Re: Gyn: OCPs
From: Gail Waldby, MD (gwaldby@main.basec.net)
Thu Aug 27 19:50:29 1998
I don't understand why the Coumadin prophylaxis would not be adequate after
ortho surgery even if the patient is continued on OCP's. Do you have any data
directly relating to this issue? I am quite familiar with the extensive
literature on DVT/PE and prophylaxis having successfully defended myself against
a case of post-op collapse leading to a chronic vegetative state attributed at
least by the plaintiffs' attorneys to post-op PE. I am also reading the
Selected Readings in General Surgery current issue on DVT/PE prophylaxis. This
is a 5 year series of articles with overviews and quizzes on topics of interest
to general surgeons. We get 110 CME I credits per year if we do the whole
thing. If anyone is interested in this program, I can get you the 800 toll free
number and or address.
Gail Waldby, MD
Huron Clinic SD
Betsy Hyde wrote:
> >
> >Clearly a different league of estrogen dosing however as contrasted with
> >OCPs. I was never trained to discontinue OCPs and am not aware of any data
> >to say that it makes a difference so I would disagree with an earlier
> >posters "flabergasted" tone.
>
> Perhaps the fact that I spent many years my life prior to midwifery doing
> research (and publishing extensively) on venous thromboembolic disease
> makes me more aware of the literature on oral contraceptives and post-op
> venous thromboembolic disease.
>
> My post did not address itself to minor gyn surgery. It referred to women
> undergoing major orthopedic surgery and/or fractures, and whose
> orthopedists did not have them discontinue their oral contraceptives, even
> though they were placed on coumadin.
>
> A recent review article addresses this issue. (Weinmann EE and Salzman EW.
> Medical Progress: Deep Vein Thrombosis. N Engl J Med 331(24):1630-1641,
> 1994.
> The authors state:
>
> >Prevention of Venous Thromboembolism
> >
> >The goal of prophylactic therapy in patients with risk factors for
> >deep-vein thrombosis is to prevent both its occurrence and its
> >consequences, pulmonary emboli and the postphlebitic syndrome. Affected
> >patients often have no symptoms, and the detection of deep-vein thrombosis
> >is therefore apt to be delayed. Of the patients who will eventually die of
> >pulmonary emboli, two thirds survive less than 30 minutes after the event,
> >not long enough for most forms of treatment to be effective (Ref. 153).
> >Preventing deep-vein thrombosis in patients at risk is clearly preferable
> >to treating the condition after it has appeared, (Ref. 154) a view that is
> >supported by cost-effectiveness analysis (Ref. 154-157). The presence of
> >clinical risk factors identifies patients with the most to gain from
> >prophylactic measures, (Ref. 158) as well as patients who should receive
> >antithrombotic prophylaxis during periods of increased susceptibility,
> >such as postoperatively or post partum.
>
> >Risk factors may combine synergistically to increase the incidence of
> >venous thromboembolism in various circumstances (Table 3). At one extreme,
> >the risk of deep-vein thrombosis in the course of daily activities may be
> >so low that no specific preventive measures are necessary. A patient at
> >low risk needs only minimal prophylactic measures, such as early
> >ambulation after surgery and the use of elastic stockings, augmenting the
> >propulsion of blood from ankle to knee (Ref. 159,160).
> >
> >The risk may be much higher in a patient older than 40 years of age who is
> >undergoing an operation that lasts longer than an hour, who has congestive
> >heart failure, who has been taking an oral contraceptive, or who has had
> >multiple traumatic injuries. Unless prophylactic measures are used, the
> >incidence of deep-vein thrombosis can exceed 60 percent (Ref. 2,55) after
> >an orthopedic operation on the lower extremities, especially if there is a
> >lengthy convalescence involving bed rest (Ref. 55). During a total hip
> >replacement, mechanical trauma to the femoral or iliac veins, (Ref. 161)
> >thermal damage from the heat of polymerization of the acrylic cement,
> >(Ref. 162) and a possible chemical effect of circulating absorbed monomer
> >contribute to the hazard.
>
> So, I do remain flabbergasted (it is a real word, "to overwhelm with shock,
> surprise or wonder: astound) that orthopedists would put someone on
> coumadin for 3 months, but leave them on OCPs during a prolonged period of
> immobility following a hip replacement or femoral fracture.
>
> Betsy Hyde CNM
> Branford, CT
>
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