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Outline MVA protocols extracted from papers
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This document is a summary of details regarding MVA protocols extracted from several papers discussing the Manual Vacuum Aspiration technique. It therefore only contains those elements of the protocols discussed within the papers themselves. It could be useful for units wanting to prepare their own MVA protocol. We have listed the papers and their references so you can look them up (or ask us for a copy). We have not listed in this document the references cited within the papers themselves.
You may also wish to read The Royal Cornwall Hospitals, ‘Manual Vacuum Aspiration (MVA) for treatment miscarriage and retained pregnancy tissue – clinical guideline’ and the BPAS protocol, both available on our website, link
Sharma M. Manual Vacuum Aspiration: an outpatient alternative for surgical management of miscarriage. The Obstetrician and Gynaecologist 2015;17: 157-61
The MVA procedure can be performed in an outpatient setting, for example, in a treatment room in an early pregnancy assessment unit. Written consent should be obtained from the woman. Cervical preparation with synthetic prostaglandin E1 (misoprostol) 2-3 hours prior to the procedure is mostly used for termination of pregnancy or missed miscarriage, especially in women with a tightly closed cervix. Some operators prefer to dilate the cervix by starting with a smaller cannula and increasing the diameter until it is possible to insert the required size cannula.
Misoprostol (400 micrograms) can be taken by the woman sublingually, orally or vaginally 2-3 hours prior to the procedure. This makes the cervix softer and easier to dilate with the plastic Karman cannula, thereby avoiding the use of a metal dilator, which may make the procedure less painful. For pre-emptive pain relief, 500mg naproxen or 400-800 mg ibuprofen can be given orally 1 hour before the procedure. In women with contraindications to nonsteroidal anti-inflammatory drugs, paracetamol and/or codeine can be used.
Baseline observations of pulse, temperature and blood pressure are taken on admission. The patient is asked to empty her bladder just before the procedure. Vaginal examination is performed after cleaning and draping, with the woman in the lithotomy position. The size and position of the uterus and cervix are assessed.
The MVA syringe is ‘charged’, that is, a vacuum is created by pressing distal valves of the syringe until they click into the locking position. The plunger is then pulled backwards to generate a vacuum until it locks. A Cusco speculum is inserted to visualise and infiltrate the cervix with a local anaesthetic. Lidocaine hydrochloride 2% anaesthetic gel may be applies topically to the cervix, followed by paracervical injection of local anaesthetic, (30 mg/ml prilocaine and 0.03 IU/ml felypressin) into the four quadrants using a dental needle (0.40 x 35 mm, 27G). About 1-5 ml, that is half to two-and-half cartridges of the local anaesthesia can be given.
The anterior lip of the cervix is held with an Allis forceps, tenaculum or vulsellum. An appropriately sized cannula is inserted into the uterus and, if required, the cervical os is gently dilated with the rounded tip of the cannula. Alternatively, Hegar dilators can be used. The Charged syringe is then attached to the cannula. Once the syringe is fixed, the proximal valves on either side of the syringe are released and the operator moves the syringe in a rotating motion. The intrauterine contents will start being aspirated via the cannula into the syringe. After the syringe is about 80% full with products of conception, it is detached from the cannula. The contents of the syringe are emptied into a bowl. The syringe is charged again and reattached to the cannula and the process repeated until the uterine cavity is empty. At the end of the procedure the products in the bowl can be inspected for confirmation of products of conception and sent for histology. The woman can then recover in an easy chair and should be allowed to go home within 1 or 2 hours after completion of the procedure.
The procedure room in the outpatient department should be equipped with emergency resuscitation equipment including intravenous cannulae, intravenous fluids, adrenalin (epinephrine), oxygen, atropine, oxytocin, misoprostol and a defibrillator, to handle common medical emergencies. Careful selection of low-risk women is important to reduce the chance of unexpected emergencies.
There is no consensus in the literature regarding the section criteria and suitability of the women for MVA in the outpatient department, but the following criteria are used by some:
● haemodynamically stable
● parous women
● well-motivated nulliparous women who can tolerate speculum examination
● ultrasound diagnosis of early fetal demise with crow-rump length <25mm
● ultrasound diagnosis of an incomplete miscarriage with retained products of conception measuring less than 5cm (mean diameter).
● no clinical signs of infection (fever, offensive discharge or generalised lower abdominal pain).
Women who are not suitable for outpatient MVA include those with:
●.10 week period of gestation
● panic attacks
● cervical stenosis
● fibroid uterus .12 week in size
● uterine malformation
● haemorrhagic disorder and treatment with anticoagulants
● allergy or contraindication to the use of misoprostol or to local anaesthetic agents
● postnatal retained products
● uterine infection
● inability to tolerate pelvic examination
● retained products more than 5 cm.
There are no studies comparing the benefits of carrying out MVA under ultrasound guidance with a routine procedure without ultrasound guidance. Theoretically, using ultrasound may decrease the rate of perforation, ensure complete evacuation, avoid excessive curettage and thus prevent adhesions, but it depends on the operator’s expertise in scanning and may increase the overall duration of the procedure. More studies are required to establish its benefits.
One of the most important factors for the success of outpatient MVA is the appropriate management of pain during and after the procedure. Women’s experience with pain during MVA varies widely, with some women feeling no pain while others describe considerable pain. The source of the pain could be anxiety, cervical dilatation and/or uterine manipulation and evacuation. Adequate pain relief should be offered through pre-procedure and post-procedure analgesia, and adequate use of local anaesthesia. Nitrous oxide is useful for women who have severe pain during the procedure. A woman’s anxiety level strongly influences her perception of pain. Her level of comfort can be improved by different factors such as a procedure room that is quiet, comfortable and relaxing, and a clear explanation of what to expect before, during and after the procedure. Healthcare professionals who are calm, friendly, empathetic, unhurried and efficient can also make a considerable difference.
The uterine fundus is enervated by T10 to L1 spinal nerves. These Nerves follow along the ovarian plexus and uterosacral and utero-ovarian ligament. They are not fully accessible by the paracervical block since they accompany the ovarian vessels and are higher in the pelvis than the local infiltration will reach. Ibuprofen 400-800mg or naproxen 500mg given 30-60 minutes prior to the procedure are recommended to decrease the pain caused by uterine cramping.
Miscarriage is an event in a woman’s life that is beyond her control. During this vulnerable period some women may not be able to tolerate the procedure under local anaesthesia. The woman’s preference should be the primary consideration at the time of this early pregnancy loss. Informed choice should be the underlying aim when offering options for management of miscarriage.
Women should be fully counselled on what to expect with each method and be given an information leaflet and sufficient time to decide. Detailed counselling about what to expect during the MVA procedure, aftercare, and a specific telephone contact number to call if they need further discussion or support will help women to cope with the procedure better.
Milingos D, Mathur M, Smith N, Ashok P: Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss. BJOG 2009;116:1268-1271
MVA was offered as a treatment option to women who had been diagnosed with an early fetal demise, or required an evacuation following failed medical treatment of miscarriage or incomplete miscarriage at gestational age (GA) <13 weeks. MVA was also offered to women with mid-trimester incomplete miscarriage. Gestational age was calculated by date of the last menstrual period and/or ultrasound. Apart from MVA all women were offered the choice of medical, surgical and expectant management. Women were offered the option of MVA after full counselling on what to expect during the procedure and if it was felt that they would be able to tolerate it.
All women were administered 400µg of sublingual Misoprostol (Pharmacia Ltd, Milton Keynes, UK) for cervical priming 3 hours or more prior to the procedure, unless the procedure was planned following failed medical treatment. If after administration of Misoprostol, women experienced heavy vaginal bleeding or passed products of conception, a pelvic examination and/or ultrasound was performed to ensure that MVA was still indicated. Prophylactic antibiotics were not routinely administered. All women were screened for genital tract infection, including Chlamydia trachomatis and treated accordingly. The procedure was performed by one doctor and the assistance of a midwife. During the MVA, Anaesthetic gel (Instillagel®, lidocaine hydrochloride 2%; CliniMed Ltd, Loudwater, UK) was applied to the cervix and subsequently local anaesthetic (Citanest with Octapressin®, 3% prilocaine; Dentsply Ltd, Addlestone UK) was administered intracervically at 2-,4-,8- and 10-O’clock. This was administered using a Terumo dental needle (0.40 x 35mm, 27G).
Products of conception were sent to pathology for histology evaluation. Anti-D prophylaxis was administered to all Rhesus negative women. Patients could be discharged 2-hour post-MVA, if they were clinically well, haemodynamically stable, with minimal bleeding and pain. Patients were managed in a dedicated pregnancy loss ward and were advised to contact the ward with any problems on a 24 hour basis. All women were offered a follow-up appointment with a midwife.
Vinod Kumar, Jonathan Chester, Janesh Gupta, Manjeet Shehmar: Manual vacuum aspiration under local anaesthetic for early miscarriage: 2 years experience in a university teaching hospital in the UK. GynaecolSurg; DOI 10.1007/s10397-013-0804-6
All women, with ultrasound scan (USS) confirmed incomplete or early missed miscarriage at less than 12 weeks of gestation, were offered the MVA procedure under LA as an option for the management of miscarriage. Exclusion criteria included suspected septic miscarriage, known uterine anomalies, molar pregnancy, multiple pregnancy and previous cervical knife cone treatment.
Written consent was obtained by the operating surgeon on the gynaecological ward prior to the procedure. All patients were given the option of further intra-operative analgesia or Entonox® (50% nitrous oxide and 50% oxygen; BOC healthcare, Manchester, UK) should they require it.
As the procedure was performed under local anaesthetic, there was no need to fast beforehand. Therefore, all elective patients were encouraged to eat and drink before the procedure to reduce the incidence of hypoglycaemia and vasovagal episodes. All women were administered 800µg of vaginal misoprostol (Pharmacia Ltd. Milton Keynes, UK) for cervical priming at least 2 h before the procedure. All patients had a full blood count and group and save measured before the procedure except in emergency cases.
The procedure was mostly performed electively in the outpatient setting by two hospital consultants in the early pregnancy assessment unit (EPAU). However, in emergency situations of heavy haemorrhage with cardiovascular compromise, the procedure was carried out in the gynaecology ward treatment room, accident and emergency (A&E) or in an operating theatre. Pre-procedure vaginal misoprostol was not administered in emergency situations.
During the MVA, every effort was made to keep the procedure room a relaxed and comfortable environment. One dedicated registered nurse sand one health care assistant (HCA) were present to support the clinician performing the procedure. The patient was positioned on a couch in a lithotomy position and a HCA stood beside her to offer psychological support (Vocal Local) and Entonox if required.
The clinician visualised the cervix, cleaned it with antiseptic solution (unisept®) and applied a single tooth vulsellum to stabilise the anterior lip of the cervix. The LA consisted of a direct intracervical block using 6.6ml 3% mepivacaine hydrochloride (Scandonest, Septodont ltd.) infiltration deep at the cervical isthmus level at 12, 3, 5, 6, 7, and 9 o’clock positions using dental needle (Solo Supra). The cervix was dilated to a minimum of 7mm and the MVA curette of 6 to 9 mm was introduced into the uterine cavity to commence the aspiatyion using a 60-ml self-locking syring (IPAS MVA Plus ® aspirator). Typically , the MVA procedure consisted of no more than three separate suction events, initially rotatingthe syringe and then finishing with an in and out motion, lasting in total between 60s to 2 min. The products retrieved were sent to pathology for histopathology evaluation.
Immediately, post-procedure, 50-100 mg diclofenac and 1 g paracetamol were given rectally for pain relief. When patients could not be prescribed diclofenac due to contraindications then co-dydramol two tablets or Tramadol 100 mg was given orally. In all emergency cases, IV morphine was given in a titrated 5-mg bolus dose up to a maximum of 20-mg dose with Entonox®
Anti-D prophylaxis was administered to all Rhesus negative women.Oxygen saturation monitoring was carried out for at least 2 h prior to discharge in women who underwent emergency MVA and had IV morphine. Patients were usually discharged within 2 h of the procedure. All women were advised to rest for the remainder of the day and were advised to return to work usually within 24-48 h.
On discharge, the patient was given the ward’s contact number, in case of problems, and analgesia in the form of diclofenac or co-dydramol. The patient was instructed to do a urine pregnancy test 2 weeks after the procedure. No follow up was specifically arranged. The patient was instructed to get in contact if experiencing heavy bleeding, pyrexia, severe abdominal pain, abnormal vaginal discharge or had a positive pregnancy test
Pillai M, Welsh V, Sedgeman K, et al: Introduction of a manual vacuum aspiration service: a model of service within a NHS Sexual Health Service.
J FamPlannReprod HealthCare Published Online First: doi:10.1136/jfprhc-2013-100700
Women up to 12 weeks 6 days were also offered the option of MVA under local anaesthesia within the Sexual Health Service outpatient setting.
Woman attending PAS had an ultrasound scan and were offered counselling within the clinic. They were asked to do a self-taken swab for chlamydia and had blood taken for haemoglobin, blood group and antibody screen and, with consent, full antenatal virology screening. Verbal and written information was provided covering the full range of procedural options and available dates. Women were considered unsuitable for outpatient MVA if they were not inclined to have a procedure while fully conscious, if they gave a history of difficulty tolerating speculum examination, or if they had complex medical problems (such as cyanotic congenital heart disease) or were at high risk for bleeding (known clotting factor deficiency or significant platelet disorder). High-risk medical and surgical cases, particularly those at significant risk of bleeding, were managed in theatre with anaesthetic support and trained recovery staff, even if their procedure was performed under local anaesthesia. The MVA procedure was offered to women who had never experienced a speculum examination provided they expressed a clear preference for MVA following detailed discussion of all the procedures for which they were suitable. Women attending with evidence of retained products after medical or surgical termination, or where an intrauterine pregnancy was found to be non-viable at assessment, were offered the same medical and surgical options, including MVA, or conservative management.
MVA procedures were carried out in the outpatient setting of the Sexual Health Service.
On arrival, women self-administered 2×200 mg misoprostol tablets sublingually or vaginally, and they were offered diclofenac 100 mg rectally, which most chose to
self-administer. Some 60–90 minutes later, 11 ml Instillagel® (2% lidocaine gel with chlorhexidine) was inserted through the cervix into the extra amniotic space using an Instillaquil, as described elsewhere. In a minority of cases the cervix was found to be tight, so a further 200 mg misoprostol was administered and more time allowed for cervical preparation. The MVA procedure was otherwise performed approximately
20–30 minutes after the Instillagel administration. Additional analgesia was given by means of a paracervical block with 3×2.2 ml ampoules of 3% mepivicaine injected at the 12, 3 and 9 o’clock positions using a dental syringe with a long 27 g needle, in the manner described by Hamoda et al. Entonox® was available on request.
The same gynaecology couch used for scanning during assessment was used for the MVA procedures, so the scanner was available at the bedside if needed.
The procedures were performed using suction curettes of 6–10 mm diameter, aiming to use a curette size equivalent to the number of weeks of gestation. Where significant resistance was encountered when dilating, a smaller suction catheter was used. We did not attempt to use a suction curette greater than 10 mm diameter in any MVA case. For cases beyond 10 weeks gestation a 10 mm catheter was used and we found this efficient up to 12 weeks 6 days.
Where necessary the cervix was dilated using Hegar dilators, and in a small minority where cervical rigidity was encountered, tapered dilators were used. In difficult cases, and during some training procedures, transabdominal ultrasound was used during the procedure to assist guidance. At the end of the procedure if there was any doubt about completeness the uterus was checked with transabdominal or transvaginal ultrasound.