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Manual Vacuum Aspiration

(Published June 2008)

Indications for MVA Use

Use of MVA in Early Pregnancy Loss

Early pregnancy loss is a common experience for women. Approximately one in four women will experience a miscarriage in her lifetime. 1 For women undergoing early pregnancy loss, vacuum aspiration is one treatment option. MVA has been reported to be safe and effective for this indication.1-3

Use of MVA for Elective Termination of Early Pregnancy

The efficacy of MVA is comparable to that of EVA, with completion rates in most studies of 98% or greater.4 With highly sensitive urine pregnancy tests that can detect pregnancy even before a missed period, early abortions are possible. Because women can make a decision about their pregnancy as early as three or four days after a missed period, providing safe and effective options early in pregnancy increases the opportunities for women to access desired care.

Use of MVA for Completion of Failed Medical Abortion

Although the success rate of medical abortion using modern regimens of mifepristone and misoprostol typically exceeds 95%, aspiration is sometimes necessary for management of a continuing pregnancy, a persistent gestational sac, or heavy or prolonged bleeding. MVA offers an alternative to either D&C or EVA to manage this situation.2,3,5

MVA Safety and Efficacy

Studies over the past 30 years have documented the safety and efficacy of MVA for early elective abortion and management of early pregnancy loss.

Table 1: Summary of Results from Six Comparative Studies of MVA versus EVA4,6-10

Data from a major retrospective study of 1,677 MVA procedures for elective abortion (99% < 10 weeks’ gestational age) show:6

  • 99.5% effectiveness*
  • Minimal complications
    • 8 repeat aspirations (0.5%)
    • 12 infections (0.7%)
    • 1 uterine perforation (0.06%)

Data from a randomized study comparing MVA with EVA for elective abortion (91 MVA vs. 88 EVA procedures < 56 days gestational age) show:4

  • 98% effectiveness**
  • Minimal complications
    • 2 repeat aspirations (2.0%)
    • 2 infections (2.0%)
  • No differences for MVA vs. EVA

Data from a randomized trial comparing MVA with EVA for first trimester elective abortion (41 MVA vs. 42 EVA procedures < 10 weeks’ gestational age) show:7

  • No statistically significant differences between groups in procedure time, estimated blood loss, complications, amount of analgesia used, or recovery time
  • The two methods (MVA and EVA) equally acceptable to patients

Data from a retrospective cohort analysis comparing MVA and EVA for first trimester abortion (1002 MVA vs. 724 EVA < 10 weeks’ gestational age) show:8

  • Procedure times similar for MVA and EVA
  • Blood loss statistically lower with MVA***
  • 22 reaspirations in MVA (2.2 %)
  • 12 reaspirations in EVA (1.7%)
  • Overall, no difference in rate of uterine reaspiration with MVA or EVA

Data from prospective study of 115 women with early pregnancy loss cared for in the outpatient setting show:9

Minimal complications

  • 3 repeat aspirations (3%)
  • 2 post-procedure infections (2%)
  • 1 unplanned hospital admission (resolved before intervention needed) (0.9%)

Data from randomized study comparing 89 MVA in outpatient clinic with 68 EVA in OR for treatment of early pregnancy loss show:10

95% effectiveness for MVA

  • •Minimal complications
    • 1 fever (temp >101.4 º F (2%)
    • 3 emergency hospital visits on same day of treatment (5%)
  • No safety of side effect differences for MVA vs. EVA
  • Less missed time from school or work and less need for help from others in MVA patients.
* Overall, MVA was 99.5% effective in terminating pregnancy through 12 weeks of gestation. There were no major complications, and the minor complications of retained products of conception and infection were easily treated.
** MVA is effective in emptying the uterine cavity, on par with the standard vacuum aspiration. The rate of complications with MVA was on the same low level as EVA.
*** Although blood loss was statistically lower with MVA, the difference between an estimated blood loss of 35 and 42 mL is not clinically important.

Contraindications and Cautions in Use of MVA

There are no contraindications for aspiration of the uterus using MVA up to 12 weeks gestation. Use of MVA for pregnancies between eight and 12 weeks gestation may require emptying of the syringe barrel one or more times to complete the procedure. Alternatively, multiple syringes may be used in succession. Like EVA, MVA should not be used for endometrial biopsy in the case of suspected pregnancy11 and should be used with caution in women who have:
  • Uterine anomalies
  • Coagulation problems
  • Active pelvic infection
  • Extreme anxiety
  • Any condition causing the patient to be medically unstable

Life-threatening conditions must be addressed and managed before uterine aspiration, regardless of the vacuum source.

Possible MVA Complications

Any instrumentation of the uterus can result in complications.11,12 MVA use is associated with an overall complication rate of about 2%, the majority of which are required reaspiration and perforation.8

It is important to be able to diagnose and manage possible complications of MVA. These complications are similar for procedures performed with EVA or are a function of the indication for the procedure itself:

  • Incomplete evacuation: Although using a cannula that is too small or stopping the aspiration too soon can result in retained tissue, subsequent hemorrhage, and infection, the majority of such complications occur when the procedure is performed appropriately. Careful observation for signs of procedure completion and meticulous tissue examination are the best ways to minimize the likelihood of incomplete evacuation. Risk factors for retained products of conception include greater patient age, body mass index, and pregnancy gestational age.13 Incomplete evacuation can be treated by repeating the uterine aspiration.
  • Uterine perforation: This complication is most likely to occur during dilation. Careful examination to determine the position of the uterus and cervix is essential to minimize the risk of this complication.
  • Cervical laceration: If treatment is needed, hemostatic agents like silver nitrate may be sufficient for minor tears. In rare situations, suturing is needed.
  • Pelvic infection: Should post-operative infection occur, treatment depends on location and type of infection.
  • Hemorrhage: Heavy bleeding (e.g. the soaking of a maxi-pad every 20 minutes for 1 hour) is rare but can occur following MVA. Treatment depends on the severity of hemorrhage.
  • Hematometra: This is a condition in which the uterus is distended with clots and blood. The most likely etiology is an adherent clot in the endocervical canal from a small tear that occurred during the procedure. The uterus may be larger than before the procedure and extremely tender. This condition can be treated by re-aspirating the uterus, although dilation alone is often sufficient.
  • Vagal reaction: Typically occurs near or after completion of the procedure. Woman may feel lightheaded or nauseated. If the procedure has not yet been completed, halt the procedure until the reaction has ceased. Have the woman lie either flat or in reverse trendelenburg with her feet raised above the level of her heart. Provide a cool compress for her forehead and the back of her neck. Once the reaction has subsided, continue the procedure.15

References

  1. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure—current management concepts. Obstet Gynecol Surv. 2001;56(2):105-113.
  2. Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynecol Obstet. 1994;45:261-267.
  3. Fawcus S, McIntyre J, Jewkes RK, Rees H, Katzenellenbogen JM, Shabodien R, et al. Management of incomplete abortions at South African public hospitals. SAMJ. 1997;87(4):438-42.
  4. Hemlin J, Moller B. Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination. Acta Obstet Gynecol Scand. 2001;80:563-67.
  5. Mahomed K, Healy J, Tandon S. A comparison of manual vacuum aspiration (MVA) and sharp curettage in the management of incomplete abortion. Int J Gynecol Obstet. 1994;46:27-32.
  6. Westfall JM, Sophocles A, Burggraf H, Goldberg A. Manual vacuum aspiration for first-trimester abortion. Arch Fam Med. 1998;7:559-61.
  7. Dean G, Cardenas L, Darney P, et al. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception. 2003;67:201-6.
  8. Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol. 2004;103:101–7.
  9. Dalton VK, Harris L, Weisman CS, Guire K, Castleman L, Lebovic D. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol. 2006;108(1):103-10.
  10. Edwards S, Tureck R, Fredrick M, Huang X, Zhang J, Barnhart K. Patient acceptability of manual versus electric vacuum aspiration for early pregnancy loss. J Womens Health. 2007;16(10):1429-36.
  11. MVA Label, United States, English. Ipas. 2007.
  12. Narrigan D. Early abortion: update and implications for midwifery practice. J Nurse-Midwif. 1998;43(6):492-501.
  13. Inal MM, Yildirim Y, Ertopcu K, Ozelmas I. The predictors of retained products of conception following first-trimester pregnancy termination with manual vacuum aspiration. Eur J Contracept Reprod Health Care. 2006;11(2):98-103.
  14. Klein S, Miller S, Thomson F. A Book for Midwives: Care for Pregnancy, Birth, and Women’s Health. Berkeley, California: Hesperian Foundation; 2000: Chapter 23.