MM-TI
Miscarriage Management
Training Initiative
Sample Protocol
MVA for Early Pregnancy Miscarriage Management
POLICY:
Purpose: To outline staff and provider responsibility in the performance of manual
vacuum aspiration for early pregnancy miscarriage management or endometrial biopsy.
LEVEL: Intradependent
SUPPORTIVE DATA: Manual vacuum aspiration (MVA) is a safe, relatively painless,
and cost-effective diagnostic and therapeutic means of evacuating the uterus during
early pregnancy miscarriage or for evaluating the endometrium for abnormal uterine
bleeding, infertility, and malignancy.
INDICATIONS:
A) Treatment/completion of incomplete spontaneous abortion in first trimester (<13
weeks)
1) Ensures POC are fully evacuated
2) Controls hemorrhage
3) Evacuates post-abortal hematometra
B) See policy #4529.00 for outline of indications for endometrial biopsy
CAUTION/CONTRAINDICATION:
A) Coagulation disorders, anticoagulant drug therapy
B) Uterine anomalies
C) Pelvic inflammatory disease/cervicitis
D) Extreme anxiety
E) Any condition causing patient to be medically unstable
F) Cervical stenosis
G) Endometrial biopsy also contraindicated in pregnancy
EQUIPMENT:
Sterile gloves, mask with face shield, fluid resistant gown
Vaginal speculum (sterile), light source
Lubricant
Antiseptic solution (povidone-iodine) or Benzalkonium Chloride for iodine allergy,
small
Sterile bowl for iodine, sterile gauze
Manual vacuum aspirator
Cannula for aspirator (4-12 mm)
Cervical dilator (4-12 mm)
Tenaculum, ring forceps
Sterile syringe and needle, 1% Lidocaine, Hurricaine spray
Long hemostat
Sterile basin for emptying aspirator
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Strainer
Glass bowl and backlight for examining uterine contents
Container and formalin for pathology
Monsel’s solution/Gelfoam available
Cytotec (Misoprostol), Methergine, Ibuprofen
Rhogam if indicated
STEPS
PREPARATION OF THE PATIENT:
A) Verify patient name and date of birth.
B) Take vital signs and weight, complete
nursing intake note in medical record.
C) Have patient empty bladder and
obtain urine pregnancy test, if
indicated.
D) Explain procedure to patient. Patient
should have opportunity to read
“Miscarriage” handout if not already
read.
E) Assure that patient has ride home.
F) Administer NSAID as ordered
(optimally one hour prior to
procedure).
G) Review chart for results of Rh factor
and prepare Rhogam if indicated (50
mcg). Perform in-house hematocrit if
ordered.
H) Once consent is obtained, prepare
patient for vaginal exam; assist
patient into dorsal lithotomy position
and drape with draw sheet.
PROVIDER RESPONSIBILITIES:
A) Obtain informed consent and perform
procedural verification.
B) Perform bimanual exam noting size
and position of uterus. May perform
ultrasound.
C) Place speculum and perform
antiseptic prep and paracervical
block.
D) Inform patient that she may
experience cramping because of
dilation of the cervix during the
procedure.
E) Dilate cervix to admit suction cannula
of the appropriate size, usually equal
to estimated gestational age of
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KEY POINTS
Fever may be a reason to delay
procedure.
Pregnancy test only necessary for
endometrial biopsy.
Ideally, patient will have appt. prior to
procedure to meet with social worker
and/or behavioral health services, so as
to deal with issues of loss.
If patient is not pre-sedated, and is
stable following endometrial biopsy, she
should be able to drive self.
May also pre-medicate with Ativan 1 hr.
pre-procedure (RX to pharmacy, no
Ativan kept on site)
Informed consent should be obtained
prior to any pre-procedure sedation.
Ascertain patient’s drug sensitivity
and/or history of allergy to skin prep,
materials, and anesthetics prior to
administration of local anesthetic.
Use size 4 dilator and suction cannula
for endometrial biopsy.
i.e. 7 or 8mm dilator and cannula for 7
weeks gestation.
pregnancy or one size larger.
F) Perform MVA by generating suction
before insertion of suction cannula.
G) Place suction cannula into the
cervical os and move the cannula
slowly into the uterine cavity until it
touches the fundus; then withdraw it
slightly.
H) Release the buttons on the aspirator
to transfer the vacuum through the
cannula into the uterus.
I) For uterine evacuation, evacuate the
contents of the uterus by rotating the
cannula 180 degrees in each
direction while using a gentle in-andout motion.
J) For endometrial biopsy, movement of
the cannula gently back and forth
along the anterior uterine wall, then
rotating and taking a sample from the
posterior uterine wall in same fashion
should provide sufficient tissue for
diagnosis.
K) Empty syringe if needed and repeat
until all uterine contents removed,
usually 2-3 times.
L) For endometrial biopsy, collect
aspirated material in formalin and
send specimen to pathology.
M) For uterine evacuation, inspect
aspirated tissue. If visual inspection
is not conclusive, strain the tissue
and put in water or vinegar in clear
glass container and examine through
backlight. Send to pathology if
indicated.
N) Order methergine/cytotec
(misoprostol) if needed.
O) Order Rhogam if indicated.
POST PROCEDURE CARE:
A) Ask the patient to remain supine for a
few moments following the
procedure. Place peri-pad.
B) May elevate head of table after a few
minutes; assess for vasovagal
reaction. Offer fluids if not
nauseated.
C) Monitor BP every 15 minutes for
minimum of 30 minutes, longer if
unstable. Check amount of bleeding
Miscarriage Management-Training Initiative
If cannula becomes clogged, ease it
back toward, but not through, the
external cervical os. This movement will
often unclog the cannula. If it does not,
cannula can be removed and tissue
removed with sterile forceps or gauze.
Depress valve buttons and disconnect
cannula from the aspirator while leaving
cannula inserted through the cervical os.
Signs that uterus is empty include red or
pink foam without tissue passing through
cannula, gritty sensation felt as cannula
passes over the surface of the
evacuated uterus, uterus contracts
around or “grips” the cannula, and/or
patient notes pain as uterus contracts
Would you give one or the other, or
both?
at same intervals.
D) Assess for painful uterine cramping.
Communicate pain level to provider
and document along with vital signs
in medical record.
E) If heavy bleeding is not observed and
the vasovagal reaction (if it has
occurred) has resolved, discharge the
patient after 30 minutes.
F) Review discharge instructions with
patient/significant other.
G) Patient to be contacted by provider or
provider’s representative in 24 hrs.
for phone follow-up. Patient to
schedule follow-up appt. in 2 weeks.
H) Dispose of aspirated contents per
“Blood and Body Fluids Disposal”
procedure, VMC Infection Control
Manual
I) Dispose of cannula per VMC
guidelines. Aspirator should be
disassembled, cleaned and sterilized,
per VMC disinfection procedures.
DOCUMENTATION
A) Document procedure and patient’s
tolerance.
B) For uterine evacuation, document
visual inspection of aspirated uterine
contents
C) Document vital signs and patient’s
pain level, before, during and after
procedure.
D) Document that patient received
discharge instructions and verbalized
understanding, and plan for follow-up
care.
PATIENT EDUCATION
A) The patient may resume sexual
relations in one week, or after
bleeding has stopped. If birth control
is desired, sexual relations should
wait until method of birth control is
chosen.
B) Daily activities may be resumed as
soon as patient feels up to it, but
strenuous activities should be
delayed for several days following
uterine evacuation.
C) Pads should be used while bleeding
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For endometrial biopsy, inform patient
that she will be contacted by phone or
mail within three weeks, of biopsy
results. Follow-up in clinic not
necessary unless patient is having
problems.
Patients may be allowed to take home
products of conception if desired.
High level disinfection using Cidex OPA
is acceptable if sterilization is not
feasible.
For endometrial biopsy, sexual relations
may be resumed earlier, in 3 days
unless bleeding is heavier.
is heavier, but tampons may be used
after heavier bleeding lets up.
D) Patient should report the following:
1) Fever with a temperature higher
than 100.4 degrees F for more
than 24 hours post procedure
2) Severe cramping not relieved by
medication, especially more than
24 hrs. post-procedure
3) Bleeding and soaking through
more than two maxi pads per hour,
for two or more hours in a row.
4) Dizziness or syncope
5) Nausea, vomiting or diarrhea for
more than 24 hours post
procedure.
6) Overwhelming sadness or
depression
E) Give written aftercare instructions,
including how to get help after hours.
F) Provider to send in RX for antibiotic,
Doxycycline 100 mg X 2 doses, take
1st dose with next meal, take 2nd dose
following day with meal.
Check allergies
Is antibiotic given after endometrial
biopsy as well?
REFERENCES
A) Valley Medical Center Clinic Network, Endometrial Biopsy Procedure, #4529.00, and
related references
B) Sarah Prager, MD, Department of Obstetrics and Gynecology, University of
Washington
C) IPAS Gynecological Aspiration System instruction manual, 4/07
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Miscarriage Management-Training Initiative