysis and anticoagulation, who developed severe vaginal bleeding after stopping the contraceptive pill. While discontinuation of combined contraceptive is important in reducing the risk of recurrent thrombosis, we argue that discontinuation can potentially be postponed until after the initial phase of high-intensity anticoagulation and until a safe alternative has been established.