Advice at time of fitting

• insertion and removal cause discomfort and bruising but technical problems occur in fewer than 1 in 100 procedures
• if an implant cannot be palpated it should be localised by ultrasound before being removed; deeply inserted implants often need to be removed by an expert
• there is no routine follow-up recommended; however the patient should be advised to return at any time if problems or to change or discontinue the method

Risk of neurovascular injury and implant migration

• have been reports of neurovascular injury and migration of the contraceptive implant from the insertion site and in rare cases into the pulmonary artery. Some cases have reported haematoma and excessive bruising at the insertion site and dyspnoea (2)

• although no specific risk factors have been identified, potential risk factors include:
  • deep insertion
  • insertion in an inappropriate site
  • insertion in thin arms

Updated advice for insertion of the implant (2)

• the recommended site for insertion is just under the skin at the inner side of the non-dominant upper arm about 8-10 cm from the medial epicondyle of the humerus and 3-5 cm posterior to the sulcus (groove) between the biceps and triceps muscles
  
  
• subdermal insertion of the implant is the best way to avoid injury, and use of the new site is thought to minimise the risk of migration to the lung and neurovascular injury in case of inadvertent deep insertion. The insertion site is located in an area overlying the triceps muscle, a location generally free of major blood vessels and nerves

• the woman’s arm should be flexed at the elbow with her hand underneath her head (or as close as possible) during insertion and removal of the implant. This increased flexion should deflect the ulnar nerve away from the insertion site, potentially further reducing the risk of ulnar nerve injury during implant insertion and removal. On insertion, it is essential to view the needle and tenting of the skin to ensure subdermal insertion.

Women should be shown how to locate the implant immediately following insertion and advised to check the position of the implant occasionally to ensure it has not migrated.

Advice for healthcare professionals:

• an implant should be inserted subdermally by a healthcare professional who has been appropriately trained and accredited – correct insertion of the implant just under the skin is essential to reduce the risk of neurovascular injury and the implant migrating through the vasculature

• review the updated guidance for how to correctly insert the implant, including an amended diagram that illustrates:
  • the new insertion site
  • the correct position of the arm for insertion (flexed at the elbow with the woman’s hand underneath her head)
  • how to view the needle (by sitting and viewing it from the side) to avoid deep insertion

• show the woman how to locate the implant and advise her to do this occasionally; if she has any concerns, she should return promptly to the clinic for advice

• localise any implant that cannot be palpated (for example, by imaging the arm) and remove it at the earliest opportunity – perform chest imaging if it cannot be located in the arm

• implants inserted at the previous site that can be palpated should not pose a risk and do not need to be moved to the new site; only replace implants if you have concerns regarding their location or if routine replacement is due

• report any suspected side effects to Nexplanon on a Yellow Card, including difficulties with insertion or adverse incidents from migration of the implant or related to its removal

Reference:

1. NICE (October 2005). Long-acting reversible contraception
2. MHRA (February 18th 2020). Drug Safety Update - Nexplanon (etonogestrel) contraceptive implants: new insertion site to reduce rare risk of neurovascular injury and implant migration