A 31-year-old woman, gravida 3 para 0, comes to the office for contraception management. The patient has a history of 3 first-trimester spontaneous abortions and a left lower extremity deep vein thrombosis that occurred during the last pregnancy. During evaluation after the most recent spontaneous abortion, she was diagnosed with antiphospholipid antibody syndrome based on positive lupus anticoagulant and anticardiolipin antibody tests and was placed on chronic anticoagulation. The patient's menses occur every 30 days and consist of 5 days of heavy vaginal bleeding and 2 days of moderate cramping that is relieved by nonsteroidal anti-inflammatory medications. She has no other chronic medical conditions or previous surgeries. The patient does not use tobacco, alcohol, or illicit drugs. Her maternal grandmother was diagnosed with metastatic ovarian cancer at age 65; family history is otherwise noncontributory. Blood pressure is 110/70 mm Hg and pulse is 70/min. BMI is 23 kg/m². Cardiopulmonary examination is normal. Pelvic examination reveals a normal-sized, nontender uterus and no adnexal masses or tenderness. Urine pregnancy test is negative. Which of the following is the best contraception option for this patient?

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Explanation: 11ec2b69_bee8_0676_8f63_17625c1f9da9_MD0005_00 Antiphospholipid syndrome is an autoimmune disorder characterized by hypercoagulability; obstetric complications (eg, recurrent pregnancy loss, preeclampsia, fetal growth restriction, fetal demise); and the presence of anti-beta-2 glycoprotein, anticardiolipin, or lupus anticoagulant antibodies. These antibodies contribute to a hypercoagulable state that results in an increased risk for arterial and venous thromboembolism. These risks are further exacerbated by estrogen-containing contraceptives and pregnancy. Therefore, all estrogen-containing contraceptives (eg, pills, transdermal patch, vaginal ring) are contraindicated in patients with antiphospholipid syndrome (Choices B and D). Patients with contraindications to estrogen can use nonhormonal contraception (eg, barrier method, copper-containing intrauterine device [IUD]) or progestin-only contraception (eg, progestin subdermal implant, progestin-releasing IUD). The progestin-releasing IUD is an effective, long-acting, reversible contraceptive that is inserted into the uterine cavity. In addition to providing contraception, the progestin-releasing IUD decreases menstrual blood loss (which is often increased in patients on anticoagulation) by causing endometrial atrophy. Therefore, it is recommended for patients on chronic anticoagulation as it improves heavy menstrual bleeding and decreases the risk of anemia. progestin-releasing IUD (Choice A) Bilateral tubal ligation is an irreversible method of contraception that is indicated for patients who have completed childbearing. However, tubal ligation will not improve this patient's heavy menstrual bleeding. (Choice C) The copper-containing IUD is an effective, long-acting, reversible contraceptive. However, it is associated with increased menstrual bleeding and dysmenorrhea and is, therefore, not recommended for patients with heavy menstrual flow or on anticoagulation. Educational objective: The progestin-releasing intrauterine device is a long-acting, reversible contraceptive recommended for patients who have contraindications to estrogen (eg, antiphospholipid syndrome). It has an added benefit of decreasing menstrual blood loss in patients on anticoagulation. References: Contraception in patients with systemic lupus erythematosus and antiphospholipid syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25228715)

A 31-Year-Old Woman, Gravida 3 Para 0, Comes to the Office