UTERINE EVACUATION METHODS

- DR. NIDHI SINGH

1

Objectives

At the end of this session, participants will be able to:

1. Describe how each method of uterine evacuation works

2. List main advantages/disadvantages of each method

3. Identify the instruments (or parts) used in each method

4. Describe any indications, contraindications and precautions as

applicable for each method

5. Identify the parts of the MVA equipment and select correct

syringe/cannula size

6. Demonstrate ability to check, assemble and prepare equipment

7. Perform the VA procedure according to the steps outlined

8. Demonstrate appropriate counseling before, during and after

the VA procedure

9. Recognize and solve technical or procedural problems during

VA2

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

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Single-Valve Syringe with Cannulae

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Double-Valve Syringe with Cannulae

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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

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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.

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Adapted from: Gaertner et al.,1998.

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.

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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.

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Electric Vacuum Aspiration Machine

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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

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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.

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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

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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

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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.

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Comparison of Vacuum Aspiration and

Dilatation and Curettage

Characteristics Vacuum Aspiration

(EVA)

Dilatation and

Curettage (D&C)

Effectiveness Rate 98% 99%

Pain Less pain Increased pain

Complications Fewer minor

complications than

D&C

Increased bleeding

(may be due to use

of anesthesia)

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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

• Outpatient procedure, reducing

the need for hospital stay

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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

• Operating theater procedure,

often requiring hospital stay

D&C Instruments

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Source: www.HealthAtoZ.com 2004.

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

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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.

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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.

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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.

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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

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Manual Vacuum Aspiration

Manual vacuum aspiration (MVA) uses a specially designed, hand-

held vacuum syringe with a flexible plastic cannula to apply suction

in order to remove the products of conception from the uterus. This

method does not require electricity.

Note: MVA is not the ideal procedure for evacuating the uterus

in molar pregnancies:

• The amount of tissue in such cases is often copious.

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Indications for MVA

• Uterine evacuation first trimester

– Induced abortion

– Spontaneous abortion or early pregnancy failure (EPF)

• Complications management

– Incomplete medical abortion

– Post-abortal hematometra

• Uterine sampling

– Endometrial biopsy

MVA vs EVA

EVA

• Electric pump

• Costly but longer life

• Variable noise level

• Not easily portable

• Capacity: 350-1,200 cc

• Constant suction

• Fragmentation of POCs

MVA

• Manual aspirator

• Inexpensive

• Quiet

• Portable

• Capacity: 60 cc

• Suction decreases as aspirator fills

• POCs likely intact

Complications with MVA

• Rare

• Same as for EVA

– Incomplete evacuation

– Uterine or cervical injury

– Infection

– Hemorrhage

– Vaso-vagal reaction

MVA Instruments

MVA: Key Benefits

• Safety & efficacy equivalent

to EVA

•Portable

•Low tech

•Low-cost

•Small and quiet

Significant implications for

incorporating services into the office

setting

Other Clinical Benefits of MVA

POCS are easier to visualize & inspect

– Often more intact

– Easier detection of early EGA

• Fewer re-aspirations in MVA vs EVA group

(Goldberg 2004)

– Can still send to pathology for genetics

MVA POC Check: Benefits for EPL

Creinin and Edwards 1997

Electric Suction Machine MVA Aspirator

What

is

that?

Ther

e it

is!

Preparing VA Instruments

• Select cannulae:

– Inspect cannulae for cracks or other defects; discard if there

are any visible signs of weakness or wear.

– Select cannulae according to the assessment of uterine size

(weeks LMP).

– Prepare several cannulae of different sizes. The cannula

needs to be large enough to allow passage of tissue

expected (according to gestation) and fit snugly through the

cervix.

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• Performing the MVA Procedure

• Step One: Prepare and Check Instruments

• Position the plunger all the way inside the cylinder.

• Have collar stop in place with tabs in the cylinder

holes.

• Push valve buttons down and forward until they lock

• Pull plunger back until arms snap outward and catch

on cylinder base . This “charges”the instrument.

• Check vacuum by leaving the instrument in the

“charged” position for two to three minutes, then

release the buttons. A rush of air indicates that the

aspirator maintained a vacuum42

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• Step Two: Prepare the Patient

• Ask the woman to empty her bladder.

• Conduct a bimanual exam to confirm uterine size and

position.

• Insert speculum.

• Step Three: Perform Cervical Antiseptic Prep

• Clean cervical os with antiseptic.

• Follow No-Touch Technique: no instrument that

enters the uterus can contact contaminated surfaces

before being inserted through the cervix

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• Step Four: Perform Paracervical Block

• Paracervical block is recommended.

• Using local protocols, administer paracervical block

and place tenaculum.

• Use lowest anesthetic dose possible to avoid toxicity.

• Step Five: Dilate Cervix

• Use mechanical dilators or progressively larger

cannulae to dilate the cervix.

• Dilate the cervix to allow a cannula approximate to

the uterine size to fit snugly through the os

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Paracervical Block

• Step Six: Insert Cannula

• While applying traction to the tenaculum, insert the

cannula through the cervix, just past the os and into

the uterine cavity until it touches the fundus, and then

withdraw it slightly.

• Do not insert the cannula forcefully.

• * For endometrial biopsy, use the Ipas 3mm cannula

with an adapter.

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48

• Step Seven: Suction Uterine Contents

• Attach the cannula to the prepared aspirator.

• Release the vacuum by pressing the buttons.

• Evacuate the contents of the uterus by gently and slowly

rotating the cannula and using a gentle in-and-out motion.

• * For endometrial biopsy, aspirate tissue by moving the

cannula gently back and forth along the uterine wall,

taking the appropriate sample.

• When finished, depress the buttons and withdraw the

instruments.

• * For endometrial biopsy, withdraw instruments when an

adequate amount of tissue is obtained

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• Signs that indicate the uterus is empty:

• Red or pink foam without tissue is seen 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, indicating

that the uterus is contracting

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• NOTE: If more than one aspirator is required to empty the

uterus:

• (1) Detach the cannula from the aspirator, leaving the cannula in

place. Empty the aspirator,recharge it and carefully reattach it to

the cannula. Resume evacuation.

• (2) Remove both the aspirator and the cannula. Use strict No-

Touch Technique, never allowing the tip of the cannula to

contact a contaminated surface. Detach the cannula. Empty the

aspirator.Recharge the aspirator and carefully reattach it to the

cannula, ensuring that the cannula remains sterile. Reinsert the

cannula, and resume aspiration.

• OR(3) Have a second aspirator readily available if more than

one aspirator is needed.

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• Step Eight: Inspect Tissue

• The MVA procedure is not complete until products of

conception have been inspected and confirmed.

• Empty the contents of the aspirator into a container.

• Inspect tissue for products of conception by straining material or

floating material in water or vinegar and viewing with a light from

beneath.

• If inspection is inconclusive, reaspiration may be necessary. If

indicated, follow clinic protocols to rule out ectopic pregnancy.

• * Endometrial biopsy samples should be handled according to

laboratory protocols

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• Step Nine: Perform Any Concurrent Procedures

• When the procedure is complete, proceed with any

contraception or other concurrent procedures, such

as IUD insertion.

• Step Ten: Process Instruments

• As soon as the procedure is complete, immediately

discard cannulae and soak the aspirator and

adapters (if used) to ease cleaning.

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The VA Procedure

*Absence of POC in a woman with symptoms of pregnancy

may strongly indicate the possibility of ectopic pregnancy.

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Post-Procedure Care-

Monitor recovery of the client:

• Take vital signs before moving the client from the procedure

area.

• Continue with pain management as needed.

• Encourage the woman to eat, drink and walk as she wishes.

• Explore the client’s feelings and concerns and provide

explanation and support as needed.

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Post-Procedure Care—

• Check bleeding at least once before discharge and check to see

that cramping has reduced. Prolonged cramping is not normal.

• Client may be discharged as soon as she is stable, can walk

without assistance and has received post-procedure counseling

and family planning information and services.

• In most instances, uncomplicated cases can be discharged in

1–2 hours.

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Post-Procedure Care—

• complete FP counseling and assist client in deciding on a

method before she is discharged.

• Provide other health services as needed (if available) such as

tetanus prophylaxis or Rh immune globulin if client Rh-negative.

• Advise the client of signs that need immediate attention:

– Prolonged cramping (more than a few days)

– Prolonged bleeding

– Bleeding more than a normal menstrual period

– Severe or increased pain

– Fever, chills

– Fainting

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Management of Problems during the VA Procedure

• The key to recognizing and managing problems during VA is to

know that they can occur even under the best circumstances.

• Most problems are not serious and if recognized immediately

and corrected or treated, the client’s recovery will not be

affected.

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Technical Problems—VA Procedure

1. Syringe is full (MVA):

– Keep a second prepared syringe on hand during the aspiration and switch syringes if one becomes full.

2. Cannula is withdrawn prematurely (MVA, EVA, FSE):

– If the opening of the cannula is pulled into the vaginal canal with the valve still open, the vacuum will be lost.

3. Cannula is clogged (MVA, EVA, FSE):

– Never try to unclog the cannula by pushing the plunger back into the barrel with the cannula tip still in the uterus.

4. Syringe does not hold vacuum (MVA):

– Try lubricating the plunger and barrel with a drop of silicone. If this does not work, replace the O-ring. If the syringe still does not hold a vacuum, discard it and use another syringe.

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Procedural Problems—MVA, EVA, FSE

1. Less than expected tissue/No POC:

– Consider possible ectopic pregnancy.

– Consider complete abortion or misdiagnosis.

2. Incomplete evacuation:

– Use correct size cannula.

– May need to repeat evacuation.

3. Uterine perforation:

– This is rare.

– Signs include severe pain, abdominal distention, cervical

motion tenderness, shoulder pain and rigid abdomen.

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Other Problems

1. Vaginal bleeding not due to pregnancy:

– Break-through bleeding (hormonal contraceptive use)

– Uterine fibroids

2. Ectopic pregnancy:

– Delay in treatment of an ectopic is dangerous.

– Risk is higher in women with:

• Previous ectopic pregnancy

• Pelvic infection

• IUD or progestin-only contraceptive use

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Processing the Ipas MVA Plus Aspirator

• Basics of Infection Prevention

• Wash hands immediately before and after every patient contact.

• Consider all blood and body fluids from all patients to be

potentially infectious.

• Use personal protective barriers (gloves, gowns, face protection,

shoes) when contact with blood or other body fluids is

• expected.

• Avoid skin punctures, especially when handling needles.

• Use No-Touch Technique: the tip of the cannula, or the tip of

any other instrument that enters the uterus, shouldnever touch

non sterile surfaces (including the vaginal walls) prior to

insertion.

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• Step 1: Soak Instruments Immediately After Use

• Following the procedure, all aspirators and adapters

that will be reused should be kept wet until cleaning.

Using a 0.5% chlorine solution is an option.

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• Step 2: Clean all aspirators and adapters thoroughly in

warm water and detergent, not soap. Wear gloves and face

protection.

• Disassemble the aspirator by pulling the cylinder out of the valve

• Wash all surfaces of the instrument in warm water and detergent

• Use soft brush

• Clean until no blood or tissue is visible

• Rinse

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Step 3: Processing Options

• Sterilize

• Steam autoclave in linen or paper for 30 minutes at 250ºF

(121ºC) with a pressure of 15 lbs/in2 (106 kPa).

• DO NOT USE HIGHER TEMPERATURES AS DAMAGE MAY

OCCUR. This device cannot withstand temperatures higher

than 250ºF.

• High-Level Disinfect (HLD)

• Soak immersed in a 2% glutaraldehyde solution (Cidex) for

20 minutes. Rinse aspirators as appropriate.

• Boiling water for 20 minutes

• Step 4: Store or Use Immediately

• Store: Aspirators should be stored in dry, covered

containers or packages, protected from dust and other

contaminants.67

CASES

Case 1

You see a 18-year old woman, G2P1001, whose last period was 8 weeks ago. She had a positive home pregnancy test 3 weeks ago. She has not had an ultrasound during this pregnancy.

Three days ago, she began to spot. Today, her bleeding has increased, like a very heavy period with some clots. She began cramping last night and now reports that the cramping is severe. She comes to your clinic today for assessment and treatment if required.

Case 1

Her medical history includes a spontaneous vaginal delivery 2012. She is otherwise healthy. On exam, she appears comfortable and is able to walk around the room and talk easily. Her vital signs:

BP 110/70, Pulse 90, Temp 97.8

At this point, how would you proceed with evaluation?

Case 1

The examination reveals the following

– Abdomen: soft, non tender

– Vaginal vault: scant amount of blood, consistent with a menses

– Cervix: os open, tissue at os noted

– Bimanual exam: uterus enlarged, approx. 8 weeks size, non tender

• Her hemoglobin is 12.2.

• Urine pregnancy test: positive

What tests do you think you should order now?

Case 1

The ultrasound reveals an intrauterine

gestational sac, and thickened

endometrial stripe.

What is the diagnosis?

What are the treatment options available

for this patient?

Case 1 continued

The same 18 yro G2P1001, experiencing mild-moderate cramping with mild-moderate bleeding in your clinic, and an ultrasound evidence of an incomplete abortion elects an MVA procedure as she wants to take care of this as soon as possible.

You are performing the MVA-all seems to be going well. However, the aspirator is only about one-quarter full and you remember from this course that at this gestational age, you would expect more tissue than this. You are not sure whether or not you are done.

Case 1 continued

How can you tell if you are done? List 4 signs

suggesting completion.

What do you do?

MVA Key Concepts

• MVA safe & effective for early pregnancy loss in first

trimester

• Allows for care that day, in the office, with their

primary provider

• Any uterine evacuation’s efficacy is improved by

systematically checking for completion

Case 2

41 yr G1P1 presents to the Clinic for her first prenatal visit in a very desired pregnancy. Her LMP was 10 weeks ago and she is certain of her dates. The pregnancy has been uncomplicated except for a small amount a bleeding she had about 1 week ago. You evaluate the patient and finds that her BM exam is consistent with a 7 wk IUP, os is closed.

What other information might you be interested in knowing about?

What might you order to get a diagnosis?

Case 2

Fortunately, your Clinic has a portable

ultrasound, and you are able to supervise the

resident with a vaginal probe ultrasound. You

see a well-circumscribed, though empty

gestational sac.

What are your differential diagnoses? What do

you tell the patient?

Case 2

The patient returns 5 days later with further

spotting and cramping. A 2nd serum β-hCG is

done, as well as a repeat ultrasound. The

ultrasound now shows a large irregular shaped

gestational sac. The serum β-hCG level has

dropped.

What is your assessment?

Case 2 Anembryonic Pregnancy

• Consider the emotional aspects of miscarriage

• Element of choice in patient satisfaction

• Effectiveness of medication methods as well as

surgical methods

Case 2 continued

The patient decided to opt for medical treatment.

She took both mifepristone and misoprostol and is now seeing you for her routine follow-up visit, scheduled 2 weeks after she took mifepristone. She has been having persistent spotting, and says that she is really “sick of it.” Vaginal ultrasound reveals a non-viable, persistent gestational sac. Specifically, there is no evidence of growth but the sac is still present.

Case 2 continued

You counsel her about options, including

observation, repeating misoprostol, and

surgical completion. The woman has

significant childcare problems and wants

to minimize the number of visits she must

make to your clinic. Therefore, she

requests surgical completion.

Case 2 continued

You perform MVA and are partway through the aspiration when you note that the cannula seems to be sliding back and forth over the uterine lining too easily; it feels like nothing is happening.

What could be going on?

What do you do to test your answer to question #1?

How might MVA on this patient be different from that performed on surgical abortion patients who have not received mifepristone or misoprostol?

Case 3

26 yo G2P2002 LMP uncertain because of irregular periods well known to you presents to your office with spotting x 4 days. She denies any pain. Her urine pregnancy test is positive, her cervical os closed. Her uterus is retroverted. She has a remote history of Chlamydia infection about 10 years ago.

What is your differential diagnosis?

What tests would you order now?

Case 3

You perform an ultrasound and you see small

echolucent area, which could be a small

gestational sac or a pseudosac.

What should you do now?

What is your diagnosis? What are you options for

treatment?

Case 3 Key Concepts

Ectopic Pregnancy

• Ectopic vs early pregnancy may be hard to

differentiate

• Methotrexate an option for early & stable patients

• MVA can help evaluate POC in clinic, guiding

diagnosis & referral decision

Case 3 continued

26 yo G2P2002 LMP uncertain because of irregular periods is at your office for pregnancy termination with either early intrauterine versus ectopic pregnancy in the differential. She would like to deal with it today and with you if possible. You want to make sure it is not an ectopic pregnancy….

Case 3 continued

Initially, dilitation of the cervix seems slightly more difficult than usual. However, after the first two dilator passes, it then progresses uneventfully. A 6 mm cannula is placed in the os, the aspirator is connected, and only scant blood is obtained. Dilitation for correct placement is attempted again. Again, only scant blood is obtained.

What do you think is happening?

What do you do now?

MVA Key Concepts

• Helpful to trouble shoot & know how to solve common MVA

problems

• Lack of suction can caused by

– Device not assembled or working properly

– Clogged cannula

• Can never go wrong by stopping & reassessing

MVA Key Concepts

• Checking device & placement helpful when not

getting scant or no products back

• Ultrasound helps assess placement of cannula

• MVA can be help diagnose ectopic pregnancy

• Floating products of conception very helpful in

assessing uterine contents (and is easy to do)

Conclusions

Evidence demonstrates

• Uterine evacuation can be managed safely in an out-patient clinic setting

• Moving out of the operating room

– Saves both time, money, resources

– Offers significant both choice & advantages to both women & clinicians

“Never, ever, think outside the box.”