Arm flexion during ultrasound assists localization of an intramuscular etonogestrel contraceptive implant

Intramuscular Placement of Birth Control Device: A Multimodality Case and Review

Implantable forms of birth control have been used as a means for convenient and effective medication delivery. Nexplanon® (Merck Sharp & Dohme B.V., Haarlem, the Netherlands) is an implantable birth control device placed in the subcutaneous tissue of the upper medial arm during an in-office procedure. The location of the device is usually confirmed by palpation during a physical exam. In cases where the device is non-palpable, imaging may aid in localization. Implantable birth control devices have a characteristic radiologic appearance, and the location of the device can be confirmed by utilizing ultrasound and/or radiography. Occasionally, sonographic and radiographic studies may have equivocal results necessitating advanced imaging with computed tomography (CT) and/or magnetic resonance imaging (MRI). Subcutaneous location of the device is essential for efficacy and safety. An intramuscular position of the device is inappropriate and may lead to insufficient medication delivery and/or injury to the deep soft tissues. This case reviews the imaging features of a Nexplanon device which had been inappropriately placed into the muscle.

Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert

OBJECTIVES

We aim to describe our experiences and identify patients who may benefit from referral to a peripheral nerve surgeon for removal of contraceptive subdermal implants in which neurovascular injury may occur, and describe a treatment pathway for optimal care.

STUDY DESIGN

We reviewed the charts of 22 patients who were referred to the Division of Family Planning for difficult removal of etonogestrel contraceptive implants between January 1, 2014, and April, 1 2016. Of these, five were referred to a peripheral nerve surgeon due to pain or location of the implant. We evaluated and described these cases and, from our findings, developed recommendations for care in a multidisciplinary team approach.

RESULTS

Two patients reported pain, including one with four previous failed removal attempts. In the two patients with pain, the implants were adherent to a sensory nerve. In another, the implant was within the biceps muscle and difficult to locate. In all cases, ultrasound imaging, general anesthesia and a wide exposure allowed for safe removal and good outcomes. Our multidisciplinary care approach has elucidated important referral and technical considerations that improve patient care and safety.

CONCLUSION

When necessary, multidisciplinary care with a Family Planning expert and possibly a peripheral nerve surgeon may be beneficial in safely removing etonogestrel contraceptive implants that would be difficult or risky to remove in an ambulatory setting.

Removal of a Contraceptive Implant From the Brachial Neurovascular Sheath

Subdermal implantable devices are commonly used for long-acting contraception in the United States and Europe. Although relatively safe in nature, their implantation and removal may be associated with potential complications, some of which may require surgical intervention. Complications may include infection, incorrect implantation, migration, or difficulty with removal. Proximal migration has been reported; however, there are no reports of devices that have migrated within the brachial neurovascular sheath. This case report describes migration of an implantable contraceptive within the brachial neurovascular sheath that required surgical removal.