MVA Template
(required information sheets are attached or available through the OB/Gyn resident website.)
Complete enter in CareWeb and call 763-6495 for appointment.
MVA Procedure Referral/History and Physical
Referral Plan: MVA date: / /201_ Time:
Patient contact phone number:
HPI: year old G P , LMP
Documented IUP:
Missed Abortion:
Gestational age by LMP:
Gestational age by U/S on(date)
CRL= MSD=
Missed Abortion confirmed by (either)
Fetal Pole with no FHT
Falling BHCG
Bleeding?
Cramping?
Past medical history, surgical history, allergies, and medications updated in PSL.
No medical contraindications to office MVA procedure
Ob:
Gyn:
SH: Partner status, Tobacco/Alcohol/illicits
FH: No significant FH.
ROS: Negative other than the above.
Labs: CBC/Rh Pending. **OR** CBC WNL, Rh positive/negative
PE: Weight
BP Pulse RR
Airway: Mallampati I- see all uvula II- see part of uvula III- see none of uvula
Mouth opens >3cm, 3 finger breadths between chin and neck, normal neck flexion/extension
(If poor airway, Mallampati III or does not meet all secondary criteria, she is not a candidate for IV sedation.)
General: WNL?
HEENT: WNL?
Neck: WNL?
Abdomen: WNL?
Pelvic: Normal External Genitialia, Speculum normal cervical mucosa (if mucopurulent cervicitis, treat prior to
procedure), Bimanual without adnexal fullness/tenderness.
Extremities: WNL?
Assessment:
1. Documented IUP
2. Missed abortion:, discuss TX Options using “Treatment Options for Early Pregnancy Loss…” patient information
sheet
3. Desires MVA
(Contraindications to MVA include: bleeding disorder, hgb <8.0, severe cardiopulmonary disease, uncontrolled
seizures, severe anxiety, mole>10 weeks, uncontrolled IDDM, untreated mucopurulent cervicitis)
(Discuss the following with the surgeon who will perform the MVA: uterine anomaly, fibroids >16 weeks size,
weight >300lbs, combination of hypertension and asthma (how severe for determination of ability to use
Methergine or Hemabate for hemorrhage).
4. Anesthetic Assessment: patient desires IV sedation and is appropriate candidate given no medical
contraindications to IV sedation and adequate airway. **or** Patient desires local anesthetic and/or oral
medications only.
Plan:
1. MVA on
2. Desires oral sedation only (OR) IV sedation to be administered (NPO for 6 hours prior to procedure)
3. Pre- and Post-operative instructions reviewed
4. CBC and Rh ordered/completed.
5. Two week follow-up with primary provider scheduled
6. Birth control plan made, if applicable
7. Prescriptions given to patient for:
Ativan 1mg, #1 (Give only if not getting IV sedation)
Doxycycline 100mg PO BID, #14 : Start after procedure with food
Ibuprofen (take 600mg pre-op and as needed afterwards.)
8. Fact sheets given for:
Treatment options for early pregnancy loss or miscarriage
Pre-op Instructions: facts about Uterine Aspiration
Post-op Instructions
Optional:
10. Pt to bring inhaler
11. Cytogenetics to be sent