An 18 year old university student had been taking the combined oral contraceptive pill microgynon (cyproterone acetate and ethinylestradiol) for 18 months for dysmenorrhea. She went to her doctor worried about acne. She had heard from a friend that dianette was a better pill than microgynon for acne. She discussed this with her doctor and as she was a non smoker with normal BMI and BP he agreed to change her pill to dianette .

Two weeks after starting dianette she was rushed to hospital with sudden onset chest pain and respiratory distress. She was diagnosed as pulmonary embolism and while still in the emergency room had a cardiac arrest. She was thrombolysed immediately which resulted in spontaneous circulation. She was then transferred to the intensive care unit.

On recovery she was found to have homonymous hemianopia and a scan suggested cerebral infarction and a small subdural haemorrhage. The attending haematologist attributed the PE to dianette and the cerebral bleed the result of thrombolysis. She was treated in hospital for a month and was discharged on long-term warfarin when most of her symptoms appeared resolved. She had no focal limb deficits or neurological symptoms.

When reviewed at 2 months she had some difficulty with verbal and visual processing. She recovered fully by the end of the year and was able to return to her university studies. She then sued her doctor for not having warned her about the increased risk of thromboembolism with dianette and that he should have suggested other treatment options for her acne.

The case was discussed by experts. The general consensus was that the standard of care was satisfactory. It was reasonable to prescribe dianette for the management of acne and contraception to an 18 year old nonsmoker who was otherwise healthy. The only thing against the doctor was that he had not discussed the slightly higher risk of thromboembolism with the patient. They agreed that the timing of PE was closely linked to switching of contraceptive. However on the balance of probabilities she may have still suffered a PE had she continued on microgynon.

The medical protection society defended the doctor and before the trial, settled on a drop hands offer with each party bearing their own costs. This was accepted by the patient.

Badri.

( This case was reported from the case files of the Medical Protection Society in November 2015)