Description
The etonogestrel contraceptive implant is a radiopaque rod inserted into the subcutaneous tissue of the upper arm which should be palpable and easily removed. Intravascular migration of a contraceptive subcutaneous implant is referred in the literature but is considered a rare complication.1
The authors report a case of a healthy 20-year-old woman who had a contraceptive implant placed 2.5 years ago on her left arm and wanted to remove it since she had been experiencing irregular bleeding. The insertion scar was visible near the bicipital groove of her left arm, but the implant was not palpable subcutaneously.
The arm ultrasound and X-ray did not show any signs of the implant and a chest X-ray was performed which also did not reveal any suspicious images. Her etonogestrel serum assay was positive. A chest CT scan revealed the implant in the transition from the left subclavian vein to the left brachiocephalic vein (figures 1 and 2). The implant removal was attempted by fluoroscopy-guided endovascular procedure, with pigtail catheter, without success, because it was already endothelialised in the vein.
Figure 1.
Thoracic CT scan, showing the subcutaneous implant in the transition from the left subclavian vein to the left brachiocephalic vein.
Figure 2.
3D image reconstruction of the thoracic CT scan.
Generally, intravascular foreign bodies should be removed once identified due to risk of thrombosis, further migration or infection, but risks or removal must be balanced against the risk of vascular damage with a second invasive procedure. The patient was informed and after the first failed attempt of implant removal, she accepted that the vascular risk of a second attempt was higher than the benefit.2
Since her etonogestrel serum concentration at 86 pg/mL was below the ovulation suppression concentration of 90 pg/mL, other contraceptive methods were considered and the patient opted for a combined contraceptive pill.
Learning points.
According to manufacturer instructions, the etonogestrel contraceptive implant should be placed over the triceps, other than the bicipital groove.
The diagnostic approach to an impalpable contraceptive implant should include ultrasound and/or X-ray of the arm; if the implant is not visible, then a chest X-ray and/or CT scan should be performed. The etonogestrel serum concentration can help to confirm the presence of the implant.
A multidisciplinary team is imperative in defining a therapeutic approach to each patient and the removal of the implant is not always possible.
Footnotes
Contributors: JPD and CM first received the patient and conducted the clinical case. The imagiological results and future clinical approach were discussed with AB (Chief of the Family Planning Department) and JSB (Chief of the Obstetrics Clinic). JPD explained and asked for the patient consent form. JPD and CM wrote the case report, which was then revised and approved by the other two authors.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient consent for publication: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
- 1. Kang S, Niak A, Gada N, et al. Etonogestrel implant migration to the vasculature, chest wall, and distant body sites: cases from a pharmacovigilance database. Contraception 2017;96:439–45. 10.1016/j.contraception.2017.08.009 [DOI] [PubMed] [Google Scholar]
- 2. Thomas PA, Di Stefano D, Couteau C, et al. Contraceptive implant embolism into the pulmonary artery: thoracoscopic retrieval. Ann Thorac Surg 2017;103:e271–2. 10.1016/j.athoracsur.2016.08.094 [DOI] [PubMed] [Google Scholar]