Manual Vacuum Aspirator- A Safe and Cost Effective Tool for Decentralization of Post Abortion Care

N Tasnim, G Mahmud, S FatimaMaternal and Child Health Centre, Pakistan Institute of Medical Sciences, Islamabad. Pakistan

Introduction

Objective

To assess safety and efficacy of office based Manual Vacuum Aspiration (MVA) in comparison with inpatient based elective procedure.

Materials and Methods

A single-centre randomized controlled trial was conducted at MCH centre, PIMS, Islamabad from January 2009 to January 2010.

Inclusion Criteria

• Anembryonic pregnancy• Incomplete miscarriage• Missed miscarriage

Exclusion Criteria

• Bleeding disorders• Hemodynamic instability• Hemoglobin <8g/dl• Medical disorders• Severe anxiety• Molar and septic induced

abortion

A total of 177 women with gestational age less than 12 weeks met the inclusion criteria. Cases which presented in odd dated days underwent

MVA in operation theatre while those in even dated days underwent MVA as outdoor procedure .

Statistical Analysis

Data was analyzed through SPSS version 15. Chi square and student t-test were used for categorical and continuous variables respectively.

Results

•Baseline characteristics

Day care groupn=78

Indoor groupn=99

p-value

Age(yrs)mean±SD

27.15±4.7 27.2±5.20 0.949

Gestational age (wks)mean±SD

9.927±1.258 9.727±1.458 0.338

Parity,n(%)- Primigravida- Multigravida- Grandmultigravida

25(32.0)38(48.7)15(19.2)

32(32.3)60(60.6)7(7.07)

0.043

Indication for procedure,n(%)- Incomplete miscarriage- Missed miscarriage- An embryonic pregnancy

37(47.4)28(35.8)13(16.6)

45(45.5)38(38.3)16(16.2)

0.944

Co-existing risk factors,n(%)Low risk patientsHigh risk patients- Previous I LSCS- Previous II LSCS- Previous III LSCS- Diabetes mellitus- Previous pelvis surgery

76(97.4)1(1.28)0(0)1(1.28)0(0)0(0)

88(88.8)2(2.02)4(4.04)1(1.01)1(1.01)3(3.03)

0.401

Ultrasound parametersmean±SD- Crown-rump length (CRL),mm- Gestational sac diameter,mm- RPOCs,mm

51.21±9.5026.36±6.7452.94±9.19

46.27±10.8529.49±8.9458.39±6.55

0.690.080.06

0102030405060708090

100

96.179.7

Daycare group Indoor group

%

•Complete evacuation rate (success rate)

P<0.05

•Outcome measures assessed were complete evacuation rate of the procedure, mean blood loss, mean hospital stay, mean hospital cost and procedure related complications (uterine perforation, hemorrhage, infection and vagal shock)

•Safety and effectiveness of MVA as an outdoor procedure

Day care groupn=78

Indoor groupn=99

p-value

Hospital stay(hrs)mean±SD

2.72±0.507 12.30±6.89 <0.05

Hospital cost(Rs)mean±SD

779.49±49.304 1428.03±1363.72 <0.05

Mean blood loss(ml)mean±SD

59.62±16.78 58.99±27.68 >0.05

Uterine perforation 0(0) 2(2.02) 0.207

Evacuation rate was significantly higher in women undergoing MVA as daycare procedure. The remaining cases required sharp curettage for the completion of process in both the groups.

Hospital stay and cost was significantly reduced in the day care group as compared to indoor group whereas the mean blood loss was comparable in both the groups. Only 2 cases of uterine perforation were noted in the indoor group.

Conclusion

MVA in office setting is safe, cost-effective and reduces hospital stay as compared to inpatient based management. The intervention provides an excellent opportunity for decentralization of post abortion care.Incorporation of evaluation of patients’ satisfaction and choice would further strengthen the model.

References

Day care group Indoor group

100%Paracervical

block +systemic analgesia

95.9%Paracervical

block +systemic analgesia

4.04%General

anesthesia

•Type of anesthesia used

Manual vacuum aspiration (MVA) is a preferred surgical option for the management of first trimester pregnancy losses. It is superior in terms of being light weight, inexpensive and can be performed under local anesthesia and does not require electricity. It is especially valuable in low resource settings where electricity and surgical suites and not widely available1.Management of early pregnancy failure has moved from operating room to ambulatory setting, however the experience is limited and concerns are enormous2,3. There is only limited data on use of MVA for surgical management of early pregnancy loss and no local data is available with regards to its use in office setting.

•Tasnim N, Mahmud G, Fatima S, Sultana M. Manual vacuum aspiration: a safe and cost-effective substitute of electric vacuum aspiration for the surgical management of early pregnancy loss. J Pak Med Assoc 2011;61:149-53.•Dalton VK et al. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol 2006 Jul; 108:103.•Westfall JM, Sophocles A, Burggraf H. Manual Vacuum Aspiration for first-trimester abortion. Arch Fam Med. 1998;7:559-62.