Nexplanon migration into a subsegmental branch of the pulmonary artery

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.

Safety and Benefits of Contraceptives Implants: A Systematic Review

“…Nexplanon (Merck Whitehouse Station, NJ, USA,) is a 4 cm rod-shaped radio-opaque ENG contraceptive containing barium, easily localized even if not palpable [11,38]. It is inserted subdermally in the inner non-dominant upper arm and should be removed no later than three years after insertion [5]; insertion and removal should be performed by a trained health care practitioner [87]. ENG is released at a rate of 35-45 mcg daily for the first year, 30-40 mcg daily for the second year, and 25-30 mcg daily at the end of the third year [87].…”

“…Other AEs secondary to implant positioning are emotional instability, weight increase, headache, acne, mood disturbances, nausea, lower abdominal pain, hair loss, loss of libido, pain at the implant site, neuropathy, and follicular cysts [5]; vascular disorders (such as deep vein thrombosis) were rarely described [87].…”

“…The Nexplanon Observational Risk Assessment (NORA) study demonstrated that the incidence of incorrect insertion was 12.6 per 1000 insertions (95% CI, 10.2-15.5) [107]. Other implant site complications are pain, infection (cellulitis or abscess), hematoma, abnormal scar development, and blood vessel injuries [5,108]; wound breakdown and subdermal implant reaction were also described [109]. Even if rare, three cases of allergic reaction to barium sulfate are also described in the literature [109][110][111].…”

“…Since 1991, when they were first introduced in the United States, progestin-only subdermal implants have become a safe, widespread contraceptive option [5], providing long-acting, highly effective reversible contraception [6].…”

A case of needle embolism in a drug abuser, a diagnostic and therapeutic challenge

“…Other causes of foreign body embolization in the right heart and in the pulmonary artery are iatrogenic complications, such as embolization of inferior vena cava filter fragments [19,20], or needle-like cement after percutaneous vertebroplasty [21], or embolization of subdermal contraceptive implants [22], all causing cardiac or pulmonary injury.…”