1
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Guilbert É, Arguin H, Bélanger M. Migration of etonogestrel subcutaneous contraceptive implants: systematic review and recommendations for practice. EUR J CONTRACEP REPR 2024; 29:115-130. [PMID: 38712717 DOI: 10.1080/13625187.2024.2342919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/05/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Migration is a rare but serious complication of the etonogestrel contraceptive implant, and little is known about its extent. PURPOSE To document and characterise cases of etonogestrel contraceptive implant migration in the scientific literature. METHODS A systematic review of Medline, Embase and Global Health databases was carried out between January 2000 and January 2023 to identify articles presenting implant migrations. Narrative reviews, conference abstracts and articles not written in English or French were excluded. RESULTS Forty-five articles, mostly published since 2016, were identified (eight case series and 37 case reports), for a total of 148 independent cases of migration: in pulmonary blood vessels (n = 74), in non-pulmonary blood vessels (n = 16) and extravascular (n = 58). Many patients are asymptomatic and migration is often an incidental finding. A non-palpable implant and symptoms related to implant location (intra- or extra-vascular) may be indicative of migration. Inadequate insertion and normal or underweight appear to increase the risk of migration. Scientific societies and authors offer practical strategies to deal with implant migration. CONCLUSION Professionals who insert and remove contraceptive implants must be adequately trained. They need to be on the lookout for implant migration, and promptly refer patients to appropriate care if migration is suspected.
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Affiliation(s)
- Édith Guilbert
- Direction of the Development of Individuals and Communities, Quebec National Institute of Public Health, Montreal, Quebec, Canada
- Department of Obstetrics, Gynecology and Reproduction, Faculty of Medicine, Laval University, Quebec, Quebec, Canada
| | - Hélène Arguin
- Direction of the Development of Individuals and Communities, Quebec National Institute of Public Health, Montreal, Quebec, Canada
| | - Mathieu Bélanger
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada
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2
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Hoffman ND, Alderman EM. Long-Acting Reversible Etonogestrel Subdermal Implant in Adolescents. Pediatr Rev 2024; 45:3-13. [PMID: 38161157 DOI: 10.1542/pir.2022-005685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Several effective contraceptive options are available for use by adolescents, including the long-acting reversible subdermal implant and intrauterine devices, which provide a high level of convenience, privacy, and effectiveness for an adolescent. Knowledge of all the effective birth control methods is essential for the pediatrician to be able to provide effective contraceptive counseling for an adolescent. An approach to counseling using a reproductive justice framework, which allows the provider and adolescent patient to engage in shared decision-making, is described. This article focuses on the long-acting reversible etonogestrel (ENG) subdermal implant for adolescents. The ENG implant is labeled for preventing pregnancy by suppressing ovulation. The ENG implant may also have a role in ameliorating dysmenorrhea and heavy menstrual bleeding. Postlabeling studies indicate that the ENG implant is effective for up to 5 years, although the device's labeling states effectivenessup to 3 years. The main contraindication to using the ENG implant is pregnancy itself. Safe initiation of the ENG implant is described, including an approach to determine whether an adolescent is pregnant. The main adverse effect of the ENG implant is an unpredictable bleeding pattern that is most often ameliorated by use of nonsteroidal anti-inflammatory medications, as well as estrogen, if not contraindicated for the patient. Details of the insertion and removal procedures, including potential complications, are described to enable the pediatrician to provide effective anticipatory guidance for the adolescent.
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Affiliation(s)
- Neal D Hoffman
- Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY
| | - Elizabeth M Alderman
- Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY
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3
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Enabi J, Al-Ayyubi R, Amador P, Herrera A, Deepika D. Migration of a Contraceptive Subdermal Device Into the Lung. Cureus 2023; 15:e48179. [PMID: 38046752 PMCID: PMC10693379 DOI: 10.7759/cureus.48179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/05/2023] Open
Abstract
Subdermal contraceptive implants are usually inserted subdermally and carry the possibility to migrate within a small range, usually less than 2 cm from the insertion sites; significant migration over 2 cm is rare. This paper discusses the case of a 38-year-old female patient with a migrated subdermal Implanon contraceptive implant in the left pulmonary artery. On chest computed tomography, roughly a 4 cm long linear hyperdensity foreign body in the left lower lobe was found and was favored to be a migrated Implanon in a subsegmental pulmonary artery branch. An interventional radiologist performed an endovascular removal of the left pulmonary artery Implanon using a right common femoral vein access. Very few cases have been reported of complications with inserting and removing the subdermal contraceptive implants as it is considered a reasonably safe procedure in the hands of physicians familiar with the technique. Therefore, if a properly trained individual had carried out the correct procedure of inserting a subdermal implant, the migration of an implant over 2 cm should not occur.
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Affiliation(s)
- Joud Enabi
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Rami Al-Ayyubi
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Pablo Amador
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Alejandro Herrera
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
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4
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Murshed I, Hon K, Ramponi F. Endovascular retrieval of a symptomatic subdermal contraceptive implant device (Implanon-NXT) lodged in the left pulmonary artery. ANZ J Surg 2023; 93:402-403. [PMID: 35662371 DOI: 10.1111/ans.17841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 04/19/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Ishraq Murshed
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,University of Adelaide, Adelaide, South Australia, Australia
| | - Kay Hon
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Fabio Ramponi
- Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Al Kindi R, Al Salmani A, Al Hadhrami R, Al Sumri S, Al Sumri H. Perspective Chapter: Modern Birth Control Methods. Stud Fam Plann 2022. [DOI: 10.5772/intechopen.103858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This chapter focuses on various modern birth control methods, including combined oral contraceptives, progestogen-only pills, progestogen-only injectables, progestogen-only implants, intrauterine devices, barrier contraceptives, and emergency contraceptive pills. Each contraceptive method is covered in detail, including mechanism of action, effectiveness, health benefits, advantages, disadvantages, risks, and side-effects.
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6
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Humphries H, Upfold M, Mahlase G, Mdladla M, Gengiah TN, Abdool Karim Q. Implants for HIV prevention in young women: Provider perceptions and lessons learned from contraceptive implant provision. PLoS One 2022; 17:e0262043. [PMID: 35025908 PMCID: PMC8758078 DOI: 10.1371/journal.pone.0262043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/15/2021] [Indexed: 12/05/2022] Open
Abstract
Preventing new HIV infections, especially amongst young women, is key to ending the HIV epidemic especially in sub-Saharan Africa. Potent antiretroviral (ARV) drugs used as pre-exposure prophylaxis (PrEP) are currently being formulated as long-acting implantable devices, or nanosuspension injectables that release drug at a sustained rate providing protection from acquiring HIV. PrEP as implants (PrEP Implants) offers an innovative and novel approach, expanding the HIV prevention toolbox. Feedback from providers and future users in the early clinical product development stages may identify modifiable characteristics which can improve acceptability and uptake of new technologies. Healthcare workers (HCWs) perspectives and lessons learned during the rollout of contraceptive implants will allow us to understand what factors may impact the roll-out of PrEP implants. We conducted eighteen interviews with HCWs (9 Nurses and 9 Community Healthcare Workers) in rural KwaZulu-Natal, South Africa. HCWs listed the long-acting nature of the contraceptive implant as a key benefit, helping to overcome healthcare system barriers like heavy workloads and understaffing. However, challenges like side effects, migration of the implant, stakeholder buy-in and inconsistent training on insertion and removal hampered the roll-out of the contraceptive implant. For PrEP implants, HCWs preferred long-acting products that were palpable and biodegradable. Our findings highlighted that the characteristics of PrEP implants that are perceived to be beneficial by HCWs may not align with that of potential users, potentially impacting the acceptability and uptake of PrEP implants. Further our data highlight the need for sustained and multi-pronged approaches to training HCWs and introducing new health technologies into communities. Finding a balance between the needs of HCWs that accommodate their heavy workloads, limited resources at points of delivery of care and the needs and preferences of potential users need to be carefully considered in the development of PrEP implants.
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Affiliation(s)
- Hilton Humphries
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Michele Upfold
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Gethwana Mahlase
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Makhosazana Mdladla
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Tanuja N. Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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7
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Kwal J, Maguire K, Carugno J. Localization and management of nonpalpable radiopaque contraceptive implant. Contraception 2021; 106:3-5. [PMID: 34648815 DOI: 10.1016/j.contraception.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jaclyn Kwal
- Obstetrics, Gynecology and Reproductive Sciences Department, Generalist Division, University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Karla Maguire
- Obstetrics, Gynecology and Reproductive Sciences Department, Generalist Division, University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Division, University of Miami, Miller School of Medicine, Miami, FL, United States.
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8
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FSRH Guideline (February 2021) Progestogen-only Implant. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:1-62. [PMID: 33593815 DOI: 10.1136/bmjsrh-2021-chc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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9
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Carraro do Nascimento V, De Villiers L, Chia GS, Rice H. Aspiration technique for percutaneous endovascular retrieval of contraceptive device embolized to the pulmonary vasculature. Radiol Case Rep 2020; 16:571-574. [PMID: 33384758 PMCID: PMC7772520 DOI: 10.1016/j.radcr.2020.12.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
Contraceptive implant migration into the pulmonary circulation is an uncommon, but potentially serious complication. We describe an "aspiration" technique for percutaneous retrieval of a contraceptive implant from a subsegmental pulmonary artery, using a Penumbra Neuron MAX 088 guiding catheter and a Merit Medical VacLok Vacuum Pressure Syringe, as an alternative to the previously described snare technique. Our patient had an uneventful recovery and was discharged home on the same day.
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10
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Rivera F, Bianciotto A. Contraceptive subcutaneous device migration: what does an orthopaedic surgeon need to know? A case report and literature review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:232-237. [PMID: 32555102 PMCID: PMC7944845 DOI: 10.23750/abm.v91i4-s.9498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/10/2020] [Indexed: 11/23/2022]
Abstract
Subdermal contraceptive implant is approved in more than 60 countries and used by millions of women around the world. Although relatively safe in nature, their implantation and removal may be associated with potential complications, some of which may require surgical intervention. Two types of peripheral neurological complications are reported: complications related to compressive neuropathy caused by device decubitus and complications related to device improper removal. An healthy 35-year-old woman come to our attention for paresthesia from medial side of right elbow to fourth and fifth fingers. Tinel sign was positive on medial side of distal third of right arm, above the elbow, as well. Clinical history of patients revealed a subcutaneous placement of a etonogestrel implant 3 years before. Patients reported disappearing of tactile feeling of subcutaneous contraceptive implant since two months. At clinical examination, implant was not felt in its original subcutaneous place. X-rays control revealed its proximal and deep migration. Surgical exploration for subcutaneous contraceptive implant removal revealed it lying on the ulnar nerve. Patient referred immediate paresthesia disappearing after surgery. At 1 month follow up no motor or sensory alteration were evident. Removal of implants inserted too deeply must be carefully performed to prevent damages to nervous and vascular structures and it should be performed by operators who are very familiar with the anatomy of the arm. In case of chronic neuropathy caused by implant nerve compression only an appropriate patients information about rare but possible neuropathic symptoms related to device migration and a careful medical history collecting can avoid a mistaken diagnosis of canalicular syndrome.
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Affiliation(s)
- Fabrizio Rivera
- Orthopedics and Trauma Department, SS Annunziata Hospital, Savigliano (CN), Italy.
| | - Andrea Bianciotto
- Department of Obstetrics and Gynaecology, SS Annunziata Hospital, Savigliano, CN, Italy.
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11
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Simon C, Maurier A, Gaboriau L, Vrignaud L, Dayani P, Vaillant T, Andrée Bos-Thompson M, Jonville-Bera AP. Incidence and characteristics of intravascular pulmonary migration of etonogestrel implants: A French nationwide study. Contraception 2020; 102:186-189. [PMID: 32417204 DOI: 10.1016/j.contraception.2020.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 03/06/2020] [Accepted: 05/07/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE(S) To describe the features of etonogestrel implant (Nexplanon and Implanon) migration into the pulmonary vasculature and to estimate its incidence in France. STUDY DESIGN We retrospectively reviewed French cases of implant migration into the pulmonary vasculature reported up to 2018. Patient clinical data were collected. The annual incidence of migration was estimated from the number of cases reported and number of implants sold. RESULTS Twenty-seven cases of migration into the pulmonary vasculature were identified. In 19 cases (70%) it was stated that this was into the pulmonary artery (nine into the left branch, four into the right branch and six unspecified) and in the other eight cases (30%) it was it not specified whether this was into the pulmonary artery or one of its branches. The migration was discovered following a request for implant removal in 59% of cases, following respiratory complaints in 24%, and because the implant was no longer palpable in 17%. In the 24 cases for which information on removal (or not) was available, the implant was removed in 15 (60% by an endovascular procedure and 40% by invasive surgery); in the remainder it was left in situ. The incidence of migration into the pulmonary vasculature was 1.23 per 100,000 implants sold [95% CI 0.25-3.58] in 2014, increasing to 3.17 per 100,000 implants sold [1.37-6.24] in 2017. In 2016, the French National Agency for Medicines and Health Products Safety (ANSM) had recommended performing a systematic search for non-palpable implants, including at thorax level. CONCLUSIONS The incidence of migration into the pulmonary vasculature is low. Nonetheless, because the consequences are potentially serious, in December 2019 the ANSM made recommendations to reduce this risk.
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Affiliation(s)
- Corinne Simon
- Regional Pharmacovigilance Center, Department of Pharmacosurveillance, CHRU de Tours, 37044 Tours, France
| | - Ana Maurier
- Regional Pharmacovigilance Center, Department of Pharmacosurveillance, CHRU de Tours, 37044 Tours, France
| | - Louise Gaboriau
- Regional Pharmacovigilance Center, Department of Medical Pharmacology, CHRU de Lille, Lille, France
| | - Laura Vrignaud
- Regional Pharmacovigilance Center, Department of Pharmacosurveillance, CHRU de Tours, 37044 Tours, France
| | - Pauline Dayani
- French National Agency for Medicines and Health Products Safety (ANSM), 93285 Saint-Denis Cedex, France
| | - Tiphaine Vaillant
- French National Agency for Medicines and Health Products Safety (ANSM), 93285 Saint-Denis Cedex, France
| | - Marie Andrée Bos-Thompson
- Regional Pharmacovigilance Center, Department of Medical Pharmacology and Toxicology, CHRU de Montpellier, Montpellier, France
| | - Annie-Pierre Jonville-Bera
- Regional Pharmacovigilance Center, Department of Pharmacosurveillance, CHRU de Tours, 37044 Tours, France; Université de Tours, Université de Nantes, INSERM, SPHERE U1246 Tours, France.
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12
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Rael CT, Martinez M, Giguere R, Bockting W, MacCrate C, Mellman W, Valente P, Greene GJ, Sherman SG, Footer KHA, D'Aquila RT, Carballo-Diéguez A, Hope TJ. Transgender Women's Concerns and Preferences on Potential Future Long-Acting Biomedical HIV Prevention Strategies: The Case of Injections and Implanted Medication Delivery Devices (IMDDs). AIDS Behav 2020; 24:1452-1462. [PMID: 31654172 PMCID: PMC7181384 DOI: 10.1007/s10461-019-02703-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
There are several long-acting biomedical HIV prevention products in the development pipeline, including injections and implanted medication delivery devices (IMDDs). It is critical to understand concerns and preferences on the use of these products in populations that shoulder a disproportionate burden of the HIV epidemic, such as transgender women. This will allow researchers and public health professionals to construct interventions tailored to the needs of these women to promote optimal use of these tools. In studies of other biomedical HIV prevention products (e.g., oral PrEP) it is clear that transgender women have unique concerns related to the use of these strategies. This may have an impact on this group's uptake and sustained use of longacting HIV prevention products. This study conducted four focus groups with N = 18 transgender women in New York City to understand their concerns and preferences on long-acting PrEP injections and IMDDs. Findings showed that participants were overwhelmingly positive about long-acting HIV prevention strategies, though they had some apprehensions. Overall, participants felt that injections and IMDDs could help address adherence challenges, and that transgender-specific needs should be addressed during clinical trials. Also, there were concerns related to injection or IMDD logistics, concerns about injections' or IMDDs' presence in the body, and familiarity with these products affected participants' opinions on them. Findings from this work can be used to inform protocols, measures, materials, and adherence interventions in future initiatives for transgender women using PrEP injections or IMDDs.
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Affiliation(s)
- Christine Tagliaferri Rael
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA.
| | - Michelle Martinez
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - Rebecca Giguere
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA
| | - Walter Bockting
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
| | - Caitlin MacCrate
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- CUNY School of Public Health, New York, NY, USA
| | - Will Mellman
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
| | - Pablo Valente
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - George J Greene
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan G Sherman
- Department of Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Katherine H A Footer
- Department of Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Richard T D'Aquila
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alex Carballo-Diéguez
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA
| | - Thomas J Hope
- Northwestern University Feinberg School of Medicine, and Biomedical Engineering in the McCormick School of Engineering and Applied Sciences, Chicago, IL, USA
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Hindy JR, Souaid T, Larus CT, Glanville J, Aboujaoude R. Nexplanon migration into a subsegmental branch of the pulmonary artery: A case report and review of the literature. Medicine (Baltimore) 2020; 99:e18881. [PMID: 31977894 PMCID: PMC7004701 DOI: 10.1097/md.0000000000018881] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Nexplanon is a 4 cm rod-shaped barium sulphate coated contraceptive implant with a usual subdermal insertion in the inner non-dominant upper arm. Complications proper to subdermal contraceptive implants are unusual and principally localized and minor, comprising infection at the site of implantation, hematoma, abnormal scar development, or local nerve and blood vessel injuries. Infrequently, contraceptive implant migration can happen, though habitually not far from the site of insertion. Pulmonary embolization of the device is remarkably rare and can present with symptoms such as chest pain or dyspnea. PATIENT CONCERNS AND DIAGNOSIS We report one of the rare cases of asymptomatic Nexplanon pulmonary embolism in a 26-year-old female. INTERVENTIONS AND OUTCOMES An endovascular intervention successfully retrieved the device from the lateral segment right middle lobe pulmonary artery without any complications. CONCLUSION Several cases of contraceptive implant migration into the pulmonary artery have been reported to this day. Preventing this life-threatening complication is challenging, and yet, no clear guidelines have been established.
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Affiliation(s)
- Joya-Rita Hindy
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Tarek Souaid
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | | | - Joanne Glanville
- Department of General Surgery at Johnston-Willis Hospital, Richmond, VA, USA
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14
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Thwaites A, Shenava Y. A fractured arm and forgotten contraceptive implant. BMJ Case Rep 2019; 12:12/6/e229361. [PMID: 31177199 DOI: 10.1136/bcr-2019-229361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Annette Thwaites
- EGA Institute for Women's Health, UCL, London, UK.,Sexual and Reproductive Health, King's College Hospital NHS Foundation Trust, London, UK
| | - Yathish Shenava
- Trauma and Orthopaedic Surgery, Queen Elizabeth Hospital, London, UK
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15
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Real world data on Nexplanon® procedure-related events: final results from the Nexplanon Observational Risk Assessment study (NORA). Contraception 2019; 100:31-36. [PMID: 30980829 DOI: 10.1016/j.contraception.2019.03.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/06/2019] [Accepted: 03/17/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES We conducted this study to characterize the frequency of insertion-, localization- and removal-related events and their clinically significant consequences among Nexplanon® (etonogestrel radiopaque contraceptive implant) users in the United States during standard clinical practice. STUDY DESIGN The Nexplanon Observational Risk Assessment (NORA) study was a large, prospective cohort study conducted in the United States. A total of 428 Health Care Professionals (HCPs) who had completed the Nexplanon clinical training program recruited women who were newly prescribed Nexplanon. We collected data on insertion-, localization- and removal-related events experienced during routine clinical practice via questionnaires completed by patients and HCPs. Recruitment began in December 2011 and follow-up ended in October 2017. Data analysis characterized the frequency of procedure-related events. RESULTS We collected data on 7364 insertion procedures. The incidence of incorrect insertion (i.e., initially unrecognized non-insertion, partial insertion or deep insertion) was 12.6 per 1000 insertions (95% CI, 10.2-15.5). Pins and needles/numbness in the arm/hand/fingers was the most common patient-reported event. We obtained data on 5159 removal procedures, of which all were successful but one (due to the location of the implant in deep muscle tissue). No implants were localized outside the arm. The most common challenge reported by HCPs during implant removal was encasement of the implant within fibrotic tissue. CONCLUSIONS Events associated with the insertion, localization and removal of the Nexplanon contraceptive implant were rare and their clinical consequences were generally not suggestive of serious injury. IMPLICATIONS This study is the largest prospective evaluation of events associated with insertion and removal of Nexplanon during routine clinical practice. It demonstrates that complications associated with insertion and removal of Nexplanon are rare when performed by trained clinicians.
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16
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Wilcox KK, Turcer F, Soltes GD, Shin DS. Endovascular retrieval of contraceptive implant embolized to pulmonary artery. Radiol Case Rep 2018; 13:1285-1288. [PMID: 30275923 PMCID: PMC6161411 DOI: 10.1016/j.radcr.2018.08.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 11/26/2022] Open
Abstract
Embolization of subdermally implanted contraceptive devices is a rare but potentially serious event. Timely removal of the embolized foreign body should be considered to prevent possible hemodynamic, respiratory, or hormonal complications. We present a case of a 22-year-old woman with a contraceptive implant embolized to her right lower lobar pulmonary artery, which was successfully managed by endovascular retrieval.
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Affiliation(s)
- Kyle K Wilcox
- Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
| | - Filip Turcer
- Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
| | - George D Soltes
- Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
| | - David S Shin
- Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
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Akhtar MM, Bhan A, Lim ZY, Akhtar MA, Sekhri N, Bharadwaj P, Mullen M. Percutaneous extraction of an embolized progesterone contraceptive implant from the pulmonary artery. Open Access J Contracept 2018; 9:57-61. [PMID: 30140161 PMCID: PMC6054767 DOI: 10.2147/oajc.s165827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The Nexplanon® implant is a commonly used radiopaque contraceptive device that contains progestogen associated with an ethylene vinyl-acetate copolymer resulting in a slow release of the active hormonal ingredient. It is inserted into the subdermal connective tissue and provides contraceptive efficacy for up to 3 years. Device removal for clinical, personal or device “end-of-life span” reasons is straightforward. In rare cases, implant migration can occur locally within centimeters of the insertion site. Distant device embolization is extremely rare and can result in complications including chest pain, dyspnoea, pneumothorax and thrombosis or prevent conception until the active ingredient is depleted. We present one such case, where a Nexplanon® implant embolized into the pulmonary artery of a young female patient. We describe the initial “missed” diagnosis of embolized device on a chest radiograph and subsequent successful percutaneous removal once distant embolization was diagnosed.
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Affiliation(s)
- Mohammed Majid Akhtar
- Institute of Cardiovascular Sciences, University College London, London, UK, .,Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
| | - Amit Bhan
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
| | - Zhan Yun Lim
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
| | - Mohammed Abid Akhtar
- Department of Cardiology and Cardiac Transplantation, Harefield Hospital, Royal Brompton & Harefield NHS Trust, London, UK
| | - Neha Sekhri
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
| | - Preeti Bharadwaj
- Community Gynaecology and Sexual & Reproductive Health Department, Waltham Forest, North East London Foundation Trust, London, UK
| | - Michael Mullen
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
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18
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Laumonerie P, Blasco L, Tibbo ME, Leclair O, Kerezoudis P, Chantalat E, Mansat P. Peripheral Nerve Injury Associated with a Subdermal Contraceptive Implant: Illustrative Cases and Systematic Review of Literature. World Neurosurg 2018; 111:317-325. [DOI: 10.1016/j.wneu.2017.12.160] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 11/30/2022]
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19
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Benjamin MA, Radhakrishnan S. Proximal migration of a subcutaneous contraceptive device resulting in neuropathy. Eur J Obstet Gynecol Reprod Biol 2018; 221:199-200. [PMID: 29290524 DOI: 10.1016/j.ejogrb.2017.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Mridula Ambwani Benjamin
- Department of Community Gynaecology, Royal Free London Hospital, Pond Street, London, NW3 2QG, United Kingdom.
| | - Sheila Radhakrishnan
- Department of Community Gynaecology, Royal Free London Hospital, Pond Street, London, NW3 2QG, United Kingdom
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20
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Park JU, Bae HS, Lee SM, Bae J, Park JW. Removal of a subdermal contraceptive implant (Implanon NXT) that migrated to the axilla by C-arm guidance: A case report and review of the literature. Medicine (Baltimore) 2017; 96:e8627. [PMID: 29310336 PMCID: PMC5728737 DOI: 10.1097/md.0000000000008627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE To report the distant migration of a subdermal contraceptive implant and to suggest that C arm-guided technique is one of the feasible options for removal of the device migrated to the axilla. PATIENT CONCERNS A 41-year-old multipara with tingling sensation in the left axilla was referred for removal of an Implanon NXT which could not be palpated by physical examination or detected by ultrasound scanning. Finally, the device was detected by computed tomography and found migrating to the left axilla. DIAGNOSIS Migration of Implanon NXT to the left axilla abutting the brachial plexus. INTERVENTIONS The device was removed by C arm-guiding. OUTCOMES The patient went home without any procedure-related complications. LESSONS The incidence of distant migration of a subdermal implant is possible and should be checked up regularly. If the device cannot be palpated or detected by ultrasound at the original implanting site, this should be concerned. Since the single-rod subdermal implant is radiopaque, it can be detected by roentgenography. In this case the distant migration was detected in the axilla, therefore using C arm-guided technique is feasible for the removal of the migrating device. After reviewing the literature, totally 10 cases of distant migration were reported including 2 cases of migration which were advanced further to the pulmonary artery as an embolization.
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Affiliation(s)
- Ji Ung Park
- Department of Plastic and Reconstructive Surgery
- Department of Plastic and Reconstructive Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul
| | - Han Sol Bae
- Department of Plastic and Reconstructive Surgery
| | - Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine
| | - Jaehoon Bae
- Korea Association of Health Promotion Medicheck
| | - Jeong Woo Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine
- Department of Obstetrics and Gynecology, Jeju National University Hospital, Jeju, Republic of Korea
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21
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Etonogestrel implant migration to the vasculature, chest wall, and distant body sites: cases from a pharmacovigilance database. Contraception 2017; 96:439-445. [DOI: 10.1016/j.contraception.2017.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/17/2022]
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22
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Kew EP, Senanayake E, Djearaman M, Bishay E. Migration of contraceptive implant into the left pulmonary arterial system. Asian Cardiovasc Thorac Ann 2017; 25:537-539. [PMID: 28605952 DOI: 10.1177/0218492317716589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An 18-year-old woman had an etonogestrel implant inserted into her left upper arm 2 years earlier for menorrhagia. Her symptoms were not well controlled and she requested the implant to be removed. However, clinicians were unable to locate the implant on her left arm. Computed tomography showed that the implant had migrated to a sub-lobar branch of the left lower lobe pulmonary artery. The long-term effect of leaving an etonogestrel implant in the pulmonary arterial system is unknown. This report adds to the small body of evidence on intravascular migration of a subdermally placed contraceptive implant.
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Affiliation(s)
- Ee Phui Kew
- 1 Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Eshan Senanayake
- 2 Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, UK
| | - Madava Djearaman
- 3 Department of Radiology, Birmingham Heartlands Hospital, Birmingham, UK
| | - Ehab Bishay
- 2 Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, UK
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23
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Odom EB, Eisenberg DL, Fox IK. Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert. Contraception 2017; 96:89-95. [PMID: 28583591 DOI: 10.1016/j.contraception.2017.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/17/2017] [Accepted: 05/18/2017] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth B Odom
- Washington University School of Medicine, Division of Plastic and Reconstructive Surgery
| | - David L Eisenberg
- Washington University School of Medicine, Department of Obstetrics and Gynecology
| | - Ida K Fox
- Washington University School of Medicine, Division of Plastic and Reconstructive Surgery.
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Contraceptive Implant Embolism Into the Pulmonary Artery: Thoracoscopic Retrieval. Ann Thorac Surg 2017; 103:e271-e272. [PMID: 28219567 DOI: 10.1016/j.athoracsur.2016.08.094] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 08/06/2016] [Indexed: 11/24/2022]
Abstract
An 18-year old woman had migration of a subdermal contraceptive implant in a subsegmental branch of her left lower lobe pulmonary artery. She was managed successfully through a conservative surgical approach, as the implant was removed from the pulmonary artery thoracoscopically, thereby avoiding the need of thoracotomy or lung resection.
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25
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The US etonogestrel implant mandatory clinical training and active monitoring programs: 6-year experience. Contraception 2017; 95:205-210. [DOI: 10.1016/j.contraception.2016.07.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/12/2016] [Accepted: 07/18/2016] [Indexed: 11/19/2022]
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26
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Gallon A, Fontarensky M, Chauffour C, Boyer L, Chabrot P. Looking for a lost subdermal contraceptive implant? Think about the pulmonary artery. Contraception 2016; 95:215-217. [PMID: 27888047 DOI: 10.1016/j.contraception.2016.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 11/07/2016] [Accepted: 11/16/2016] [Indexed: 11/24/2022]
Abstract
This case highlights a rare but potentially life-threatening complication of a contraceptive implant insertion that was corrected by a noninvasive endovascular procedure. This procedure requires a quick intervention to be successful.
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Affiliation(s)
- A Gallon
- Radiology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - M Fontarensky
- Radiology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France.
| | - C Chauffour
- Gynecology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - L Boyer
- Radiology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - P Chabrot
- Radiology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
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28
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Migration of a contraceptive subcutaneous device into the pulmonary artery. Report of a case. Case Rep Womens Health 2015; 8:6-8. [PMID: 29629312 PMCID: PMC5886001 DOI: 10.1016/j.crwh.2015.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 09/16/2015] [Accepted: 09/16/2015] [Indexed: 11/22/2022] Open
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29
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Amico J, Kumar B, Rosenstein H, Gold M. The Contraceptive Implant: An Updated Review of the Evidence. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-014-0110-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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30
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Patel A, Shetty D, Hollings N, Dodds N. Contraceptive implant embolism into the pulmonary artery. Ann Thorac Surg 2014; 97:1452. [PMID: 24694432 DOI: 10.1016/j.athoracsur.2013.09.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 08/27/2013] [Accepted: 09/05/2013] [Indexed: 11/15/2022]
Affiliation(s)
- Anish Patel
- Royal Cornwall Hospital, Treliske, Truro, Cornwall, United Kingdom.
| | - Dushyant Shetty
- Royal Cornwall Hospital, Treliske, Truro, Cornwall, United Kingdom
| | | | - Nicholas Dodds
- Royal Cornwall Hospital, Treliske, Truro, Cornwall, United Kingdom
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31
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Implanon: A Review of the Literature With Recommendations for Clinical Management. J Midwifery Womens Health 2010; 54:142-9. [DOI: 10.1016/j.jmwh.2008.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Revised: 09/16/2008] [Accepted: 09/16/2008] [Indexed: 11/22/2022]
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32
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Affiliation(s)
- Sam Rowlands
- Institute of Clinical Education, Warwick Medical School, University of Warwick, Coventry, UK.
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Jørgensen NP. [Contraceptive implants--aberrations from insertion and removal procedures]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:733-4. [PMID: 20379334 DOI: 10.4045/tidsskr.08.0511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Contraceptive implants with progestogens are options for women who need long-term contraception. Implanon which contains etonogestrel (the active metabolite of desogestrel) effectively prohibits ovulation over a period of three years. This study presents aberrations from insertion and removal procedures for Implanon in the period 2 February 2002 - 30 June 2008. MATERIAL AND METHODS Information about sales of Implanon in Norway is taken from statistics provided by Farmastat Norway. Aberrations from procedures for insertion and removal of Implanon are based on reports from doctors to the producer. Non-palpable implants to be removed at Volvat Medical Centre in Oslo, were localized by ultrasound and removed surgically. RESULTS In the period 2 February 2002 - 30 June 2008, the producer Organon AS (now Schering- Plough AS) sold 12 898 Implanon implants in Norway and recorded 112 aberrations from existing procedures, the first one 3 March 2003. 18 patients were referred for removal of implants (too deeply inserted) at Volvat Medical Centre in the period 19 January 2004 - 30 June 2008. INTERPRETATION The number of unsuccessful or wrongly inserted implants indicates that doctors should have practiced and be better informed about insertion and removal procedures before using this method. Localization and removal of implants inserted too deeply requires high-frequency ultrasound equipment and surgical experience.
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Mansour D, Fraser IS, Walling M, Glenn D, Graesslin O, Egarter C, Herbst J. Methods of accurate localisation of non-palpable subdermal contraceptive implants. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2008; 34:9-12. [DOI: 10.1783/147118908783332285] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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35
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Hotton J, Salvignol G, Bouaziz H. Relative contraindication to midhumeral block in a patient with contraceptive implant. Anesth Analg 2007; 105:297. [PMID: 17579011 DOI: 10.1213/01.ane.0000263060.95757.d9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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36
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Fraser IS. The challenges of location and removal of Implanon ® contraceptive implants. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2006; 32:151-2. [PMID: 16857065 DOI: 10.1783/147118906777888459] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ian S Fraser
- Department of Obstetrics and Gynaecology, University of Sydney, Sydney, Australia.
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