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Case History

image A 30-year-old woman was referred to the gynaecology clinic with premature ovarian insufficiency (POI). This was secondary to chemotherapy for Hodgkin lymphoma. Initial chemotherapy comprised six cycles of doxorubicin, bleomycin, vincristine and dacarbazine (ABVD) to complete remission. Treatment was complicated by PICC line associated deep vein thrombosis (DVT) and basilic vein thrombosis due to peripherally administered chemotherapy. Disease relapse 7 months after finishing treatment meant that embryo cryopreservation was rapidly undertaken prior to salvage chemotherapy with two cycles of gemcitabine, dexamethasone and cisplatin (GDP). A month after Hickman line insertion, she presented acutely with extensive superior vena cava and right atrial thrombosis and pulmonary embolus, despite high intensity thromboprophylaxis with low molecular weight heparin (LMWH). She received thrombolysis with Alteplase and was anti-coagulated with split therapeutic dose LMWH. Repeat imaging 1 month later showed no sign of residual thrombosis. She underwent a carmustine, etoposide, cytarabine, and melphalan (BEAM) autograft, continuing with high intensity LMWH adjusted to platelet count throughout the transplant. She had no family history of venous thromboembolism (VTE), and no other unprovoked VTE, with a normal/negative thrombophilia screen. Post autograft, her anti-coagulation was converted to a treatment dose direct oral anti-coagulant (apixaban) and she completed 6 months, before continuing at prophylactic dose in view of the history of multiple and life-threatening VTE events (albeit provoked). She experienced significant symptoms from POI, and it was deemed that she would benefit from oestrogen replacement therapy. Apixaban prophylaxis was continued to mitigate the potential risk of VTE with hormone replacement therapy (HRT) which was given as a transdermal patch. She remained in complete remission post-transplant,and after 2 years she returned to the fertility clinic with her husband to discuss pregnancy. It was noted that the life-threatening thrombosis had occurred 2 months after fertility treatment, and hormonal factors may have contributed to the thrombosis. A plan for embryo transfer was made using transdermal instead of oral oestrogen to mitigate thrombotic risk. A switch was made from apixaban to higher intensity LMWH prophylaxis through embryo transfer, pregnancy and post-partum.

What are the risk factors for cancer-associated VTE?

What are the risks and benefits of HRT for this patient?

What is the evidence basis for risk of VTE with hormone replacement therapy?

Which anti-coagulants are safe for use in pregnancy?

What are the indications for thromboprophylaxis in pregnancy?

What are the risk factors for cancer-associated VTE?

Venous thromboembolism, including DVT and pulmonary embolism (PE), is a common complication of cancer. The risk of VTE in cancer patients is at least 4 times the risk in non-cancer patients. This risk is further elevated to seven-fold with chemotherapy treatment.1 Risk factors for cancer-associated VTE can be classified into patient-related, tumour-related and treatment-related factors. Patient-related factors include advanced age, co-morbidities, previous VTE, immobilization or hospitalization. Tumour-related factors include tumour type (very high risk includes pancreatic and gastric cancers), cancer stage, histology and presence of localized tumour ...

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