Emergency Treatment
Module 2 - Session 2
Uterine Evacuation Methods
Module 2 - Session 2
Objectives
At the end of this session, participants will be able to:
1.
2.
3.
4.
Describe how each method of uterine evacuation works
List main advantages/disadvantages of each method
Identify the instruments (or parts) used in each method
Describe any indications, contraindications and precautions as
applicable for each method
5. Describe the counseling appropriate during any uterine
evacuation procedure
2
Uterine Evacuation
• Because most complications result from retained products of
conception (POC), removal of the contents of the uterus (uterine
evacuation) is one of the primary components of emergency
treatment.
3
Uterine Evacuation Methods
• The main methods for treatment of first and second trimester
incomplete abortion are vacuum aspiration (VA), sharp
curettage (SC) and pharmacological methods.
• Vacuum aspiration is generally preferred to sharp curettage (or
D&C) due to lower minor complications rate and reduced need
for surgical facilities (WHO, 1994).
4
Vacuum Aspiration (VA)
• Safe and effective method that works by applying suction to
remove uterine contents
• Used in industrialized countries for more than 20 years
• Suction is produced by a manual syringe, foot pump or electric
pump, via a cannula (tube) placed into the cervix
5
Manual Vacuum Aspiration (MVA)
• A safe, effective and low-cost method of uterine evacuation
• A hand-held vacuum syringe is used to empty the uterus
• Syringes come as no-valve, single-valve, double-valve and MVA
Plus:
– No-valve syringes not recommended:
• Do not create a vacuum until cannula is inserted,
increasing risk of uterine perforation
6
Single-Valve Syringe with Cannulae
7
Double-Valve Syringe with Cannulae
8
MVA Plus
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Foot Pump Suction Evacuation (FSE)
• An alternative device for uterine evacuation.
• Uses flexible cannulae and is operated by the provider
performing the uterine evacuation procedure. Vacuum can be
easily obtained.
• The provider controls the vacuum by digitally occluding with the
thumb a small venting port at the point of attachment of the
cannulae to the suction tubing.
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Foot Pump Suction Evacuator
11
Comparison of MVA and Foot Pump Suction
Evacuation
• A study published in the South Africa Medical Journal compared
the foot pump suction evacuator with the manual vacuum
aspirator for uterine evacuation.
• Findings showed that the FSE and MVA were similar in
effectiveness and outcomes. The time to perform the FSE was
not significantly different in operative blood loss estimation or
the time needed to perform the procedure.
• There were no cases of uterine perforation, cervical injuries or
blood transfusions. Both techniques were easy to use.
Adapted from: Gaertner et al.,1998.
12
Electric Vacuum Aspiration (EVA)
• Uses an electric pump and cannulae to evacuate the uterus by
providing either intermittent or continuous suctioning.
• Most devices provide a continuous level of suction. However,
newer models may also provide intermittent suction.
13
Electric Vacuum Aspiration (EVA) (2)
• The EVA method has about the same effectiveness as the
manual device:
– No evidence showing a significant difference in the rate of
complications between the two methods. Patient satisfaction
is also comparable, aside from the noise level.
• Due to the electricity requirements and the initial high cost
of the machine, EVA may not be the most suitable method
where resources are limited.
14
Electric Vacuum Aspiration Machine
15
Vacuum Aspiration: Advantages
• MVA and FSE do not require electricity and can be used in
remote settings, extending a woman’s access to emergency
treatment.
• EVA, MVA and FSE have the same effectiveness rate. There is
no evidence showing a significant difference in the rate of
complications.
• Patient satisfaction for EVA and MVA is also comparable.
• Flexible cannula (MVA, FSE):
– Can reach deep into the uterus even when it is anteverted or
retroverted
– Rounded tip and narrow width requires little dilatation
16
Vacuum Aspiration: Advantages
• Though VA and sharp curettage (SC) are equally effective for
treatment of incomplete abortion, women undergoing VA
procedures experience less blood loss and less incidence of
uterine perforation than those undergoing SC.
17
Vacuum Aspiration: Contraindications (MVA,
FSE)
Contraindicated for use in clients with:
• A uterine size over 12 weeks LMP (MVA)
• Acute cervicitis or pelvic infection, except in an emergency
• Large fibroids unless emergency back-up is available
18
Vacuum Aspiration: Precautions
• In the following cases, VA should be used with caution, and only
in facilities with full emergency backup.
• Clients with:
– History of bleeding disorders
• Risk of excessive bleeding or hemorrhage
– History or suspicion of prior uterine perforation:
• Risk of injuring the bowel
– Severe anemia:
• Risk of severe shock and death
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Vacuum Aspiration: Precautions (2)
• Hemodynamic instability (hemorrhage/shock, cardiac disease):
– Risk of severe shock and death
• Uterine fibroids:
– Risk of perforation
• In the presence of infection, proceed only with antibiotic
coverage (initiate antibiotics before starting procedure):
– The client may require referral to a higher level of care
20
Dilatation and Curettage (D&C) Sharp Curettage
(SC)
• WHO recommends that this method be used only when vacuum
aspiration is not available.
• Uses a curette or a similar metal surgical instrument to empty
the uterus.
• Usually performed under general or regional anesthesia, or
heavy sedation.
• Recent studies show that it can be performed as an outpatient
procedure in hospitals/some health centers.
21
Comparison of Vacuum Aspiration and
Dilatation and Curettage
Characteristics
Effectiveness Rate
Pain
Complications
Vacuum Aspiration
(EVA)
Dilatation and
Curettage (D&C)
98%
99%
Less pain
Increased pain
Fewer minor
complications than
D&C
Increased bleeding
(may be due to use
of anesthesia)
22
Comparison of VA and SC
MVA:
• Vacuum suction with plastic
cannula, lowering the risk of
uterine perforation
• Minimal cervical dilatation
required
• Analgesia, light sedation and/or
local anesthesia can be used
• Can be performed by midwife,
general MD or other trained
health provider
• Outpatient procedure, reducing
the need for hospital stay
D&C:
• Scraping with sharp, metal
curette, increasing the risk of
uterine perforation
• Mechanical dilatation often
required
• Heavy sedation, analgesia
and/or general anesthesia
often used
• Usually performed only by
trained gynecologist or general
MD
• Operating theater procedure,
often requiring hospital stay
23
D&C Instruments
Source: www.HealthAtoZ.com 2004.
24
Indications for Sharp Curettage (SC)
• Sharp curettage has been effectively used for many conditions.
Some of the indications include:
– Excessive vaginal bleeding
– Abnormal vaginal bleeding
– Polyps
– Incomplete abortion:
• When VA not available
– Molar pregnancy:
• Risk of uterine perforation is high with SC; VA may be
safer and associated with less blood loss
– Diagnostic:
• Endometrial cancer
• Determine cause of vaginal bleeding
25
Pharmacological Methods of Uterine
Evacuation: Misoprostol
• A prostaglandin initially developed to treat gastrointestinal
problems:
– Prostaglandins are a group of chemicals made by nearly all
of the body's cell membranes.
• Different prostaglandins have different effects on the body:
– They can help treat inflammation and pain, raise or lower
blood pressure, affect the immune system and stimulate
uterine contractions and labor.
26
Pharmacological Methods of Uterine
Evacuation: Misoprostol (2)
• Research indicates that 600 ug of misoprostol (oral) is an
effective dosage for use in postabortion care.
• Studies for sublingual dosage amounts for use in postabortion
care are ongoing.
• WHO has included misoprostol on its list of essential medicines
for miscarriage and incomplete abortion.
27
Expectant Management
• Spontaneous abortion with partial expulsion of POC sometimes
resolves itself as part of the natural process.
• Over time, the remaining uterine contents will be expelled
without any intervention. Expectant management is allowing this
process to take place.
• During this time, the provider must monitor the client for signs of
complications and make sure the complete evacuation of uterine
contents has occurred.
28
Indications for Expectant Management
• Expectant management should be carried out only under the
following circumstances:
– Clients with uncomplicated spontaneous abortions
– Availability of skilled care and emergency services in case of
complications
– If possible, ultrasound and hCG monitoring capability should
be available
29
Uterine Evacuation: Integrating Counseling
• Counseling should be integrated throughout postabortion care
(before, during, after).
• The content, context and timing of counseling will differ from
client to client.
• Explain all counseling and health care information in the
language that the client understands.
• Explain any medical terms and always encourage the client to
ask questions or express any concerns she may have.
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