Pulmonary embolism due to a contraceptive vaginal ring (NuvaRing)

Pulmonary Embolism With Pulmonary Infarction in a Patient Using the Annovera® Segesterone Acetate and Ethinylestradiol Combined Vaginal Contraceptive Ring

Combined hormonal contraceptives (CHC) are a very popular form of contraception among young women. Recently, vaginal contraceptive rings (VCR) have been formulated, offering greater convenience and ease of use. Venous thromboembolism (VTE) has been associated with CHC use and is a significant cause of mortality and morbidity in women. Here, we present the case of a 48-year-old woman who presented with right upper quadrant abdominal pain for four days associated with one day of shortness of breath. She had a history of anemia and abnormal uterine bleeding due to uterine fibroids. She was found to have a large embolus in the right pulmonary artery, associated with a right lower lobe pulmonary infarction. No evidence of lower-extremity deep venous thrombosis was found. She was using a segesterone acetate and ethinylestradiol combination VCR, which was removed. She was started on intravenous heparin anticoagulation with improvement in symptoms. This was later transitioned to an oral apixaban regimen prior to discharge. The exact mechanism of CHC-induced thrombotic risk remains unclear. They affect numerous proteins involved in the coagulation, anticoagulation, and thrombolytic pathways, thereby expressing their net thrombogenic potential. Estrogens have often been implicated as the more thrombogenic hormone, with progestogens being added to mitigate some of the risks. CHC use can cause a sixfold increased risk for VTE. Reducing the dose of estrogen and proper patient selection with attention to their risk profile remain essential for the safe use of these agents. This represents the first case report relating segesterone acetate and ethinylestradiol combination VCR to pulmonary embolism and infarction.

Venous Thromboembolism Requiring Anticoagulation Following Knee Arthroscopy in a Young Woman With an Intravaginal Contraceptive Device

Venous thromboembolism following elective knee arthroscopy remains relatively rare. NuvaRing (Merck & Co), an intravaginal contraceptive device, has received attention recently due to reports detailing unexpected catastrophic pulmonary embolism and further suggesting an increased risk of venous and arterial thrombotic events in women who use it. A healthy, 30-year-old woman with a NuvaRing contraceptive device presented to the sports medicine clinic with knee pain, swelling, and mechanical symptoms. She was diagnosed with a lateral meniscus tear via magnetic resonance imaging and subsequently underwent a routine partial lateral meniscectomy. Her postoperative course was complicated by a rare deep venous thrombosis requiring anticoagulation therapy. This case highlights the risk of NuvaRing contraception and raises awareness within the orthopedic community regarding its use among patients undergoing arthroscopic outpatient surgery. [Orthopedics. 2021;44(5):e687-e690.].