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+A 40-year-old woman visited the Department of Obstetrics and Gynecology in our hospital because of a complaint of sudden dyspnea on effort.
+She was previously diagnosed with endometriosis and prescribed a combination oral contraceptive pill (drospirenone/ethinylestradiol betadex, trade name; Yaz™, Bayer, Leverkusen, Germany).
+Following the Kumamoto Earthquakes and subsequent aftershocks in April 2016, she spent 7 nights in a vehicle.
+She noticed sudden dyspnea on effort when she walked outside the car on the 8th morning after the first earthquake.
+Although she walked around for personal reasons during the daytime, she spent nights in her small car with her legs in a hanging position.
+She noticed swelling and pain in her left lower extremity, and her serum D-dimer levels were 13.2 μg/mL.
+Deep vein thrombosis (DVT) was suspected by her home doctor.
+A contrast-enhanced computed tomography (CT)-scan revealed a contrast deficit in the bilateral pulmonary artery (Fig.2A) and in the left lower extremity (posterior tibial, soleus and gastrocnemius vein) (Fig.2B).
+Her right ventricular function was intact (estimated pulmonary artery pressure=29/8 mmHg in cardiac ultrasound).
+Her plasma brain natriuretic peptide and high-sense troponin T concentration levels were 97.2 pg/mL and 0.0061 ng/mL, respectively.
+She was diagnosed with PTE and admitted to our department.
+On admission, her blood pressure was 129/80 mmHg and her heart rate was 72 beats per minute.
+Her degree of oxygen saturation (SaO2) in arterial blood gas was 97.7%.
+Her body mass index was 24.4 kg/m2.
+Electrocardiography and cardiac ultrasound did not indicate heart failure.
+An investigation of most factors related to thrombus formation (including protein C, protein S, antithrombin, and antiphospholipid antibodies) revealed that all such factors were normal.
+The discontinuation of the oral contraceptive and the administration of rivaroxaban (30 mg, daily), a direct oral anticoagulant (trade name: Xarelto™, Bayer) was initiated according to the results of the EINSTEIN-PE trial (3).
+After 7 days, a follow-up contrast-enhanced CT scan revealed a reduction in the thrombosis (Fig.3).
+The patient was followed up with rivaroxaban.
+The patient gave her consent for the publication of this study.