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Clinical Crossroads: A 36-Year-Old Woman Recuperating From Stroke

Jeffrey A. Kuller, MD; John M. Thorp Jr, MD; Watson A. Bowes Jr, MD
JAMA. 1997;278(13):1061. doi:10.1001/jama.1997.03550130035023.
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To the Editor.  —We read with interest Dr Alexander's Clinical Crossroads, which discussed a 36-year-old woman recuperating from a stroke,1 but we are surprised that, despite advising the patient to increase activities at home, including resumption of her sex life, there is no discussion of contraception issues in this married, apparently fertile woman with 4 previous pregnancies. Pregnancy prevention is particularly important in this patient recuperating from a life-threatening event. In addition, warfarin is a teratogen; 15% to 20% of infants exposed to coumarin derivatives in the first trimester develop the fetal warfarin embryopathy syndrome.1Contraceptive issues in this patient are complex. Certainly barrier methods would be considered safe. An intrauterine device would be another reasonable option. Oral contraceptives should be considered with caution since the risk of both ischemic and hemorrhagic stroke is slightly increased in older users of combined oral contraceptive agents.2,3 Male or female sterilization is another reasonable


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