Cerebral Vein Thrombosis in Concomitant Combination Oral Contraceptive Pill Use and COVID-19​

Abstract

Case Description:

Patient is a 27-year-old female who presented with confusion, fever, and chills and was found to have a cerebral vein thrombosis (CVT) on MRI. She had a seven-year history of combination oral contraceptive pill (OCP) use and prior to onset of symptoms tested positive for COVID-19. After CVT diagnosis, she started apixaban, which was discontinued 6 months later. She decided to discontinue her OCP and had a copper intrauterine device (IUD) placed.

Clinical Significance:

CVT is a rare form of stroke that most commonly affects young women. Pregnancy, puerperium, and OCP all use induce a hypercoagulable state which increases risk for CVT. Estrogen causes increased circulating procoagulant factors in the plasma, and combined OCP users are often found to have an acquired resistance to activated protein C6, which both contribute to a hypercoagulable state. COVID-19-associated coagulopathy also induces concurrent hyper-inflammatory response, hypercoagulability, and vascular endothelial cell dysfunction. These pathologic mechanisms are believed to be linked to elevated plasma levels of coagulation factors and reduced fibrinolysis, resulting in prothrombotic events. COVID-19 infection is thought to exacerbate existing prothrombotic states like OCP use.

Conclusion:

Concomitant hypercoagulable states, such as combination OCP use and COVID-19 coagulopathy, increase overall risk for thrombotic events. Patients with risk factors for hypercoagulability presenting with headache, visual changes, and confusion should be evaluated for CVT. Following a thrombotic event in a patient on combined OCPs, finding an alternative contraceptive that meets the patient’s reproductive goals and lowers their risk of repeat thromboembolic events is important. Progesterone-only and non-hormonal contraceptive options, such as IUDs, have a decreased risk of thrombosis compared to combined OCPs and can provide alternative contraceptive methods.