Pulmonary Embolism and Mortality after Laparoscopic Bariatric surgery in patients using NuvaRing(r)

Ashish Padnani, MD1, Koji Park, MD1, Ninan Koshy1, James McGinty, MD1, John Harvey, MD1, Darshak Shah2. 1Mount Sinai St. Luke’s Hospital, 2Mount Sinai Hospital

INTRODUCTION: Estrogen containing hormonal contraceptives have been known to have risk of venous thromboembolism (VTE). The risk is much higher in obese patients undergoing laparoscopic bariatric surgery. NuvaRing® is a contraceptive vaginal ring containing etonogestrel and ethinylestradiol, inserted in vagina once a month. Some studies show significantly higher risk of VTE compared to oral contraceptives. We present two cases of mortalities from pulmonary embolism (PE) in patients undergoing laparoscopic sleeve gastrectomy. Both patients used NuvaRing® preoperatively and continued it postoperatively. They had no other known risk factors.

CASE 1: 23 years old female patient with BMI of 48 kg/m2, past medical history of asthma underwent an elective laparoscopic sleeve gastrectomy. She received unfractionated heparin (UFH) subcutaneously preoperatively and sequential compression devices (SCDs) for VTE prophylaxis, and were continued postoperatively. Her postoperative course was unremarkable. She was discharged home on postoperative day (POD)#2. POD#10 she had an episode of syncope and was taken to outside hospital where she was found to have lower extremity VTE and PE. She was started on anticoagulation. She became hemodynamically unstable and expired on POD#11.

CASE 2: 21  years old female patient with BMI of 42.75 kg/m2 and no other significant past medical history underwent elective laparoscopic sleeve gastrectomy.  She received unfractionated heparin (UFH) subcutaneously preoperatively and SCDs for VTE prophylaxis, and were continued postoperatively. Her postoperative course was unremarkable. She was discharged home on POD#2. Patient presented back to emergency room (ER) on POD#5 with epigastric discomfort. She was not dyspneic and her vital signs were stable. An ultrasound of abdomen obtained was unremarkable. She was discharged home without surgical consultation. POD#6 patient developed severe shortness of breath. She was taken to outside hospital and found to have massive PE. She was hemodynamically unstable and expired the same day.

CONCLUSION: NuvaRing® poses a unique challenge. Since its not daily administered medication, patients often forget to mention about it during preoperative assessment. It is relatively new and there is minimal literature about its side effects and safety profile in obese patients undergoing laparoscopic bariatric surgery. So it is important to do careful screening preoperatively. The purpose of this paper is to increase awareness amongst surgeons about NuvaRing® and its potential side effects. Per manufacturer, it is recommended to discontinue its use for at least 4 weeks before surgery and to not restart it until at least 2 weeks after surgery.

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