9.5 Manual vacuum aspiration (MVA)

 

Evacuation of the uterine contents using suction.

9.5.1 Indications

• Incomplete abortion before 13 weeks LMP
• Molar pregnancy
• Termination of pregnancy before 13 weeks LMP (see Chapter 12)

 

Note: beyond 13 weeks LMP, MVA is ineffective, except in case of molar pregnancy.

9.5.2 Precautions

• Purulent cervicitis and pelvic infection: start antibiotics before performing the procedure.
• Coagulation disorders: risk of haemorrhage. MVA must be performed in a facility where emergency surgery and blood transfusion are available.

9.5.3 Equipment

• MVA set:
  • 2 Ipas MVA Plus® 60-ml syringes
  • 2 bottles of silicone for lubricating the syringe
  • 20 sets of Ipas Easy Grip® flexible cannulae (4, 5, 6, 7, 8, 9, 10, 12 mm) sterile, single use
  • 5 double-ended Hegar’s uterine dilators (3-4, 5-6, 7-8, 9-10, 11-12 mm)
  • 1 Pozzi forceps, tenaculum
  • 1 Collin vaginal speculum
  • 1 uterine sound
  • 1 Cheron dressing forceps
  • 1 100-ml gallipot
  • 1 stainless steel instrument basket

All the equipment is autoclavable, except the cannulae, which are strictly single use.

 

• For the procedure:
  • 1 sterile drape for laying out the sterile equipment
  • 1 aperture drape to place over the patient’s vulva
  • povidone iodine scrub solution or, if not available, ordinary soap
  • 10% povidone iodine dermal solution
  • sterile compresses and gloves
  • absorbent pad to place under the patient’s buttocks
  • 1 bright light

 

• For local anaesthesia:
  • long sterile needle (either 22G LP or 21G IM)
  • 1% lidocaine (without epinephrine) + sterile syringe and needle

9.5.4 Technique

Follow precautions common to all intrauterine procedures (Section 9.1.1).

Preparing the patient

If the patient has a purulent cervicitis or pelvic infection, start antibiotherapy before performing the MVA (increased risk of uterine perforation). For antibiotherapy, see Section 9.6.6.

 

Cervical ripening

• The cervix is open: no cervical ripening with misoprostol.
• The cervix is closed: misoprostol 400 micrograms single dose, sublingually 1 to 3 hours before the procedure or vaginally into the posterior fornix, 3 hours before the procedure [1] Citation 1. Ipas. (2018). Clinical Updates in Reproductive Health. L. Castleman & N. Kapp (Eds.). Chapel Hill, NC: Ipas.
  https://ipas.azureedge.net/files/CURHE18-march-ClinicalUpdatesinReproductiveHealth.pdf to open the cervix and prevent traumatic cervical dilation.

 

Antibiotic prophylaxis
One hour before the procedure: doxycycline PO 200 mg single dose or azithromycin PO 1 g single dose

 

Oral premedication

• One hour before the procedure: ibuprofen PO 800 mg single dose
• Only in the event of excessive anxiety: diazepam PO 10 mg single dose

 

Note: in case of incomplete abortion with heavy bleeding, the procedure cannot be delayed. In such cases:

• Do not administer oral premedication;
• If the context permits (CEmONC facility and anaesthetist available), perform the procedure under IV conscious sedation or general anaesthesia;
• If IV conscious sedation or general anaesthesia is not feasible, replace the oral premedication with diclofenac IM: 75 mg

Preparing the equipment

Prepare several cannulae of different sizes:

• As a rule of thumb, the cannula diameter should correspond roughly to the gestational age in weeks LMP. For example, at 10 weeks LMP, choose a cannula that is 8 to 10 mm in diameter.
• In practice, the diameter of the cannula inserted will depend on the dilation obtained. For example, if at 10 weeks LMP it is only possible to easily dilate up to a No. 8 dilator, use an 8-mm cannula.

Paracervical block

• Prepare the local anaesthetic: draw up 20 ml of 1% lidocaine.
• Insert the speculum; apply 10% povidone iodine solution on the cervix and vagina.
• Place the Pozzi forceps on the anterior cervix at 12 o'clock and apply gentle traction to the cervix in order to see the transition between the cervix and the vaginal wall. Injections for the paracervical block are given in this transition zone.
• Perform 4 injections, 3 to 5 ml each, at 4 sites around the cervix (2, 5, 7 and 10 o'clock sites), to a maximum depth of 2 to 3 mm; do not exceed 20 ml in total.

Dilation

Dilate the cervix if the cervical canal cannot accommodate the cannula appropriate for gestational age (or the size of the uterus). Dilation should be smooth and gradual:

• With one hand, pull the forceps attached to the cervix and keep traction in order to bring the cervix and the uterine body into the best possible alignment.
• With the other hand, insert the smallest diameter dilator; then switch to the next larger dilator. Continue in this way, using the next size dilator each time, until obtaining dilation appropriate to the cannula to be inserted, without ever relaxing the traction on the cervix.
• Insert the dilator through the internal os. A loss of resistance may be felt: this indicates that there is no need to advance the dilator any further. This loss of resistance is not necessarily felt. In such case, it can be assumed that the internal os has been penetrated when the dilator has been inserted 5 cm beyond the external os.
• Do not force the cervix with the dilators (risk of rupture or perforation, especially when the uterus is very retro- or anteverted).

Aspiration

• Maintain traction on the cervix with one hand by holding the Pozzi forceps.
• With the other hand, gently insert the cannula into the uterine cavity. Rotating the cannula while applying gentle pressure facilitates insertion. Slowly and cautiously push the cannula into the uterine cavity until it touches the fundus; then pull back 1 cm.
• Attach the prepared (i.e. under vacuum) sterile syringe to the cannula.
• Release the valves on the syringe to perform the aspiration. The contents of the uterus should be visible through the syringe (blood and the whitish products of conception).
• Hold the syringe by the tube (not the plunger) once a vacuum has been established in the syringe and the cannula has been inserted into the uterus; otherwise, the plunger can go back in, pushing the aspirated tissue or air back into the uterus.
• Carefully (risk of perforation) suction all areas of the uterus, gently rotating the cannula back and forth 180°. Take care not to lose the vacuum by pulling the cannula out of the uterine cavity.
• If the syringe is full, close the valves, disconnect the syringe from the cannula, empty the contents, re-establish the vacuum, and reconnect the syringe to the cannula and continue the procedure.
• Stop when the uterus is empty, as indicated by a foamy, reddish-pink aspirate, with no tissue in the syringe. It is also possible to assess the emptiness of the uterus by passing the cannula over the surface of the uterus: if a grating sensation is felt or the uterus contracts around the cannula, assume that the evacuation is complete.
• Close the valve, detach the syringe and then, remove the cannula and the forceps. Check for bleeding before removing the speculum.

 

In a surgical setting, aspiration can be done using a cannula connected to the electric suction machine, with a maximum pressure of 800 millibars.

Examining the aspirated contents

To confirm that the uterus has been emptied, check the presence and quantity of debris, estimating whether it corresponds to the gestational age.
The debris consists of villi, foetal membranes and, beyond 9 weeks, foetal fragments. To inspect the tissues visually, place them in a compress or strainer, and rinse them with water.

 

Routine ultrasound to confirm complete uterine evacuation is not recommended.

9.5.5 Patient follow-up

• Do not administer an uterotonic routinely, except in the event of molar pregnancy.
• After the procedure, mild bleeding continues without clots. Monitor vital signs and blood loss for at least 2 hours. Settle the patient comfortably during monitoring period.
• Pain is usually moderate, and relieved by paracetamol and/or ibuprofen (Appendix 7).
• Check and update tetanus vaccination if unsafe abortion is suspected (Chapter 2, Section 2.1.3).
• The patient can go home if the vital signs are stable, she can walk, and she has been given the following information:
  • cramps will continue for a few days (give an analgesic);
  • bleeding will last for 8 to 10 days;
  • menstrual periods will resume within 4 to 8 weeks;
  • she will be fertile again within 8 to 10 days (offer contraception, Chapter 11, Section 11.5);
  • advice on hygiene; no vaginal douches;
  • signs and symptoms requiring consultation: prolonged bleeding (more than 2 weeks), bleeding heavier than normal menstrual periods, severe pain, fever, chills, malaise, fainting.

9.5.6 Complications

• Incomplete evacuation of the uterus due to the use of a cannula too small or to interrupted suction: start over.
• Perforated uterus, bleeding, pelvic infection: see Section 9.6.6.
• Air embolism: very rare; can occur when the plunger of the syringe is pushed while the cannula is still inside the uterine cavity.
• Haematometra: in the hours following the procedure, retention of blood in the uterine cavity. The uterus becomes distended and extremely sensitive. Treat by re-evacuating the uterus, administering an oxytocic agent and massaging the uterus.