Evidencing successful experience in removing a lost Implanon using C-arm machine: A case report

Myat San Yi¹, Soe Lwin², Khin Than Yee², Mi Mi Khaing3, Philip Korah¹, Tin Moe Nwe²,

Mon Mon Yee⁴

¹Suri Seri Begawan Hospital, Kuala Belait.

²Universiti Kuala Lumpur (Royal College of Medicine Perak), Ipoh, Malaysia.

³Segi University, Sibu, Malaysia.

⁴Newcastle University Malaysia Campus, Jahore Baru, Malaysia.

*Corresponding Author E-mail: myatsanyee@gmail.com

ABSTRACT:

Subdermal contraceptive implants are one method of long-acting reversible contraception. Implanon NXT provides contraception for 3 years, and Jadelle (Levonorgestrel-releasing implant) for 5 years. The implants are easy to remove through a small opening in the skin. In a small proportion of women the implant will not be palpable or, very rarely, may have migrated. Non-palpable and migrated implants can be removed in an outpatient setting, by doctors who are specially trained and have access to ultrasound and special instruments. In this case report authors share their experience using C-arm machine which resulted in successful removal of Implanon non-palpable contraceptive implant that had become misplaced.

A 26-year-old woman was referred to the hospital for lost Implanon after using Implanon as a long-acting contraceptive. GP's attempt to remove it in the clinic was unsuccessful. It appeared to be embedded in the muscle and after taking the X-ray elbow standard view, it was found to be located 15.6 cm from the dorsal surface of the olecranon process. It was successfully removed with the aid of C-arm machine.

KEYWORDS: Implanon non-palpable, Misplaced implanon, Contraceptive C-arm.

Case Report

A - 26 years old woman with a normal body mass index (BMI) was referred to our clinic by her GP doctor to have her lost Implanon removed. She delivered her baby by Caesarean Section for acute fetal distress 3 years ago. It was inserted in GP surgery on 23rd November 2021. Even though she was happy with this method, she needed to remove in its due time. GP doctor informed her it will be difficult as the rod was merely palpable. It was lost in its track and she was referred here. She was ensued with Xray Elbow and Implanon was found to be 15.6 cm away from dorsal surface of olecranon process, seemed to be embedded in muscle. (Fig 1) Orthopaedic surgeon removed it under general anaesthesia in operation theatre with the aid of C-arm machine. The operation was successful and she was discharged from hospital on the same day.

INTRODUCTION:

Implanon is a long-acting reversible contraceptive which is accepted as well-tolerated, safest and the most-effective method. It is quickly reversible with the estimate pearl index =0.031.¹ The ENG implant is a single (coaxial) rod made up of an EVA copolymer core (40 percent EVA) that contains 68 mg of ENG and a 60-μm skin of EVA copolymer (100% EVA). The length of the implant is 40 mm and 2 mm in diameter. It is popular for its long-acting, reversible contraceptive efficacy releasing progestin etonogestrel (The biologically active metabolite of desogestrel) subdermally.

Its efficacy lasts for up to 3 years. It can be inserted on D1-5 of the cycle. The ideal location for insertion is just beneath the skin on the inside of the non-dominant upper arm, approximately 3–5 cm posterior to the sulcus (groove) between the triceps and biceps muscles and 8–10 cm from the medial epicondyle of the humerus. Pre-insertion counselling should be arranged. Prior to implant insertion, a negative Pap test and pregnancy test are necessary. Its insertion seems to be easy especially after proper training but difficulty may encounter once it becomes impalpable. Most of the cases using ultrasound ensue to detect the location and accomplish to remove it successfully.²

Side effects include change in their bleeding pattern and progesterone side effects such as acne, headache, mood changes, breast tenderness and weight gain. These symptoms usually resolve within the first few months. Others are pain at injection site, haematoma, broken rod and lost/impalpable Implanon as in this case.

Interaction with other drugs like anti-epileptics, anti-viral or for tuberculosis. Risks informed are small scar, infection, migration or loss of its track. Implanon migration or loss of its normal track is not an uncommon complication. There was a case report that it could be migrated to the lungs³. Mostly it was migrated or embedded mainly in the muscle and there is a risk of neurovascular bundle invasion. It was removed under anaesthesia by orthopedic surgeon and USS is the most useful machine in most literature. It can identify the rod, measure the skin/implant depth and predict the precise location of rod in tissue layers. The posterior acoustic shadow of rods served as an indirect means of identification. With a 5 or 7 MHz transducer and a 2 cm stand-off pad positioned between the transducer and the skin surface, scanning in a transverse direction produced the best rod demonstration.⁴The specificity of Ultrasound is 95.7% (95%CI 79.0-99.2%), the positive predictive value is also 95.7%, sensitivity is 85.7% (95%CI 48.7-97.4%) and the negative predictive value is also 85.7%^.5

Etonogestrel determination should be performed to validate the absence of the Implanon when it is not visible on ultrasonography. Phillip James provided data to support the fact that the implants were located using ultrasound, which revealed a straight echogenic rod with posterior acoustic shadowing.⁶Although the literature evidenced that USS is useful during removal of lost device, it was not technically suitable to use in sterile operation theatre. The expertise of doctor to identify the rod with the prompt action of the surgeon undertake to remove the rod soon after ultrasound will achieve the good outcome. Moreover, once the implanon was embedded in the biceps it migrated deeper with the muscle movement. If there are delays, weight changes and fibrosis will make Implanon removal more difficult.

Currently with the advancement of technology, C-arm machine plays an important role in tackling with Implanon loss. C-Arm machine is noted due to its C-shaped arm. It connects the x-ray source on one end and the detector on the other. Numerous specialties, including orthopedic, urological, gastroenterological, and cardiac angiography studies, as well as therapeutic studies involving stents or needle placements, heavily rely on C-Arm devices (Fig. 2). Its foundation was fluoroscopy technology, which allows for real-time, high-resolution X-ray pictures to be delivered, allowing surgeons to do more precise treatments that, like this one, result in improved patient outcomes. There are Compact systems and standard-sized systems, both are capable of handling the majority of cases. The monitor, generator, tube, image intensifier, console, and C-arm are all integrated into a single unit in compact C-Arms. It clears the operation room of clutter and saves a significant amount of space. Compact systems can accommodate the majority of cases and are also less expensive than standard-sized systems.

Aim and objective of this case report is to share our experience on the use of C-arm machine in tackling its uncommon complication.

CASE PROCEEDINGS AND DISCUSSION:

26 year, Parity 1, normal BMI lady was referred to our clinic for removal of lost Implanon from her GP.

It was inserted on 23rd November 2021 after her first delivery by Caesarean section. She attended GP to remove after 3 years according to its validity. GP doctor informed her it will be difficult as the rod was merely palpable. It was totally lost during removal and she was referred to the hospital. She was ensued with Xray Elbow (Fig 1) and Implanon was found to be 15.6 cm away from dorsal surface of olecranon process, seemed to be embedded in the muscle.

Orthopaedic surgeon removed it under general anaesthesia in operation theatre with the aid of C-arm machine. The operation was successful and she discharged from hospital on the same day. Surgeon put the probe on a possible site of lost Implanon and adjusted with C-arm. Once the image was accurately set with the probe, surgeon excised on the skin and cut through layer by layer until it reached the site of Implanon. After identified the Implanon, it was extracted with ease. Haemostasis was thoroughly secured. Wound was closed back in layers and dressing was applied. Patient was discharged uneventfully.

In this case, patient claimed the Implanon was felt deep since the first insertion which is likely due to improper entry technique. Upon removal, GP lost the track of Implanon due to injection lignocaine infiltration and faced with difficulty. The handling during the procedure may escalate the deeper migration of Implanon and completely lost the device.

CONCLUSION:

Correct technique in the first administration of device is essential. Once the device is lost, appropriate diagnostic technique to confirm the location and extent of migration should be certain to avoid intraoperative difficulty and postoperative morbidity. The application of C-arm machine is very beneficial as it is cost-effective, user-friendly and technically easier. Quick referral of family planning provider to tertiary center for lost Implanon and valuable aid of C-arm machine in removal of device result in good outcome as in this case.

CONFLICT OF INTEREST:

There was no conflict of interest between authors.

REFERENCE:

1. Graesslin O, Korver T. The contraceptive efficacy of Implanon®: A review of clinical trials and marketing experience. The European Journal of Contraception and Reproductive Health Care. 2008 Jan 1; 13(sup1):4-12.

2. Singh M, Mansour D, Richardson D. Location and removal of non-palpable Implanon® implants with the aid of ultrasound guidance. BMJ Sexual & Reproductive Health. 2006 Jul 1; 32(3):153-6.

3. Carlos-Alves M, Gomes M, Abreu R, et al. BMJ Case Rep 2019; 12: e230987. doi:10.1136/bcr-2019- 230987

4. Lantz A, Nosher JL, Pasquale S, Siegel RL. Ultrasound characteristics of subdermally implanted Implanon™ contraceptive rods. Contraception. 1997 Nov 1; 56(5): 323-7.

5. Piessens SG, Palmer DC, Sampson AJ. Ultrasound localisation of non‐palpable Implanon. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2005 Apr; 45(2): 112-6.

6. James P, Trenery J. Ultrasound localisation and removal of non‐palpable Implanon implants. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2006 Jun; 46(3): 225-8.

Received on 17.09.2024 Revised on 11.11.2024

Accepted on 25.12.2024 Published on 20.01.2025

Available online from January 27, 2025

Research J. Pharmacy and Technology. 2025;18(1):361-364.

DOI: 10.52711/0974-360X.2025.00056

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Fig (2) C-arm machine	Fig (3) Implanon image with probe in C-Arm
Fig (4) C -Arm setting in OT	Fig (5) Exposed Implanon through wound