Manual Vacuum Aspiration (MVA) for Early Pregnancy Loss

Sarah Prager, MDDepartment of Obstetrics and GynecologyUniversity of Washington

Adapted from the Association of Reproductive Health Professionals, Washington, DC, USA

Incidence of Early Pregnancy Loss

Griebel CP, et al. Am Fam Physician. 2005.; Everett C. BMJ. 1997.Smith NC. Contemp Rev Obstet Gynecol. 1988.; Stirrat GM. Lancet. 1990.

≤ 20 weeks’ gestation

600,000to 800,000annually

12%–24% ofpregnancies

What Is a Manual Vacuum Aspirator?

Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet Gynecol. 2004.’ Hemlin J, et al. Acta Obstet Gynecol Scand. 2001.

•Has locking valve•Is portable and reusable•Vacuum is equivalent to

electric pump•Efficacy is same as electric

vacuum (98%–99%)•Has semi-flexible plastic cannula

Comparison of EVA to MVA

Dean G, et al. Contraception. 2003.

EVA MVA

Vacuum Electric pump Manual aspirator

Noise Variable Quiet

Portable Not easily Yes

Cannula 4–16 mm 4–12 mm

Capacity 350–1,200 cc 60 cc

Suction Constant Decreases to 80% (50 mL) as aspirator fills

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.

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.

MVA Instruments

Steps for Performing MVA

A step-by-step, one- page poster

is available from the manufacturer to guide clinicians through the procedure

Products of Conception (POC)

Edwards J, et al. Am J Obstet Gynecol. 1997.MacIsaac L, et al. Am J Obstet Gynecol. 2000.

Procedure is complete when POC are identified

Electric Suction Machine

MVA Aspirator

Moving Out of theOperating Room

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

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

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

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

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 L&D $200 or less in ER

Blumenthal 1994

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

Blumenthal 1994$577 saved per procedure with MVA

Use Caution in Women with…

• Uterine anomalies

• Coagulation problems

• Active pelvic infection

• Extreme anxiety

• Any condition causing the patient to be medically unstable

Complications with MVA

Very rare Same as EVA May include:

• Incomplete evacuation• Uterine or cervical injury• Infection• Hemorrhage• Vagal reaction

MVA Label. Ipas. 2004.

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

Goldberg AB, et al. Obstet Gynecol. 2004.

more…

MVA vs. EVA Complication Rates (continued)

Goldberg AB, et al. Obstet Gynecol. 2004.

Complications

• 2.5% for MVA• 2.1% for EVA (p = 0.56)• No significant difference

more…*Elective not spontaneous studies

MVA vs. EVA Complication Rates (continued)

Goldberg AB, et al. Obstet Gynecol. 2004.

Choice of MVA vs EVA in procedures

• Attendings: 52% MVA• Gyn residents: 59%

MVA• Other residents: 76% MVA

(p<0.001)

Early Abortion with MVA: Study

• Methods• 2,399 MVA procedures, < 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.

MVA and POC: Study

• In group overall • n = 1,726, up to 10 weeks LMP

• Complication rates between MVA and EVA• 37 patients at < 6 weeks’ gestation• In 35 of 37, provider chose MVA • No re-aspirations needed in patients < 6 weeks

Goldberg AB, et al. Obstet Gynecol. 2004.

more…

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.

Patient Satisfaction

• Both EVA and MVA groups were highly satisfied

• No differences in:• Pain• Anxiety• Bleeding• Acceptability • Satisfaction

• More EVA patients were bothered by noiseBird ST, et al. Contraception. 2003.; Dean G, et al. Contraception. 2003.; Edelman A, et al. Am J Obstet Gynecol. 2001.

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)

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.

Effective Pain Management

Respectful, informed, and supportive staff

Warm, friendly environment Gentle operative technique Women’s involvement Effective pain medications

Pain Management Techniques

Lichtengerg ES, et al. Contraception. 2001.Good M, et al. Pain Manag Nurs. 2002.

Local

General or nitrous

Local + IV

10%

32% 58%

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

Paracervical Block

Regular InjectionDeep Injection

Castleman L, Mann C. 2002. Maltzer DS, et al. 1999.

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.

Sharp Curettage and Pain

Often requires increased dilatation

Often painful More difficult to

reduce anesthesia

Forna F, Gulmezoglu AM. Cochrane Library. 2002.

Sharp Curettage and MVA

Generally not indicated Not routinely recommended after MVA

WHO. 2003

more…

Ultrasound and MVA

Not required for MVA

Used by some providers routinely

Use contingent on provider preference and experience

Word Health Organization. 2003.

Counseling for MVA

Effective counseling occurs before, during, and after the procedure

•Woman-centered

•Structured completely around the women’s 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

Counseling for MVA (continued)

• Prepare women for procedure-related effects

• Address women’s 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

Counseling for MVA (continued)

Picker Institute. 1999.

Quality of counseling

Patient satisfaction with care

Post-Procedure Care

• Observe for complications• Bleeding • Pain

• Monitor pain and treat accordingly Monitor vital signs Check bleeding and pain

more…

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.

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.

When Women Should Contact Clinician

Heavy bleeding with dizziness, lightheadedness

Worsening pain not relieved with medication

Flu-like symptoms lasting >24 hours Fever or chills Syncope Any questions

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

Questions?

Papaya Model Demonstration and Practice to Follow