implant guideline Flashcards
what is the dose of etonogestrel in the implant?
68mg etonogestrel (this is the active product of desogestrel)
what are the measurements of nexplanon
4cm long, 2mm wide
out of the following implants which is radio-opaque?
Implanon
Nexplanon
nexplanon (contains barium) whereas implanon doesn’t (previous implant not licensed anymore)
how many rods does Jadelle have and how long is licensed to be used for contraception
2 rod device, licensed for contraception 5 years
in what situations can you insert an implant and it be effective immediately if NOT using any contraception currently?
D1-5 natural cycle
<d21 post partum
<d5 post abortion/ectopic/miscarriage
LAM (<6 months, exclusively BF and amenorrhoeic) although this could be classed as contraception!
how many rods does Norplant have?
6 rod device, was licensed for 5 years but no longer licensed
how long is Sino-implant effective for contraception and how many rods does it have
2 rod device, good for 4 years as contraception
advice regarding a broken implant to a patient that is still within the 3 year licence period for contraception would be:-
a) best to remove as unsure if still effective
b) can stay in have evidence from RCTs no reduction in contraception efficacy
c) can stay in and be removed closer to expiry, data from in vitro (lab studies) demonstrate no reduction in efficacy as contraception
c
note we only have in vitro studies no invivo
no evidence to guide best practice to remove a broken implant
always measure a broken implant to ensure we have removed it all.
if you remove a broken implant who should you report this to and what is it called the reporting system
yellow card system via MHRA
in a broken implant the level of ENG levels increase or decrease? can you explain why
In vitro studies show that ENG levels actually increase as we have increased surface area… therefore no evidence to suggest decreasing contraception efficacy but if a patient wants it changing/removing obviously can do this…
if a patient has a broken implant what questions in your history should you ask about and what should you rule out?
-any blunt trauma
-date and time of fitting
- ? any local reaction following implant fit
- any infection post fit
- bleeding pattern has it changed to co-incide with implant break
? rule out pregnancy as has been some case reports of implant failure when broken.. but MSD stance is in vitro studies no reduction in implant efficacy
if a patient has a deep, non-palpable implant that is still in date and has been localised on x-ray or USS what would your advice be re removal
can keep in situ until time to remove. still effective as contraception, no need to rush to remove
how should a deep implant be removed
under USS guidance by a specialist, no clear evidence exists to describe the ‘best method’
what is the failure rate of an implant during its first year of use
0.05% (highly effective)
what is the licence duration of the implant and what does the current guideline state in regards to fourth year of use and need for EC?
Licence duration is 3 years, not advised to use beyond this duration but we know that risk of unintended pregnancy in the fourth year of use is very low.
Hence if attending for implant change etc no need to offer EC in fourth year of implant use just proceed to rule out pregnancy and then change implant/QS onto another option for contraception
If a patient attends and is using an implant which is currently been in situ for 3 years and 4 months, can you insert a Cu-IUD or LNG IUS
yes! new guidance would suggest:-
UPSI >21 days then PT and fit the coil if PT negative, what 7 days for LNG IUS to be effective, Cu-IUD effective immediately
UPSI <21 days ago, PT negative, fit coil with same time frame re effectiveness and then repeat UPT in 21 days
This is because risk of pregnancy is so low in 4th year of use!
if a patient attends clinic requesting LNG- IUS and has had her implant in for >4 years and last UPSI sex was <21 days ago what would you do?
UPT rule out pregnancy today, if negative, consider need for EC and bridge
bring back once >21 days and can rule out pregnancy then fit the coil.
if an individual is using an enzyme inducer for how long can they be advised that it would reduce efficacy of their nexplanon implant?
duration of use of the enzyme inducer and for 28 days after stopping
how long should someone wait after having UPA-EC before having an implant inserted
5 days, then wait 7 days for implant to become effective
what are some of the benefits of the implant (beyond contraception)
improvement in dysmenorrhoea
some patients report improvement in endometriosis pain
what does FSRH implant guideline state about the need to induce a withdrawal bleed if a patient is amenorrhoeic on the implant with a background of PCOS?
no need to induce a bleed during licence period of the implant
what happens to risk of VTE and ATE in nexplanon users
evidence suggests NO significant increase in risk
what happens to risk of reducing BMD whilst using nexplanon
too little evidence to exclude or confirm an association between ENG-implant use and reduction in BMD
what does the research suggest can happen to breast cancer risk if using nexplanon or recent use
studies have found a small but statistically significant increase in the risk of breast cancer in current or recent use of hormonal contraception (including nexplanon), but the absolute risk remains very small
how should you council patients regarding irregular bleeding with the ENG-implant
irregular bleeding with the ENG-implant is common.
It is unpredictable
Bleeding patterns can change at any time
what is the chance that patients experiencing ‘unfavourable’ bleeding in the first few months with the implant will improve?
50% chance it will improve
what are some of the reported SE associated with the implant
headache
weight gain
acne
depression
no evidence to confirm or exclude causal relationship
what is recommended insertion site for the implant
what position should the arm be when fitting an implant
measure 8-10cm from the medial epicondyle along the bicipital groove then 3-5cm posterior (inferior) to this point.
Fit the implant perpendicular to the sulcu, SUBDERMAL.
ideally fit in the non-dominant arm, arm abducted to 90 degrees, elbow flexed and hand behind their head.
by flexing the elbow it moved the ulnar nerve anteriorly
What angle should you pierce the skin and introduce the nexplanon needle introducer?
pierce at 30 degrees, then once inserted lower the inserter to be horizontal, retract the needle so you can see the bevel and then whilst retracting the skin with the other hand ensure you are tenting the skin and insert the implant subdermally.
a patient attends asking to have her implant change as her friend as recently had hers fitted over the triceps. Her implant is palpable easily and points but is located over the biceps what would you advise?
can keep in situ, wait until expired to change site no need to based on site.
what is the primary mechanism of action of the ENG-Implant and how quickly do studies suggest we achieve this action?
inhibition of ovulation.
Achieved within a day after insertion (90pg/ml)
(note ovulation is infrequent with ENG-implant, but ovarian activity is not completely suppressed, follicular development is common)
in a study of 16 women following ENG-implant removal how quickly were serum ENG levels below the detection rate
by day 7, pregnancies have been conceived within 14 days of removal of ENG-implant.
what is only UK MEC 4 for implant use
current breast cancer
what are the UKMEC 3s for implant use
past breast cancer
decompensated liver disease
HCC or adenoma
continuation of implant in stroke/ ischaemic heart disease =3
unexplained vaginal disease
if patients are experiencing irregular bleeding with ENG-implant and STIs/ cervical screening all up to date and normal, cervical exam normal and no CI to any treatment what are the additional treatment options they could try?
5 day course mefanamic acid 500mg TDS
OR
CHC 3 month trial (if medically eligible)
how many patients can be expected to be amenorrhoeic on the implant
1 in 4
if a patient attends clinic requesting Cu-IUD and has had her implant in for >4 years and last UPSI sex was <21 days ago what would you do?
check when exactly UPSI was if all UPSI in last 5 days could fit Cu-IUD based on the EC rule. If UPSI between 5-day 21 then can’t fit, rule out pregnancy and bridge and bring back
how many mls of 1% lidocaine does FSRH recommend should be used for implant insertion
2-3mls of 1% lidocaine = 20-30mg
what would addition of adrenaline to the lidocaine do?
adrenaline is a vasoconstrictor so can reduce local bleeding use with 1:200,000 adrenaline
what is the name of local anaesthetic spray that FSRH suggest could be used for implant insertion or removal and how does it work
ethyl chloride spray - is a vas-coolant that by cooling the skin and reducing impulses to local sensory nerves produces a local anaesthetic effect of rapid onset but short duration.
not good for eczema or broken skin.
short duration of action = 60 seconds (perhaps better for fit than removal)
what is standard platelet count to allow for insertion and removal of implants
platelets > 50 * 10^9/L
if a patient is taking CHC and is either on d1-2 of HFI or week 2 and 3 and no missed pills, and wants to switch to the implant do they need any additional contraceptive cover
no, fit implant, effective immediately no additional contraceptive cover.
if a patient is taking CHC and is either on d3-7 of HFI or week 1 and no missed pills but has had sex since start of the HFI, and wants to switch to the implant what would you advise?
no need for PT
fit implant
re-start CHC if (d3-7) and continue for 7 days then can stop or if in week 1 continue chc until 7 days have been completed.
if a patient is taking CHC and is either on d3-7 of HFI or week 1 and no missed pills but Iast sex was prior to HFI, and wants to switch to the implant what would you advise?
no need for PT
fit implant
condoms or re-start/ continue CHC for 7 days until implant effective then stop.
in what situations when switching from HC to an implant is it effective immediately?
correctly taken CHC and in week 2-3 or d1-2 of HFI
Desogestrel POP taken correctly
implant <3 years in situ
DMPA <14 weeks since last dose
if someone is wanting to switch to the implant from the CHC or POP and is taking incorrectly and last UPSI was <21 days ago what can you do
rule out pregnancy test
consider need for EC + EC rules
QS implant, wait 7 days to be effective,
repeat UPT at 7 days
if someone is wanting to switch to the implant from the CHC or POP and is taking incorrectly and last UPSI was >21 days ago what can you do
PT - negative
start implant - wait 7 days till effective
no need for repeat UPT
if someone is wanting to switch to the implant from a traditional POP (e.g. NET or LNG) and is taking correctly, what would you advise re switch
can switch immediately but wait 7 days until effective (condoms for 7 days or continue POP for 7 days)
if switching from and in date or out of date IUS to the implant do you need additional contraceptive cover
yes - implant always takes 7 days to become effective as inhibits ovulation whereas IUS doesn’t!
if someone is wanting to switch to the implant from an in date LNG IUS (< 6 years purpose of exam) and LSI was > 7 days ago what would you advise?
fit the implant, condoms or keep coil for 7 days as will take the implant 7 days to become effective
if someone is wanting to switch to the implant from an in date LNG IUS (< 6 years purpose of exam) and LSI was < 7 days ago what would you advise?
fit implant, keep coil in situ for a further 7 days due to last sex and also to bridge the implant being effective (guideline says condoms as well, but I don’t agree as LNG IUS still working)
if someone is wanting to switch to the implant from a LNG IUS which has been in situ for 6-7 years and LSI was > =7 days ago what would you advise?
rule out pregnancy
negative PT
fit implant
cover for 7 days with condoms or retain IUS for 7 days
if someone is wanting to switch to the implant from a LNG IUS which has been in situ for 6-7 years and LSI was < 7 days ago what would you advise?
rule out pregnancy
negative
PT
fit the implant
keep coil in for minimum of 7 days since last sex to cover that rule, but really keep in for 7 days from date of implant fit that way covers new implant and then no need for condoms (guideline says condoms 7 days and keep coil for 7 days)
if someone is wanting to switch to the implant from a LNG IUS which has been in situ for > 7 years and LSI was < 21 days ago what would you advise?
rule out pregnancy
negative PT
consider EC
fit the implant
remove coil and condoms for 7 days until coil is effective (consider retaining for 7 days to reduce risk of pregnancy)
repeat UPT in 21 days
if someone is wanting to switch to the implant from a LNG IUS which has been in situ for > 7 years and LSI was > 21 days ago what would you advise?
rule out PT
PT negative
fit implant
removal coil
and condoms for 7 days until effective
