Manual Vacuum Aspiration with local anaesthesia Marijke Alblas,MD Western Cape Department of Health Use of MVA: • Induced abortion up to 14 weeks • Incomplete abortions uterine size up to 14 weeks • As a back-up for failed medical abortion • Missed abortion • Endometrial biopsy • Molar pregnancy Goal of presentation to show that: • MVA is a safe and simple procedure • Safer, cheaper and more effective than D&C • Can help to decentralize the service and make it more accessible • Can be done by mid-level providers • Has a very low failure rate MVA is a safe and simple procedure • Priming of cervix with misoprostol(2 or 3 tablets) 2 to 3 hours before procedure • Local anaesthesia • By properly trained HCP • With the proper instruments • In the right setting: as an out-patient procedure But: don’t do a ‘curette check’!-->to check with a curette for complete evacuation adds unnecessary risks • • • • Increases pain and vagal reactions Increases chance of perforation Increases bleeding Many studies have demonstrated that using only suction has an effectiveness rate of 98% Can help to decentralize the service and therefore make it more accessible • Take it out of the theaters/ hospital-->OPD or office setting • Minimal emergency equipment necessary • MVA needs no ‘expensive’ instruments: no electrical suction machine, sets are re-usable • Beds are not really necessary(not for first trimester) • Only one trained ‘specialist’ necessary • If allowed make use of mid-level provider • Woman recover and return home quicker Make use of the right instruments and handle them gently: the woman is awake!! • Use the right size speculum • Use ‘long’ needles for para-cervical block or needle extender • Use the ‘right’ size of cannula; dilate with the different sizes of cannulae • Avoid to use too big size of cannula: be aware that woman is awake!!! • Don’t continue too long with the suction Create the Vacuum • Pull the plunger back until its arms snap outward over the end of the aspirator barrel. • Make sure the plunger arms are positioned over the wide edges of the barrel. Selecting the cannula Approximate uterine size (weeks LMP) Approximate size of the cannula 5 to 8 LMP 4 to 6 mm 8 to 9 LMP 6 to 7 mm 10 to 12 LMP ____________________ 13 to 14 LMP 7 to 10 mm ____________________ 10/12 mm Adapters for the double-valve aspirator are color-coded to the dots on the corresponding cannula 9 9 Paracervical block: --- Insert cannula Releasing the Pinch Valve • When the pinch valve is released, the vacuum is transferred through the cannula to the uterus. • Blood, tissue, and bubbles will flow through the cannula into the aspirator. MVA Technique: Vacuum Aspiration © Lisa Penalver MVA Technique: Vacuum Aspiration © Lisa Penalver Dilation cervix while doing suction: using different sizes of cannula • Misoprostol has been given according to established protocol ( 2 to 3 hours before procedure) • Gently dilate with cannula of increasing size taking care not to traumatise the cervix. Dilation (cont.) • With every cannula do suction and continue until the appropriate cannula for the procedure: POC are passing through the cannula • In between empty syringe in kidney basin • Dilatation of the cervix only necessary when the cervical canal will not allow passage of appropriate cannula Inspecting the tissue • Strain and rinse the tissue • Using a transparent container, inspect the material by examining it with a light from behind • Make sure all the tissue has been withdrawn 17 Tissue Examination Visual Inspection of the Products of Conception Gestational sac Blood clot Decidua Types of Complications Early Complications: – Cervical Injury – Uterine injury – Haemorrhage – (Pre-existing) infection – Uterine rupture – Anaesthesia related complications Recognising and managing uterine perforation Signs: • Instruments inserted beyond the fundus • Excessive bleeding • Fat or organfragments maybe in the aspirated tissue Treatment: • Usually seals itself off as uterus contracts • If fat or organfragments:needs laparoscopy or laparotomy Summary • • • • MVA is Simple to Use Safe and Effective Versatile and Cost Effective Is used for Endometrial Biopsy and Uterine Evacuation • Suction is the method advised for 1st Trimester surgical terminations by the World Health Organisation. Manual Vacuum Aspiration(MVA) vs. Electric Vacuum Aspiration(EVA) • • • • • • MVA Inexpensive/re-usable Small Portable Quiet Specimen likely to be intact Requires repeated reloading of suction EVA More costly but longer life Bulky Less portable Noisy Fragmentation of specimen possible Constant suction