Manual Vacuum Aspiration (MVA) for Early Pregnancy Loss

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Manual Vacuum Aspiration (MVA) for Early
Pregnancy Loss

• Sarah Prager, MD
• Department of Obstetrics and Gynecology
• University of Washington
• Adapted from the Association of Reproductive
  Health Professionals,

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Incidence of Early Pregnancy Loss
20 weeks gestation
600,000 to 800,000 annually
1224 of pregnancies
Griebel CP, et al. Am Fam Physician. 2005.
Everett C. BMJ. 1997. Smith NC. Contemp Rev
Obstet Gynecol. 1988. Stirrat GM. Lancet. 1990.
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What Is a Manual Vacuum Aspirator?

• Has locking valve
• Is portable and reusable
• Vacuum is equivalent to
• electric pump
• Efficacy is same as electric
• vacuum (9899)
• Has semi-flexible plastic cannula

Creinin MD, et al. Obstet Gynecol Surv. 2001.
Goldberg AB, et al. Obstet Gynecol. 2004. Hemlin
J, et al. Acta Obstet Gynecol Scand. 2001.
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Comparison of EVA to MVA
EVA MVA
Vacuum Electric pump Manual aspirator
Noise Variable Quiet
Portable Not easily Yes
Cannula 416 mm 412 mm
Capacity 3501,200 cc 60 cc
Suction Constant Decreases to 80 (50 mL) as aspirator fills
Dean G, et al. Contraception. 2003.
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Clinical Indications for MVA

• Uterine evacuation in the first trimester
• Induced abortion
• Spontaneous abortion
• Incomplete medication abortion
• Uterine sampling
• Post-abortal hematometra
• Hemorrhage

Creinin MD, et al. Obstet Gynecol Surv. 2001.
Edwards J, Creinin MD. Curr Probl Obstet Gynecol
Fertil.1997. Castleman LD et al. Contraception.
2006 MVA Label. Ipas. 2007.
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Using MVA for treatment/completion of spontaneous
abortion

• Treatment for spontaneous abortion
• Ensures POC are fully evacuated
• Comfortable for woman due to low noise level
• Portable for use in physician office familiar to
  the woman
• Women very satisfied with method
• Very few studies on MVA in spontaneous abortion

MVA Label. Ipas. 2007.
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MVA Instruments
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Steps for Performing MVA
A step-by-step, one- page poster is available
from the manufacturer to guide clinicians through
the procedure
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Products of Conception (POC)

• Procedure is complete when POC are identified

Edwards J, et al. Am J Obstet Gynecol.
1997. MacIsaac L, et al. Am J Obstet Gynecol.
2000.
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Moving Out of theOperating Room
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Miscarriage Management Why the OR?

• Current practices developed when
• Abortion was illegal
• Uterine evacuation was an emergency
• Antibiotics were not available
• Access to blood transfusion was very limited
• Puerperal (childbed) fever was the scourge of
  nineteenth-century obstetrics and abortion.
• - Joffe 1999

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Advantages of Moving Treatment from OR to
Outpatient Setting

• Avoid the repeated exams that often occur in the
  hospital
• Simplify scheduling and reduce wait time
• Average OR waiting time in U.K.-based study 14
  hours, with 42 of women not satisfied
• Save resources
• Avoid cumbersome OR protocols
• Prolonged NPO requirements discharge criteria

Demetroulis 2001 Lee and Slade 1996
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Advantages of Moving Treatment from OR to
Outpatient Setting (continued)

• Office affords more treatment options
• Vacuum aspiration or misoprostol
• Pain management choices
• Improved patient autonomy and privacy
• Convenience
• Personalized care
• Patient education

Lee and Slade 1996
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Moving Incomplete Abortion to an Outpatient
Setting Johns Hopkins

• Methods
• N 35, incomplete first-trimester abortion
• Compared treatment with MVA in labor and delivery
  vs. conventional care (suction curettage in OR)

Blumenthal and Remsburg 1994
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Moving Incomplete Abortion to Outpatient
Setting Johns Hopkins

• Results
• Decreased anesthesia requirements
• Decreased overall hospital stay, from 19 to 6
  hours
• Decreased patient waiting time by 52
• Decreased procedure time, from 33 to 19 minutes
• Decreased costs per case
• 1,404 in OR
• 827 in LD
• 200 or less in ER

Blumenthal 1994
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Moving Incomplete Abortion to Outpatient
Setting Johns Hopkins
Cost Comparisons Outpatient MVA OR Procedure
Charges Mean () Mean ()
Admission Supplies Anesthesiology ___________________ Total Hospital Charges 10 58 6 _______ 827 137 125 85 ________ 1404
577 saved per procedure with MVA
Blumenthal 1994
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Use Caution in Women with

• Uterine anomalies
• Coagulation problems
• Active pelvic infection
• Extreme anxiety
• Any condition causing the patient to be medically
  unstable

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Complications with MVA

• Very rare
• Same as EVA
• May include
• Incomplete evacuation
• Uterine or cervical injury
• Infection
• Hemorrhage
• Vagal reaction

MVA Label. Ipas. 2004.
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MVA vs. EVA Complication Rates

• Methods
• Vacuum aspiration for abortion up to 10 wks LMP
• Retrospective cohort analysis
• Choice of method (MVA vs. EVA) up to physician
• n 1,002 for MVA n 724 for EVA
• Charts reviewed for complications

more
Goldberg AB, et al. Obstet Gynecol. 2004.
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MVA vs. EVA Complication Rates (continued)
more
Elective not spontaneous studies
Goldberg AB, et al. Obstet Gynecol. 2004.
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MVA vs. EVA Complication Rates (continued)
Goldberg AB, et al. Obstet Gynecol. 2004.
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Early Abortion with MVA Study

• Methods
• 2,399 MVA procedures, lt 6 weeks LMP
• Meticulous inspection of POC immediately after
  MVA
• Results
• 99.2 effective in terminating pregnancy
• 6 repeat aspirations (0.25)
• 14 ectopic pregnancies (0.6) diagnosed and
  treated

Edwards J, Creinin MD. Curr Probl OIbstet Gynecol
Fertil. 1997.
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MVA and POC Study

• In group overall
• n 1,726, up to 10 weeks LMP
• Complication rates between MVA and EVA
• 37 patients at lt 6 weeks gestation
• In 35 of 37, provider chose MVA
• No re-aspirations needed in patients lt 6 weeks

more
Goldberg AB, et al. Obstet Gynecol. 2004.
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MVA and POC Study (continued)


Significantly more re-aspirations for inability
to accurately identify the pregnancy occurred in
electric group.
Goldberg AB et al. Obstet Gynecol, 2004
Goldberg AB, et al. Obstet Gynecol. 2004.
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Patient Satisfaction

• Both EVA and MVA groups were highly satisfied
• No differences in
• Pain
• Anxiety
• Bleeding
• Acceptability
• Satisfaction
• More EVA patients were bothered by noise

Bird ST, et al. Contraception. 2003. Dean G, et
al. Contraception. 2003. Edelman A, et al. Am J
Obstet Gynecol. 2001.
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MVA Safety and Efficacy Summary

• MVA is simple
• Easily incorporated into office setting
• Training/Practice Issues
• Expanding pain management options
• Ultrasound as needed
• No sharp curettage
• Patient-provider interaction
• Instrument processing for multiple use (new
  guidelines)

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MVA and Pain

• Pain is made worse by
• Fearfulness
• Anxiety
• Depression

Belanger E, et al. Pain. 1989. Smith GM, et al.
Am J Obstet Gynecol. 1979. Hansen GR, Streltzer
J. Emerg Med Clin N Am. 2005.
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Effective Pain Management

• Respectful, informed, and supportive staff
• Warm, friendly environment
• Gentle operative technique
• Womens involvement
• Effective pain medications

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Pain Management Techniques

• With addition of
• Focused breathing 76
• Visualization 31
• Localized massage 14

General or nitrous
Local IV
Local
Lichtengerg ES, et al. Contraception. 2001. Good
M, et al. Pain Manag Nurs. 2002.
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Paracervical Block
Deep Injection
Regular Injection
Castleman L, Mann C. 2002. Maltzer DS, et al.
1999.
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Efficacy of Ancillary Anesthesia

• Importance of psychological preparation and
  support
• Music as analgesia for abortion patients
  receiving paracervical block
• 85 who wore headphones rated pain as 0,
  compared with 52 of controls
• Verbicaine (Vocal Local)/Distraction Therapy

Shapiro AG, Cohen H. Contraception. 1975.
Stubblefield PG.Suppl Int J Gynecol Obstet. 1989.
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Sharp Curettage and Pain

• Often requires increased dilatation
• Often painful
• More difficult to reduce anesthesia

Forna F, Gulmezoglu AM. Cochrane Library. 2002.
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Sharp Curettage and MVA

• Generally not indicated
• Not routinely recommended after MVA

more
WHO. 2003
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Ultrasound and MVA

• Not required for MVA
• Used by some providers routinely
• Use contingent on provider preference and
  experience

Word Health Organization. 2003.
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Counseling for MVA

• Effective counseling occurs before, during, and
  after the procedure
• Woman-centered
• Structured completely around the womens needs
  and concerns

more
Breitbart V, Repass DC. J Am Med Womens Assoc.
2000. Hogue CJ, et al. Epidemiol Rev. 1982
Steward FH, et al. 2004. Hyman AG, Castleman L.
2005
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Counseling for MVA (continued)

• Prepare women for procedure-related effects
• Address womens concerns about future desired
  pregnancies

more
Breitbart V, Repass DC. J Am Med Womens Assoc.
2000. Hogue CJ, et al. Epidemiol Rev. 1982
Steward FH, et al. 2004. Hyman AG, Castleman L.
2005
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Counseling for MVA (continued)
Patient satisfaction with care
Quality of counseling
Picker Institute. 1999.
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Post-Procedure Care

• Observe for complications
• Bleeding
• Pain
• Monitor pain and treat accordingly
• Monitor vital signs
• Check bleeding and pain

more
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Post-Procedure Care (continued)

• Give instructions for aftercare/follow-up
• Discuss contraception, if appropriate
• Discharge patient
• Tolerates oral intake (general anesthesia only)
• Vital signs are normal
• Bleeding is minimal

Lichtenberg ES, Shott S. Obstet Gynecol. 2003.
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Instructions for Aftercare

• Warning signs to call a clinician
• Pain management options
• Prophylactic antibiotics
• Many regimens effective
• When to return to normal activities

Lichtenberg ES, Shott S. Obstet Gynecol. 2003.
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When Women Should Contact Clinician

• Heavy bleeding with dizziness, lightheadedness
• Worsening pain not relieved with medication
• Flu-like symptoms lasting gt24 hours
• Fever or chills
• Syncope
• Any questions

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For more information on EPL

• Association of Reproductive Health Professionals
  (ARHP) archived webinar Options for Early
  Pregnancy Loss MVA and Medication Management
• www.arhp.org/healthcareproviders/cme/webcme/index
  .cfm
• Ipas WomanCare Kit for Miscarriage Management
• www.ipaswomancare.com

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Questions?

• Papaya Model Demonstration and Practice to Follow