9.5 Manual vacuum aspiration (MVA)

For more information on MVA: Performing Uterine Evacuation with the Ipas MVA Plus®Aspirator and Ipas EasyGrip®Cannulae: Instructional Booklet (second edition, 2007).
http://www.ipas.org/~/media/Files/Ipas%20Publications/UTEEVAC2E08.ashx



Evacuation of the uterine contents using suction.

9.5.1 Indications

– Incomplete abortion before 12 to 14 weeks LMP.
– Molar pregnancy.
– Termination of pregnancy before 12 to 14 weeks LMP (see Chapter 12).

9.5.2 Contra-indications

Absolute

– Pregnancy (non molar) beyond 14 weeks LMP.

Relative

– Purulent cervicitis and pelvic infection: start antibiotics before doing 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 containing:

  • 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
  • 1 Collin vaginal speculum
  • 1 probe
  • 1 Cheron dressing forceps
  • 1 100-ml galipot
  • 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
  • polyvidone iodine scrub solution or, if unavailable, ordinary soap
  • 10% polyvidone iodine dermal solution
  • sterile compresses and gloves
  • absorptive 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 antibiotic therapy before performing the aspiration (increased risk of uterine perforation). For antibiotic therapy, see Section 9.6.6.

– If the cervix is firm and closed (i.e. molar pregnancy when the cervix is closed), administer misoprostol sublingually or vaginally into the posterior fornix: 400 micrograms as a single dose, at least 3 hours before the procedure1 to open the cervix and prevent traumatic cervical dilation.

– Oral premedication before paracervical block:
An hour before the procedure: diazepam PO, 10 mg
A half-hour before the procedure:
ibuprofen PO: 800 mg
+
codeine PO: 30 mg if < 60 kg; 60 mg if > 60 kg
or
tramadol PO: 50 mg if < 60 kg; 100 mg if > 60 kg

Note: in cases 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), perform the procedure under general anaesthesia;
– If general anaesthesia is not possible, replace the oral premedication with:
diazepam IM: 10 mg (do not administer IV, as there is a risk of respiratory depression)
+ tramadol SC: 50 mg if < 60 kg or 100 mg if > 60 kg before the paracervical block.

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

– Insert the speculum; disinfect the cervix and vagina with 10% polyvidone iodine solution.
– 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 four injections, 2 to 3 ml of 1% lidocaine each, at four sites around the cervix (2, 5, 8 and 11 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 resistance may be felt: this indicates that there is no need to advance the dilator any further. This 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

– Attach the prepared (i.e. under vacuum) sterile syringe to the chosen cannula.
– Maintain traction on the cervix with one hand.
– 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.
– 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 break 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 the surface feels rough, or it feels as if the uterus is contracting 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 mbar.

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.

9.5.5 Patient follow-up

– No routine uterotonic, except in the event of molar pregnancy.

– After the procedure, bleeding continues without clots. Monitor vital signs and blood loss.
Settle the patient comfortably during the monitoring period (at least 2 hours).

– Pain is moderate, and relieved by paracetamol and/or ibuprofen.

– Verify and update tetanus immunization if unsafe abortion is suspected.

– The patient can go home if the vital signs are stable, if she can walk, and she has been given the following information:
• cramps will continue for a few days (prescribe an analgesic);
• bleeding will last for 8 to 10 days;
• menstrual periods will resume within 4 to 8 weeks;
• she will be fertile again immediately (offer contraception, Chapter 11, Section 11.5);
• advice on hygiene; no vaginal douches;
• signs and symptoms for which she must be seen: prolonged bleeding (more than 2 weeks), bleeding heavier than normal menstrual periods, severe pain, fever, chills, malaise, fainting;
• routine follow-up visit 10 to 15 days after the procedure (look for signs of infection, incomplete evacuation).

9.5.6 Complications

– Incomplete evacuation of the uterus due to cannula that is 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.