A 31-year-old woman, gravida 3 aborta 3, comes to the office for an annual examination and discussion of contraceptive options. Seven months ago, she experienced her third spontaneous miscarriage and underwent a recurrent miscarriage workup. Results were consistent with antiphospholipid antibody syndrome, and the patient was informed that she is at increased risk for another miscarriage. Due to these risks, the patient and her husband have elected to adopt. She takes no medications and does not use tobacco, alcohol, or illicit drugs. Her blood pressure is 115/60 mm Hg and pulse is 88/min. BMI is 22 kg/m². Physical examination is normal. Which of the following is the best contraceptive option for this patient?

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11ec25c8_d0c9_8fe4_bc81_0b827572a909_MD0003_00 Thromboembolic events occur due to a combination of hypercoagulability, endothelial injury, and venous stasis (eg, Virchow triad) with patients typically having more than one risk factor for their development. Women with a pre-existing risk factor for thromboembolism are at increased risk for clot development during pregnancy and with exogenous estrogen exposure due to its hypercoagulable properties. Antiphospholipid antibody syndrome (APS) is an autoimmune disorder characterized by vascular thrombosis and pregnancy complications (eg, recurrent miscarriage, preeclampsia, fetal growth restriction). APS is an absolute contraindication to combined (estrogen/progestin) hormonal contraceptives due to the increased risk of arterial and venous thrombosis (Choices A and B). Patients who desire pregnancy prevention should be offered hormone-free options: the copper intrauterine device or permanent sterilization (eg, tubal ligation). (Choice C) Condoms with spermicide are a safe, hormone-free option but have the lowest efficacy rate of all contraceptive options. Patients should be placed on the most efficacious contraceptive possible. (Choice E) Depo medroxyprogesterone acetate is a systemic progestin-only contraceptive. Progestin-only contraceptives have less risk for thromboembolism compared to combined hormonal options, but systemic forms are still not recommended in high-risk patients. Educational objective: Absolute contraindications to combination hormonal contraceptives include a history of antiphospholipid antibody syndrome or thromboembolism. Patients with these conditions should be placed on hormone-free contraceptives (eg, copper intrauterine device). References: Association of venous thromboembolism with hormonal contraception and thrombophilic genotypes. (http://www.ncbi.nlm.nih.gov/pubmed/25162263) Antiphospholipid antibodies and the placenta: a systematic review of their in vitro effects and modulation by treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25228006)

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