What happens if a patient becomes pregnant with a contraceptive implant (intrauterine device)?

Pregnancy with Contraceptive Implant

If a patient becomes pregnant with a contraceptive implant (etonogestrel), the implant should be removed, but there is no evidence of increased risk of fetal abnormalities or adverse pregnancy outcomes if the implant is left in place or removed.

Initial Assessment

When pregnancy is confirmed in a patient with a contraceptive implant:

• Confirm the pregnancy with appropriate testing and establish gestational age 1
• Counsel the patient about her pregnancy options, including continuation or termination 1
• Evaluate for ectopic pregnancy, though the risk is not increased with implants compared to IUDs 1

Management Based on Patient Decision

If Patient Desires to Continue Pregnancy

Remove the implant as soon as possible 1, 2

• The implant can be removed at any time during pregnancy through a simple office-based procedure 3, 2
• No evidence suggests that implant removal improves pregnancy outcomes, unlike IUDs where removal significantly reduces risks of spontaneous abortion, septic abortion, and preterm delivery 1
• One case report documented a patient who continued her etonogestrel implant throughout pregnancy and delivery without any adverse maternal or neonatal outcomes 4

Reassurance About Fetal Safety

Etonogestrel exposure does not appear to cause fetal harm:

• Case reports of first-trimester etonogestrel exposure have not demonstrated teratogenic risks or adverse pregnancy outcomes 4
• There is no increase in risk of fetal malformation or impaired infant health in pregnancies conceived during implant use 5
• Fertility returns rapidly after implant removal, with pregnancy rates of 76-100% within 1 year 5

Key Distinction from IUD Pregnancies

Critical pitfall to avoid: Do not apply IUD pregnancy management protocols to implant pregnancies 1

• IUD pregnancies carry substantial risks of spontaneous abortion (80% with LNG-IUD left in place), septic abortion (potentially life-threatening), preterm delivery, and chorioamnionitis 1
• IUD removal significantly improves outcomes when strings are visible 1
• Implant pregnancies do not carry these same risks, as the implant is located in the arm, not the uterus 4, 5

Post-Removal Contraceptive Planning

If the patient desires future contraception after pregnancy:

• Postpartum implant insertion can occur at any time, including immediately postpartum 1
• The implant is safe for breastfeeding women ≥1 month postpartum 1
• Postabortion insertion can be performed within the first 7 days, including immediately after abortion 1

Counseling Points

• Implant failure is extremely rare (<1% in the first year) but can occur, particularly with cytochrome P450-inducing medications like rifampin 2, 6
• No increased risk of ectopic pregnancy with implants 5
• Rapid return to fertility after removal if pregnancy is desired 2, 5