Application of Point of Care Ultrasound in the Removal of Non-Palpable Nexplanon in a Teaching Community Health Center

Abstract

Background Nexplanon is a reversible non-biodegradable progestin-only long-acting hormonal contraceptive subdermal implant removed after three years. Superficial palpable implants are easy to remove in the outpatient setting. However, deep non-palpable implants are traditionally referred to surgery for elective removal. In the wake of Covid-19, emergency cases were prioritized, leaving patients with non-palpable implants unattended. Herein described are five cases of reproductive-age women who presented at our community health center with non-palpable implants. Purpose To show that non-palpable implants can be successfully and safely removed in a teaching community health center under ultrasound localization, guidance, and the direct supervision of an experienced healthcare provider without needing specialty referral. Method We performed a retrospective study by reviewing the charts of all patients who presented at our clinic for Nexplanon® removal from September – October 2021. Data was gathered from our electronic medical records system of patients database. Twenty-nine women were identified; twenty-four had palpable implants and five non-palpable implants. Using a high-frequency linear ultrasound probe to localize non-palpable implants, a 3–5 mm incision was made, and implants were removed successfully under local anesthesia and the direct supervision of an experienced provider. All implants were at depths of 0.22 to 0.56 cm from the surface, and their relationship to fascia, muscle, and vascular structures was assessed before removal. The sterile technique was observed throughout the procedure, and the site of removal was secured with steri strips and wrapped with a bandage for 24 hours to secure hemostasis. No sutures were needed post-removal, and all patients tolerated the procedure well, with minimal bleeding. Results Twenty-four patients (82.7%) had palpable implants successfully removed by manual palpation. Five patients (17.3%) had non-palpable implants removed successfully under ultrasound localization and guidance in our clinic with no complications. Four non-palpable implants were located above the fascia, and one was localized in the fascia within the subcutaneous layer. Patients were discharged in stable conditions with no need for follow-up. Conclusion Our study has shown that non-palpable Nexplanon® implants can be successfully removed under ultrasound localization and guidance in a teaching community health center under the direct supervision of an experienced healthcare provider without the need for specialty referral. It is fast, safe, practical, and cost-effective, provides accessibility and availability of expertise without heavy cost bearing to the patient, and increases overall patient satisfaction.