A fractured arm and forgotten contraceptive implant

• Published in: BMJ case reports 2019-06, Vol.12 (6), p.e229361
• Main Authors: Thwaites, Annette, Shenava, Yathish
• Format: Article
• Language: English
• Subjects: Accidental Falls; Adult; Birth control; Case reports; Contraceptive Agents, Female - administration & dosage; Device Removal - methods; Drug Combinations; Drug Implants; Ethinyl Estradiol - administration & dosage; Female; Foreign-Body Migration - diagnostic imaging; Foreign-Body Migration - surgery; Humans; Humeral Fractures - diagnostic imaging; Images In; Levonorgestrel - administration & dosage; Patients; Reproductive health; Transplants & implants; Trauma; Ultrasonic imaging; Ultrasonography, Interventional; X-rays
• ISSN: 1757-790X; 1757-790X
• DOI: 10.1136/bcr-2019-229361

Correspondence to Dr Annette Thwaites, [e-mail] Description The progestogen-only contraceptive implant is a single, non-biodegradable, flexible rod licensed for up to three years of use.1 2 It is the most effective contraceptive method currently available3 and the most common type of long-acting reversible contraception prescribed in NHS sexual and reproductive (SRH) services.4 Its popularity has risen steadily over the last 10 years and it is now the main method of contraception for 16% of females seen in these services.4 When inserted correctly the implant should be situated subdermally and significant migration is not then thought to occur.1 5 The SPC for Nexplanon states that there have been ‘occasional reports of migration of the implant; usually this involves minor movement relative to the original position, but may lead to the implant not being palpable at the location in which it was placed’.2 A literature search of the PubMed database (2000–2018) found rare cases of etonogestrel implant migration into the vasculature6 7 but no evidence of migration subsequent to arm fractures or trauma. The patient was referred for removal under ultrasound guidance with a high-frequency linear array transducer at an expert implant removal centre, as per current guidance.1 2 Although the positioning was challenging, as the patient’s arm was unable to lie flat when externally rotated, the deep implant removal was carried out successfully without complication using the u-technique and modified ringed vasectomy forceps. Increased awareness of contraceptive implants, across specialities (eg, emergency department, orthopaedics and radiology) is necessary as these may have implications for management (eg, drug interactions or upper arm surgery) and provide an opportunity for early identification of impalpable implants or other complications.