Manual Vacuum Aspiration: Uterine Evacuation, Risks and Prevention

Manual Vacuum Aspiration: Uterine evacuation is the removal of the contents of the uterus such as incomplete abortion or other retained products of conception.

What is Manual Vacuum Aspiration (MVA)?

World Health Organization (WHO) in union with UNPFA, UNICEF and the World Bank and the endorsement by FIGO and ICM approved MVA as an essential technology for uterine evacuation.

MVA is typically used in PAC treatment for uterine evacuation in the first trimester.  To perform the MVA procedure, a cannula of the appropriate size (depending on gestation age/uterine size) is inserted through the cervix into the uterus.

A hand-held plastic 60ml aspirator that is charged with a vacuum is than attached to the cannula. The vacuum is released by depressing the buttons on the aspirator and then the cannula is gently and slowly rotated while being moved back and forth in the uterus. The aspirator serves as the source of vacuum to pull to tissue through the cannula into the cylinder of the aspirator.

What are indications for MVA?

  • Incomplete abortion
  • Molar pregnancy /hydatidiform mole
  • As an option  to terminate pregnancy in early trimester
  • Diagnostic test/uterine sampling such as endometrial biopsy
  • To  remove retained products of conception,
  •  induced abortion, spontaneous abortion and/or early pregnancy failure
  • Post-abortion haematometra

What are contra-indications for MVA?

  • When uterine size is over 12 weeks gestation
  • Pelvic infection, acute cervicitis(unless in an emergency)
  • Large uterine myoma(fibroids) except in an emergency
  • Absence of skilled personnel
  • Patient’s not fully obtained

Features and Parts of IPAS MVA Plus

The IPAS instrument was manufactured by IPAS since 1973.

 IPAS MVA plusTm aspirator provides vacuum 24 – 26 inches or 609.6 – 660.4 mm of mercury. It is composed of the following parts:

  • A valve cap, a removable liner, a pair of buttons that control the vacuum.
  • A plunger with plunger handle and O-ring.
  • A 60ml cylinder for holding evacuated uterine contents with a retaining clip for the collar stop.
  • Collar stop.

Ipas EasyGrip Cannulae

Ipas EasyGrip Cannulae have the same dimensions and aperture (openings) as the flexible Karman cannulae. However, Ipas EasyGrip cannulae are slightly more rigid and have a permanently fixed base with a wing design. This helps the base to directly to the IPAS MVA Plus aspirator without requiring a separate adapter.

Ipas EasyGrip Cannulae are available in sizes 4, 5, 6, 7, 8, 9, 10 and 12mm. the smaller cannulae (4, 5, 6, 7 and 8mm) have 2 opposing apertures. The larger (9, 10 and 12mm) have a single scoop aperture to allow for removal of thicker tissue. There are dots for calibration on the cannulae at 1cm intervals.

How to determine the cannula size to use during MVA

This depends on uterine size in relation to Last Menstrual Period (LMP), i.e. the gestational age of the pregnancy

  • Uterine size 4 – 6 weeks LMP: 4 – 7mm cannulae
  • Uterine size 7 – 9 weeks LMP: 5 – 10mm cannulae
  • Uterine size 9 – 12 weeks LMP: 8 – 12mm cannulae

What are advantages of MVA?

  • It is safe, high-quality and affordable.
  • It is effective, easy to learn and easy to use.
  • It is small, portable and quiet convenient.
  • Does not require electricity, it can be used in rural setting without electricity or intermittent electric supply, thus increasing women’s access to care.
  • MVA service can be provided in clinic setting on an ambulatory, outpatient basis, it requires fewer facility resources and reduced cost of treatment.
  • It is locally available and reduced waiting time for treatment.
  • It is acceptable method for many women
  • MVA is better and safer than dilatation and curettage (D&C) which is often is associated with cervical incompetency.

Procedures for Uterine Evacuation with IPAS MVA PLUS

To provide woman-centered care, the woman’s safety and comfort during in MVA must be assured. The following ten steps below would guide you to perform uterine evacuation using manual vaccum aspirator effectively

STEP 1: Prepare Instruments – Charge the Instrument

  • Push the valve button down until you feel them lock by a click sound.
  • To create vacuum, pull the plunger back until the arms snap outward and catch on cylinder base. Check the position of the plunger arms carefully. Both arms must be carefully extended and secured over the base of the cylinder.
  • Incorrect positioning will cause the arms to slip back into the cylinder, possibly injecting the content back.
  • Check aspirator for vacuum retention before use: To do this create a vacuum and leave the aspirator for several minutes with vacuum established. Then push the button to release the vacuum. A rush of air into the aspirator should be heard as a sharp sound, indicating was retained.
  • If the sound is not heard, displace the collar stop. Withdraw the plunger and check the “o”- ring is properly lubricated, positioned in the groove and free of damage and foreign bodies.
  • Also check that the cylinder is firmly placed in the valve. Then reinsert the plunger, reposition the collar stop and test the aspirator again. If vacuum is still not retained, the aspirator cannot be used. Discard it and use another aspirator.

STEP 2: Prepare the Patient

  1. Ask her to empty her bladder.
  2. Help her unto the procedure table; ensure she is well positioned on a dorsal position with her pelvis slightly raised using stacks of linens or blankets. The legs can be placed on a stirrup if available (lithotomy position)
  3. Do bimanual examination:
  4. Wash hands and put on appropriate barriers including gloves.
  5. It is important to do bimanual examination, to confirm findings from assessment.
  6. Before performing uterine evacuation procedure, determine uterine size and position.
  7. Assess the amount of cervical dilation.
  8. If unable to determine the uterine size through bimanual examination, use ultrasound to confirm uterine size and gestational age
  9. Before proceeding, replace gloves.
  10. Speculum examination
  11. Place couscous vaginal speculum, screw.
  12. Check for any tissue or object in the cervical OS. Remove with forceps or gauze. If bowel (intestine) is present, immediate treatment of referral is necessary.

STEP 3: Perform Cervical Antiseptic Preparation

Maintain aseptic technique throughout, using sponge – holding forceps, pick sponge (gauze, swab) to clean cervical OS vaginal walls if desired. With each new sponge start at the cervical os to clean and spiral outward without retracting previously cleaned areas. Continue until the cervical os has been completely cleaned with antiseptic.

STEP 4: Give Anaesthetics

  • Inject 0.5 – 1% lignocaine 10ml is used to anaesthetize the cervix.
  • Insert the needle at angle of 6 or 12 o’clock where tenaculum will be inserted. Aspirate by drawing the plunger back if in blood vessel remove and reinsert the needle.
  • Place tenaculum at the anaesthetized site. Use slight traction to move the cervix.
  • Inject 2 – 5ml of lignocaine into each injection site at angle 3, 5, 7 and 9 o’clock or 4, 6, 8 and 12 o’clock.

STEP5: Dilate Cervix

            Cervical dilation is not required in some cases. Dilation is not required when cannula of appropriate size fits into the OS. If cervix is closed and not efficiently dilated, use a bigger cannula to dilate gently. Do not use force because it can cause cervical tear, injury to pelvic organs and uterine perforation.

STEP 6: Insert Cannula

  • Gently applying traction to the cervix insert cannula through the cervix into uterine cavity.
  • Move the cannula gently until it meets resistance of the fundus, then withdraw it slightly.
  • Rotating the cannula while gently applying pressure often help to insert it easily. Do not insert the cannula forcefully as this may cause uterine perforation or damage to the cervix.

STEP 7: Suction Uterine Content

  • Attach charged MVA aspirator to the cannula holding the tenaculum and the end of the cannula in one hand aspirator in the other hand.
  • Release the vacuum by pressing the buttons in suction begins immediately.
  • Evacuate the uterine content by gently rotating the cannula 180 degrees in each direction using an in-and-out motion.
  • You will observe blood tissue entering the aspirator through the cannula
  • Do not withdraw the opening of the cannula beyond the cervical OS as vacuum will be lost if this happens.
  • If aspirator is full, do not withdraw; rather detach the aspirator from the cannula carefully.
  • When the aspirator is emptied into a dish, re-establish vacuum.

What are signs that the uterus is completely empty?

Once the manual vaccum aspirator is in uterus and you notice these signs below, and then know that uterus has been evacuated:

  • Red or pink foam without tissue passing through the cannula.
  • A gritty sensation is felt as the cannula passes over the surface of the evacuated uterus.
  • The uterus contracts around or grips the cannula
  • The patient complains of cramping or pain
  • When the procedure is over, gently depress the button, detach the aspirator from the cannula and withdraw the cannula and aspirator together

STEP 8: Inspection of Tissue

  • Empty contents of the aspirator into a container by removing the cannula if it is still connected.
  • Release the buttons and gently push the plunger completely into the cylinder. Do not push aspirated content into the cannula to avoid contaminating it.

Inspect the tissue for:

  • Presence and quantity of products of conception
  • Complete evacuation
  • Molar pregnancy

STEP 9: Perform Any Concurrent Procedure

Other concurrent procedure such as insertion of IUD if consent was obtained when the procedure is complete is allowed.

Step 10: Process Instruments

Immediately wash the instruments (MVA), rinse in a clean water and insert in a jik solution 1:10 for 10 minutes. Discard needles and sharps appropriately. Other post procedural tasks are:

  • Remove barriers such as gloves and wash hands
  • Record information about the procedure (case).
  • Inform the woman that the procedure is finished.
  • Assist the woman into a comfortable position on a table or bed, and then assist with moving her to recovery.

What are challenges arising when using MVA?

Vacuum can decrease before completion of the procedure. They following may be the cause.

  1. The aspirator is full
  2. The cannula is withdrawn beyond the cervical os to the vagina
  3. The cannula is clogged
  4. Aspirator is correctly assembled.

What are the medications to give patient after manual vaccum aspiration?

Prescribe necessary drugs for patient such as:

  • Administer uterotonics to contract the uterus
  • Give analgesic to help control pain.

Tab Paracetamol twice daily for three days.

  • Give antibiotics: cap Ampclox 500mg thrice daily for 5 days.
  • Give haematinics (e.g. Iron, folic acid, vitamin C and so on).

What are complications of manual vaccum aspiration?

Using manual vaccum aspiration is an option to treat missed or incomplete abortion is safe provided it is done by skilled provider and under strict aseptic and antiseptic techniques.

However, MVA performed by unskilled provider and without aseptic precautions can result in the following complications:

  • Failed procedure
  • Uterine sepsis
  • Vaso-vagal reaction
  • Uterine perforation
  • Retained product if uterus is not properly emptied
  • Gross damage to pelvic organs such as cervical injury
  • Haemorrhage due to uterine perforation or rupture
  • Acute pain
  • Shock
  • Maternal death.

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