Implant migration in the axillary region: case study in Mali

Implant migration in the axillary region: case study in Mali

Ousmane Sylla^1,&, Aly Ouattara², Zakaria Keita³

¹Reference Health Center of Yanfolila, Regional Direction of Health Sikasso, Sikasso, Mali, ²Independent Consultant in Health, Association la Rage en Afrique de l´Ouest, RIWA/REAO, Mali

^&Corresponding author
Ousmane Sylla, General Direction of Health and Public Hygiene, Bamako, Mali

Introduction    

Etonogestrel implant is one of the methods that has the best theoretical and practical effectiveness (99.9%) in preventing unwanted pregnancy and birth spacing [1-3]. It is consisted mainly of 68 mg of etonogestrel and 3% of barium sulphate that determine its localization (Radio-opacity). Etonogestrel implant acts by blocking the oocyte production and alters the cervical mucus, slowing the passage of sperm. Marketed in Mali under the name Implanon NXT^®, it is a flexible rod 4 cm long by 2 mm in diameter, not biodegradable. Its laying device ensures a superficial insertion (subcutaneous). Etonogestrel implant action is spread over 3 years and reversible. The installation can be carried out by qualified personnel [2,3], but also by women who are trained to help nurses (matrone).

Patient and observation     

A 32-year-old patient came for medical examination on July 18, 2019 at the maternity unit of Cscom Central (Community Health Center); because she can no longer feel the rod of Etonogestrel implant that she had inserted at the level of the left arm by a matrone on January 22, 2019. Several unsuccessful attempts were made by the practitioner who made had inserted the Etonogestrel implant and two other colleagues to find the Etonogestrel implant through palpitation medical check. Thus, ultrasound was requested. Ultrasound confirmed the presence of the implant in the axillary region and 17 cm from the initial insertion point (Figure 1). Through clinical examination, we found that the patient has 7 children all alive (5 boys and 2 girls), blood pressure is at 115/70 mm of mercury, heart rate at 90 beats per minute, the body temperature is 37.5^oC and it weighs 45 kg. The rest of the clinical examination finds no particularity. While first attempt to remove the implant failed before ultrasound imaging, the second attempt of extraction of the rod was successfully completed after ultrasound imaging. Extraction of the implant was done by an incision of 2 cm under the skin and under local anesthesia at 17 cm from the initial insertion point (Figure 1). These were conducted without incident and accident.

Discussion     

In fact, it was a 32-year-old lady, who came to the center to know the location of it contraceptive implant rod following the impossibility of the providers to palpate the rod; the ultrasound has localized the rod in the left axillary region. It seems that this migration requires some time which is about ten months according to the clinical case study of Maroteix et al. 36 months as reported by Yibrah et al. and 7 months in our current case study [4,5]. Furthermore, Evans et al. observed two cases of migration in thin and nervous women. These women were physically active within a week of insertion. [6,7]. This confirmed our case that she is a housewife and she is the only one who takes care of her seven children, but she says that she did not engage in any intense activity during the six days of the insertion. However, other factors that would be involved in this migration are the insertion technique for Maroteix et al. Evans et al. confirmed our case study pointing out the service provider who is a matrone that not a qualified staff [4,6]. Moreover, for Evans et al. the incision point used to withdraw Norplant, was immediately used for the insertion of Implanon, an element different from our case [6]. Evans et al. reported two cases of rod migration in cranial direction with the first case at 7.3 cm and the second at 11.5 cm from the insertion point. While Yibrah et al. Uwagbai and al found a migration distance at 12 cm from the insertion point however our case is at 17 cm, a greater distance than those found by other studies [5,6]. But, for some time, cases of implant migrations to the pulmonary artery have been reported [4,6,8]. In addition, most of these migrations are observed among women under the age of 35, in our case, she was 32 years old. Diego et al. Uwagbai et al. reported cases for 19 and 20 years old respectively, unlike Yibrah et al. who find 30 years old. These results lead us to suspect age involvement in strand migration [5,7,9].

Conclusion     

Finally, we were able to remove the rod during the second attempt after an Ultrasound which localized it in the axillary region; and perhaps because we did not have an advanced technical tray as interventional ultrasound, whereas the manufacturer recommends not attempting to remove an impalpable Implanon without ultrasonic guidance. Hence the urgent need to equip rural sanitary structures in advanced care technology such as the interventional radiology department [1,10,11].

Competing interests     

The authors declare no competing interests.

Authors' contributions     

We are all responsible for the work described in this document. We have all participated in at least one of the following activities: data design, acquisition, statistical analysis and interpretation, in addition to writing the manuscript and/or editing the manuscript for intellectually significant content. We have given our final approval of the version to be published and agree to report on all aspects of the work, ensuring that questions related to the accuracy or integrity of a portion of the work are appropriately investigated and resolved.

Figures     

Figure 1: etonogestrel implant rod extraction in the left axillary region

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