Subdermal implant

Z30.0/Z30.4/Z30.8

Dual protection with barrier methods is recommended to reduce the risk of STIs, including HIV.

The subdermal implant is an effective, safe, reversible, and convenient long-term contraceptive method that does not require daily adherence or frequent follow-up.

  • Progestin-only subdermal implant contraceptive, e.g.:
  • Etonogestrel, subdermal, 68 mg, single-rod implant.

The progestin-only subdermal implant can be inserted at any time during the menstrual cycle, once pregnancy has been excluded. If the implant is inserted within 7 days of the onset of the menstrual cycle the contraceptive effect is achieved on the day of insertion.

The main reason for discontinuation of the implant is irregular bleeding. This requires good counselling before the implant is inserted to inform women that this side effect can occur and can be treated. See Breakthrough bleeding with contraceptive use.
Progestin-only hormonal contraceptives are contraindicated in certain conditions e.g. unexplained vaginal bleeding, active liver disease. Consult the package insert in this regard.

CAUTION
Medicines that induce the metabolism of progestins could reduce contraceptive efficacy. These medicines include efavirenz, rifampicin, phenytoin, carbamazepine, and phenobarbital.
Women on these medicines should be advised to use alternate contraceptive methods such as the copper IUCD or DMPA.
If the client chooses to use the implant, then she should be advised to use dual contraception.

LoEIII [7]

Insertion and removal procedures

  • Participation in a training session is strongly recommended to become familiar with the use of the subdermal implants and techniques for insertion and removal.
  • Only health care professionals familiar with these procedures should insert and remove subdermal implants under aseptic conditions.
  • Insert the implant subdermally just under the skin of the upper non-dominant arm.
  • Important: Refer to the package inserts, for detailed information.

Insertion of etonogestrel 68mg implant:

  • Insertion should only be performed with the preloaded applicator.
  • Have the woman lie on her back on the examination table with her non-dominant arm flexed at the elbow and externally rotated so that her wrist is parallel to her ear and her hand is positioned next to her head:
  • Identify anatomical surface markings to establish the area of insertion, which is the inner side of the non-dominant upper arm about 8–10 cm above the medial epicondyle of the humerus, avoiding the sulcus (groove) between the biceps and triceps muscle and the large blood vessels and nerves situated in the neurovascular bundle deeper in the subcutaneous tissue.
  • Clean the insertion site with an antiseptic solution.
  • Anaesthetise the insertion area.
  • Mark the insertion site with a marker.
  • Insert the implant subdermally
    • Remove the transparent protection cap by sliding it horizontally in the direction of the arrow, away from the needle.
    • Puncture the skin with the tip of the needle slightly angled less than 30° relative to the skin surface.
    • Lower the applicator to a horizontal position. While lifting the skin with the tip of the needle, slide the needle to its full length. You should be able to see the applicator just below the skin. Be seated, looking at the applicator from the side and NOT from above to clearly see the insertion and positioning of the needle just under the skin.
    • While keeping the applicator in the same position and the needle inserted to its full length, unlock the purple slider by pushing it slightly down. Move the slider fully back until it stops.
    • The implant is now in its final subdermal position. Remove the applicator.
  • Always verify the presence of the implant in the woman's arm immediately after insertion by palpation and allow her to feel the implant as well.
  • Apply sterile gauze with a pressure bandage to minimise bruising. The woman may remove the pressure bandage in 24 hours and the small bandage over the insertion site after 3–5 days.

Insertion of levonorgestrel 2 x 75mg implants:

  • Clean the woman‘s upper arm with an antiseptic solution.
  • The optimal insertion area is in the medial aspect of the upper arm about 6-8 cm above the fold of the elbow.
  • Use the scalpel to make a small incision (about 2 mm) just through the dermis of the skin. Alternatively, the trocar may be inserted directly through the skin without making an incision.
  • The implants will be inserted subdermally, in the shape of a narrow V, opening towards the armpit.
  • Anesthetise two areas about 4.5 cm long, to mimic the V shape of the implantation site.
  • Mark the insertion site with a marker.
  • Open the implant pouch by pulling apart the film of the pouch and let the two implants drop on a sterile cloth. Note: Always use sterile gloves or forceps when handling the implants. If an implant is contaminated, e.g. falls on the floor leave it for later disposal. Open a new package and continue with the procedure.
  • The implant is provided with a disposable trocar that is sharp enough to penetrate the skin directly. Thus the disposable trocar can be used to puncture the skin and insert the rods, without the need for an incision.
  • The trocar has two marks. One mark is close to the handle and one close to the tip. When inserting the implants, the mark closest to the handle indicates how far the trocar should be introduced under the skin before loading each implant. The mark closest to the tip indicates how much of the trocar should be left under the skin after the insertion of the first implant. When inserting the trocar, avoid touching the part of the trocar that will go under the skin.
  • Once the tip of the trocar is beneath the skin it should be directed along the subdermal plane horizontally by pointing it slightly upwards and raising the skin (tenting). Failure to keep the trocar in the subdermal plane may result in deep placement of the implants, causing a more difficult removal. Throughout the insertion procedure, the trocar should be oriented with the bevel up.
  • Advance the trocar beneath the skin about 5.5 cm from the incision to the mark closest to the handle of the trocar. Do not force the trocar, and if you feel any resistance, try another direction.
  • Remove the plunger when the trocar is advanced to the correct mark.
  • Load the first implant into the trocar with either tweezers or fingers.
  • Push the implant gently with the plunger to the tip of the trocar until you feel resistance. Never force the plunger.
  • Hold the plunger steady and pull the trocar back along it until it touches the handle of the plunger. lt is important to keep the plunger steady and not to push the implant into the tissue.
  • Do not completely remove the trocar until both implants have been placed. The trocar is withdrawn only to the mark closest to its tip.
  • When you can see the mark near the tip of the trocar in the incision, the implant has been released and will remain in place beneath the skin. You can check this by palpation.
  • Insert the second implant next to the first one, to form a V shape. Fix the position of the first implant with the left fore-finger and advance the trocar along the side of the finger. This will ensure a suitable distance between implants. To prevent expulsions, leave a distance of about 5 mm between the incision and the ends of the implants. You can check their correct position by cautious palpation of the insertion area.
  • After inserting the second implant, press the edges of the incision together, close with a skin closure and dress the wound.
  • Advise the woman to keep the insertion area dry for 3 days.
  • The gauze and the bandage may be removed as soon as the incision has healed, usually after 3–5 days

For pain after insertion:

  • Ibuprofen, oral, 400 mg 8 hourly with or after a meal as needed for up to 5 days.

Removal of progestin-only subdermal implants:

Remove etonogestrel implants at the end of 3 years and levonorgestrel implants at the end of 5 years.

  • Locate the implant/s by palpation. If impalpable refer for ultrasound removal.
  • Clean the removal site with an antiseptic solution.
  • Anaesthetise the removal area.
  • Push down the proximal end of the implant and a bulge may appear to indicate the distal end of the implant.
  • Make a 2-4 mm vertical incision with the scalpel close to the distal end of the implant, towards the elbow.
  • Remove the implant very gently, using a small forceps (preferably curved mosquito forceps). Where an implant is encapsulated, dissect the tissue sheath to remove the implant with the forceps.
  • Confirm that the complete implant has been removed by measuring the length (etonogestrel rod: 40 mm; levonorgestrel rods: 43 mm). Close the incision with a steristrip or plaster and dress.
  • Advise the woman to keep the arm dry for a few days.

REFERRAL

  • Heavy or prolonged bleeding, despite treatment with COCs.
  • Infection at insertion site, inadequately responding to initial course of antibiotic treatment. See Cellulitis .
  • Failure to locate an implant (in the arm) by palpation.