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Bitter pill

01 September 2007

Mrs S was a 29-year-old secretary with two children. She was obese, with a BMI of 35, and smoked 45 cigarettes a day. She went to see Dr D asking for contraception several months after the birth of her second child. Dr D checked her blood pressure, which was normal, and prescribed a combined oral contraceptive pill.

Several weeks later Mrs S became worried about pains in her chest, which seemed worse when she took a breath in. She went to see Dr D, who attributed the pain to muscular strain due to her obesity and advised her to lose weight. He did not ask about haemoptysis or take a medication history.

A month later she made an appointment with Dr C, complaining of shortness of breath and another episode of similar chest pain. Dr C prescribed a course of amoxicillin for what he assumed to be a chest infection. He asked her to come back if things didn’t settle down. When she re-attended, she was given a salbutamol inhaler for a possible diagnosis of asthma. Again, the issue of the combined oral contraceptive pill was not raised.

Over the next 18 months, Mrs S attended the GP practice seven times with similar symptoms. She eventually died of a massive pulmonary embolism (PE). A postmortem examination suggested that she had suffered several smaller emboli before the one that proved fatal.

Expert opinion

GP experts were critical of the GPs for prescribing the combined oral contraceptive pill in the presence of two or more risk factors (obesity and smoking). The British National Formulary (BNF) recommends that prescription should be avoided in the presence of two or more risk factors for venous thromboembolism. These risk factors include obesity with a BMI above 30kg/m2 and smoking more than 40 cigarettes a day.

Experts were also critical of the GPs for failing to consider a PE when she presented with her various complaints. Their view was that a PE should have been in the differential diagnosis with pleuritic chest pain and dyspnoea.

Neither of the GPs took a medication history. The case was settled for a substantial amount.

Learning points

  • Follow current advice when prescribing. National formularies set out clear risk factors for venous thromboembolism when prescribing the combined oral contraceptive pill.
  • Always take a medication history. Many complaints are iatrogenic.
  • If the patient is attending frequently with an ongoing complaint, they do so because they are worried or because there has been a change in their symptoms. It is good practice to take this opportunity to reconsider what could be wrong.