Introduction of a manual vacuumaspiration service: a model of servicewithin a NHS Sexual Health Service

Mary Pillai,1 Val Welsh,2 Kirsty Sedgeman,3 A Caroline Gazet,4

Juliet Staddon,5 Helen Carter6

For numbered affiliations seeend of article.

Correspondence toDr Mary Pillai, GloucestershireCare Services NHS Trust, SexualHealth Service, Hope House,Gloucestershire Royal Hospital,Great Western Road, GloucesterGL1 3 NN, UK;mary.pillai@glos.nhs.uk

Received 6 June 2013Revised 26 October 2013Accepted 7 January 2014Published Online First21 February 2014

To cite: Pillai M, Welsh V,Sedgeman K, et al. J FamPlann Reprod Health Care2015;41:27–32.

ABSTRACTBackground We assessed the applicability,acceptability and cost implications of introducingthe manual vacuum aspiration (MVA) techniquewith local anaesthesia for fully consciousfirst-trimester termination of pregnancy within ourservice and for our population.Setting The outpatient setting of a PregnancyAdvisory Service within a NHS Sexual HealthService.Methods Self-administered misoprostol anddiclofenac, extra-amniotic local anaesthetic gel andparacervical mepivicaine prior to MVA. Routinelycollected data were used to provide information onuptake, demographic details, timing, pain score,complications, contraceptive uptake, and economicimplications for our service.Results MVAwas chosen by 305/1681 potentiallyeligible women. Forty percent had the procedureon the day they attended for assessment. Seventy-nine percent gave a pain score of 3 or less out of10. Complications occurred in six cases (2%); theseincluded cervical rigidity, a false passage, retainedproducts of conception, bleeding (more than200 ml) and one allergic reaction. Eighty percent ofwomen chose to commence a long-actingreversible contraception (LARC) method at the timeof MVA. Operating theatre utilisation was reducedby one termination list per week and cost savings ofaround £60 000 per annum were realised.Conclusions The technique for fully consciousMVAwas very suitable for our outpatient setting. Itwas associated with very low levels of pain andbleeding. The uptake of LARC was high, andparticularly the ability to provide intrauterinecontraception at MVAwas associated with a veryhigh uptake.

INTRODUCTIONAbortion care remains almost the onlyacute health need not comprehensivelyprovided for within the National HealthService (NHS). Statistics for 2012 show

that although 97% of abortions for resi-dents in England and Wales were fundedby the NHS, 62% took place in the inde-pendent sector under NHS contract.1

The Pregnancy Advisory Service (PAS) inGloucestershire is part of the SexualHealth Service, serving a population ofaround 500 000. The service is located in astand-alone building on the same hospitalsite as maternity and gynaecology services.It provides care to approximately 1500women per annum who are consideringabortion, and over 90% of women with aGloucestershire postcode undergoing abor-tion complete the process within thisservice. There are multiple access pathwaysincluding general practitioner referrals,referrals from a range of other health careproviders and self-referrals. Until May2011, only surgical operating theatre-basedor medical outpatient-based procedureswere provided. Occasionally a local anaes-thetic procedure was provided to women

Key message points

▸ Manual vacuum aspiration (MVA) withextra-amniotic and paracervical localanaesthesia resulted in a low painscore in 79% of women choosing fullyconscious first-trimester surgicalabortion.

▸ Forty percent of procedures were com-pleted on the day of first attendancefor assessment, with an averageattendance time of 2.5 hours.

▸ The complication rate was 2% and theuptake of long-acting reversible contra-ception was 80%, with 51% choosingan intrauterine system fitting at the timeof the MVA.

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undergoing surgical abortion in theatre, either formedical reasons or on patient request. It was felt thatmanual vacuum aspiration (MVA), a technique origin-ally developed as a low-technology method of uterineevacuation for developing countries, might be a bettermethod for suitable women and that the outpatientfacility would be a preferable setting, with potential costsavings as well as greater choice and safety. We viewedthis as a potential QIPP (NHS Quality, Innovation,Productivity, Prevention) initiative.

METHODSPrior to May 2011, women wishing to proceed withtermination were offered a choice of early medicalabortion (EMA) up to 9 weeks 2 days or surgical ter-mination in theatre up to 16 weeks 6 days. Where thepregnancy had exceeded this gestation, women wereassessed and referred to an independent provider,accounting for 4% treated elsewhere under an NHScontract. From May 2011, in addition to the aboveoptions, women up to 12 weeks 6 days were alsooffered the option of MVA under local anaesthesiawithin the Sexual Health Service outpatient setting. Abusiness case was written and a procedural policy forMVA was ratified by the Trust Policy and ClinicalGovernance groups. Our experience and the outcomesduring the first 18 months are presented.

AssessmentWoman attending PAS had an ultrasound scan andwere offered counselling within the clinic. They wereasked to do a self-taken swab for chlamydia and hadblood taken for haemoglobin, blood group and anti-body screen and, with consent, full antenatal virologyscreening. Verbal and written information was pro-vided covering the full range of procedural optionsand available dates. Women were considered unsuit-able for outpatient MVA if they were not inclined tohave a procedure while fully conscious, if they gave ahistory of difficulty tolerating speculum examination,or if they had complex medical problems (such ascyanotic congenital heart disease) or were at high riskfor bleeding (known clotting factor deficiency or sig-nificant platelet disorder). High-risk medical and sur-gical cases, particularly those at significant risk ofbleeding, were managed in theatre with anaestheticsupport and trained recovery staff, even if their pro-cedure was performed under local anaesthesia. TheMVA procedure was offered to women who hadnever experienced a speculum examination providedthey expressed a clear preference for MVA followingdetailed discussion of all the procedures for whichthey were suitable. Women attending with evidence ofretained products after medical or surgical termin-ation, or where an intrauterine pregnancy was foundto be non-viable at assessment, were offered the samemedical and surgical options, including MVA, or con-servative management.

The proceduresManual vacuum aspirationMVA procedures were carried out in the outpatientsetting of the Sexual Health Service. The first 200procedures were performed by one of three doctorswho had extensive experience of surgical abortion.The first author was experienced at providing a rangeof intrauterine procedures with local anaesthesia,including abortion, and trained the others in the tech-nique. One nurse and one health care assistant (HCA)were present for each procedure. During the last6 months of data collection procedures were also per-formed by four specialist registrars in CommunitySexual and Reproductive Health (CSRH) whoattended the service to receive MVA training.On arrival, women self-administered 2×200 mg miso-

prostol tablets sublingually or vaginally, and they wereoffered diclofenac 100 mg rectally, which most chose toself-administer. Some 60–90 minutes later, 11 mlInstillagel® (2% lidocaine gel with chlorhexidine) wasinserted through the cervix into the extra amnioticspace using an Instillaquil, as described elsewhere.2 Ina minority of cases the cervix was found to be tight, soa further 200 mg misoprostol was administeredand more time allowed for cervical preparation. TheMVA procedure was otherwise performed approxi-mately 20–30 minutes after the Instillagel administra-tion. Additional analgesia was given by means of aparacervical block with 3×2.2 ml ampoules of 3%mepivicaine injected at the 12, 3 and 9 o’clock positionsusing a dental syringe with a long 27 g needle, in themanner described by Hamoda et al.3 Entonox® wasavailable on request.The same gynaecology couch used for scanning

during assessment was used for the MVA procedures,so the scanner was available at the bedside if needed.The procedures were performed using suction curettesof 6–10 mm diameter, aiming to use a curette sizeequivalent to the number of weeks of gestation.Where significant resistance was encountered whendilating, a smaller suction catheter was used. We didnot attempt to use a suction curette greater than10 mm diameter in any MVA case. For cases beyond10 weeks gestation a 10 mm catheter was used and wefound this efficient up to 12 weeks 6 days. Thevacuum was created with a 60 ml hand-held syringewith a self-locking mechanism (Rocket Medical).Where necessary the cervix was dilated using Hegardilators, and in a small minority where cervical rigid-ity was encountered, tapered dilators were used. Indifficult cases, and during some training procedures,transabdominal ultrasound was used during the pro-cedure to assist guidance. At the end of the procedureif there was any doubt about completeness the uteruswas checked with transabdominal or transvaginalultrasound.Contraception was discussed at the initial assess-

ment, and the full range of long-acting reversible

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contraception (LARC) methods was offered at thetime of the MVA procedure. Before discharge womenwere asked by the HCA or nurse to indicate the worstlevel of pain that they had experienced during theentire procedure, either on a visual analogue scale oron a verbal scale. The range suggested was from 1 (nopain/mild discomfort) to 10 (the worst pain imagin-able), with a score of 3 comparable with the level ofpain they might experience with a period.

Early medical abortionA standard two-stage procedure with mifepristone200 mg followed by misoprostol 24–72 hours laterwas provided. Women had the choice of going homeafter misoprostol or staying in a medical suite. Thosechoosing to go home were given a supply ofco-codamol unless contraindicated. A wider range ofanalgesia including intramuscular pethidine, oral mor-phine and Entonox was available to those choosing tostay in the medical suite.

RESULTSData are summarised for the first 18 months of theservice. Where possible and appropriate we haveincluded data for the other methods offered towomen during the time frame.All new appointments at the service are summarised

in Table 1. The age range was from 15 to 45 years.At the outset for very young nulliparous women

and women who had not undergone vaginal deliverywe included the option of MVA up to 10 weeks(70 days) and for parous women up to 12+ weeks(87 days). However, on the basis of our experiencewith the first 20 cases the procedure was subsequentlyoffered to all women up to 12 weeks 6 days. Eightwomen choosing EMA completed their procedurewith MVA due to inadequate pain control withopiates. Their data are included with the EMA casessince they started with that as their chosen procedureand had already been in the suite for several hoursand experienced severe pain before their decision torequest completion with MVA.

Time of procedureWhere possible women were offered the MVA proced-ure on the day that they first attended the PAS and40% completed the procedure on that day. Where asame-day procedure was offered, some women optedfor a later date for their convenience.The total time from arrival for the procedure to dis-

charge ranged from 1.5 to 5.75 hours. The mean andmedian times from arrival to discharge were 2.5 and2.57 hours, respectively. Eighty percent of cases had atotal attendance time of less than 3 hours, and 4%attended for more than 4 hours. No women requiredhospital admission following MVA.

Blood lossObvious products of conception were aspirated inevery case and this was accompanied by almost noblood loss except in one MVA performed for evacu-ation of retained products, where colour Dopplerscanning showed evidence of high flow, and one casethat followed a possible allergic reaction to the medi-cation given for cervical priming. These were the onlytwo cases where cannulation and intramuscularSyntometrine® were required.

Pain scoresThe pain scores are represented in Figure 1. In 22cases no score was recorded through oversight, butthere was nothing in the records or staff recollectionto indicate these were not comparable with othercases. The worst level of pain experienced was scoredat 3 or less out of 10 by 224/283 women (79%). A

Table 1 New appointments and attendance at the PregnancyAdvisory Service for the 18-month period from 1 May 2011 to31 October 2012

Summary of PAS referrals Patients [n (%)])

New clinic appointments 2401

Number of patients attending 2152

Attended – found not pregnant 29

Attended – too early to confirm location 87

Attended – non-viable pregnancy/miscarriageconfirmed

76*

Referred to gynaecology

Suspected ectopic pregnancy (eight casesconfirmed; remainder ectopics of unknownlocation or unconfirmed)

14

Molar pregnancy 1

Attended – undecided further appointments/eventual TOP

108

Attended – decide to continue pregnancy 143

Attended

≥17 weeks: referred to independent provider 49†

≥24 weeks: referred for antenatal care 2

Procedures performed

EMA 680 (36%)

MVA 305 (16%)

Theatre: Suction TOP/D&E 899 (48%)(180≥13 weeks)†

Theatre: ERPC 26

Did not attend

For PAS clinic 249

For EMA/MVA 25‡

For theatre list 53‡

*Patient choice of conservative, medical or surgical management.†MVA not offered to 229/1959 (11.5%) women wanting a procedureowing to gestation ≥13 weeks.‡Some did attend but were undecided and so did not proceed with thebooked procedure.D&E, dilatation and evacuation; EMA, early medical abortion; ERPC,evacuation of retained products of conception; MVA, local anaestheticmanual vacuum aspiration; PAS, Pregnancy Advisory Service; TOP,termination of pregnancy.

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majority of women stated they did not consider theprocedure painful or that it was much less painfulthan they had expected. Ten women gave a score of 0despite a suggested scale of 1 to 10, saying they didnot consider they experienced any pain at all duringthe procedure. Only three women took up the optionof using Entonox during the procedure. No womenchoosing MVA required controlled drugs for anal-gesia. We did not have any case with symptoms oflocal anaesthetic toxicity.We did not ask women choosing EMA to assign a

pain score, as this was not practical with less than halfof them completing the procedure within the SexualHealth Service setting. However, data available fromthe patient experience questionnaires received duringthe time frame indicated that MVA and EMA patientswere similarly satisfied with all areas of the serviceexcept that some EMA patients experienced morepain than they had expected.All eight of the women completing EMA by MVA

had already received two doses of opiates beforedeciding to complete their terminations with MVA.Of 680 women choosing EMA over the time period,just under half aborted in the unit and 84 of these

required opiate analgesia. The number of womencompleting at home who might have wished for stron-ger analgesia is unknown.

High pain scoresSeven of 305 women undergoing MVA gave a painscore of 7. Their ages ranged from 18 to 41 years,and they included both nulliparous and parouswomen. One case was the evacuation complicated byhaemorrhage and another was complicated by cervicalrigidity. These are summarised in Table 2. The otherfive cases giving a score of 7 had no identifiablefactors as to why their procedure was painful. Onewoman gave a score of 9. She is also summarised inTable 2. All three women who took up the option ofEntonox gave a high pain score.

ComplicationsSix patients with complications are summarised inTable 2.

Continuing contraceptionWomen choosing EMA were offered the same rangeof contraception as offered to surgical cases, exceptthat those wanting an intrauterine device were advisedthey would need an appointment in 4 weeks for thefitting. The contraceptive method chosen or providedat the time of MVA and EMA is detailed in Table 3.While 80% of women undergoing MVA chose a

LARC method for continuing contraception, only48% of women undergoing EMA did so.

Patient experienceOne anonymous annual patient experience surveycoincided with the 18 months of data collection. Thesurvey comprised 50 consecutive patients utilising each

Table 2 Complications with manual vacuum aspiration

Patient Complication Outcome

1 MVA for uterine evacuation 4 weeks post-EMA.Presented with moderate bleeding despite further misoprostol andantibiotics. Scan showed retained products measuring 4×2.5×3 cm withvery high flow. Brisk loss of 200 ml as soon as instrumented. Controlledwith bimanual compression and Syntometrine®

Moderate loss continued for 2 hours. Remained in the unit5.75 hours, longer than any other case.Histology showed necrotic decidua and scanty villi

2 Para 3, 7 weeks. Initial failed dilatation due to rigid cervix and pain.Further misoprostol and completion of MVA with ultrasound guidance1–2 hours later. Ultrasound demonstrated that the initial failure hadbeen associated with a false passage at the point of retroflexion.Procedure completed with ultrasound guidance and IUS fitted

High pain score (9) at initial attempt.At follow up the IUS was missing and perforation confirmed. Inretrospect it was unwise to have inserted the IUS when false passagehad occurred even though it was possible to complete with ultrasoundguidance

3 Para 0, 9 weeks 4 days. Cervical rigidity. Not possible to dilate beyond6–7 mm. Performed through a 7 mm suction catheter which blockedrepeatedly

High pain score (7).Incomplete – 3×2 cm area of retained products managedconservatively

4 Para 0, 7 weeks 5 days. Rigid cervix and prolonged bleeding Uterus empty at follow-up scan

5 Prolonged bleeding. Small amount of retained products did not resolvedespite misoprostol and antibiotics

Repeat MVA with antibiotic cover. Bleeding settled

6 Possible allergic reaction. Stridor and a rash followed administration ofmisoprostol and diclofenac. Settled with hydrocortisone andantihistamine

Moderate fresh blood loss at MVA (<150 ml) settled withSyntometrine

EMA, early medical abortion; IUS, intrauterine system; MVA, manual vacuum aspiration.

Figure 1 Manual vacuum aspiration pain score out of 10.

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of four options provided by the service, namely EMAand MVA within the Sexual Health Service clinicalarea and each of two theatres, one on the same hospitalsite and the other on a hospital site 8 miles away.The questionnaire return rate was 56% and 60% forEMA and MVA, respectively, but only 15% for womenattending a theatre site. Overall all the returned ques-tionnaires indicated a high level of satisfaction with thewaiting time for appointments and procedures, andwith the care provided by staff. The main differenceshighlighted were that 100% of responses from the sur-gical cases (MVA and theatres) indicated that thewomen were very happy with the support given andthat the process was as expected following the informa-tion and advice given. However, only 75% of EMAresponses indicated the same high level of preparation,with 25% responding that the process was to someextent not as they had expected following informationand advice. This reflected the difficulty in predictingthe level of pain and in preparing women for the painexperience and analgesia needs of EMA.

CostingsWithin 4 months of introducing MVA it was possible toreplace one of three weekly theatre lists with MVAs.The saving on the theatre recharge was £92 000 perannum. The costs for setting up and running the MVAsessions amounted to £28 000 per annum. However,the procedure room containing the scanner, the electricgynaecology couch and a mobile light were already inuse by the service and were more fully utilised once theMVA sessions commenced. The main consumable costwas contraception. Owing to the high uptake of LARC,particularly the 51% uptake of the intrauterine system,this averaged £235 per session of four cases. There wereadditional setup costs for purchase of dilator sets andtheatre clothing. Overall for our service the differencein cost of the weekly theatre list against running twoMVA sessions per week resulted in an annual saving ofaround £60 000.

DISCUSSIONMVA has been in widespread use in developing coun-tries for over two decades, and more recently in theUSA, and by some private providers in the UK. It hasbeen shown to be effective for management of bothfirst-trimester abortion3 and miscarriage.4 Despitethis, NHS services in the UK have tended to offerstandard suction termination under general anaesthe-sia to women who decline or are too late for amedical procedure. This is reflected in the difficultythat CSRH trainees in many areas are currentlyexperiencing in obtaining MVA training to achieve therequired competencies of the core curriculum. Wehope that reporting our experience may encourageother providers to introduce this option.Some providers may presume that MVA will be less

acceptable to women, or be associated with a level ofpain that women will not accept. There may also be alack of confidence among clinicians at the idea of pro-viding a surgical procedure of a sensitive nature to fullyconscious women. Our own data accord with publisheddata, which support the notion that MVA may be lesspainful than EMA and that women are more likely to besatisfied with surgical than medical abortion.5 6

At the outset our objective was to increase choicewithin our service. We did not set out to compare andcontrast MVA with EMA, but certain advantagesbecame evident. First, we found MVA to be equallyeffective from 5 weeks to 12 weeks 6 days. Althoughmedical methods can be used at later gestations, evi-dence shows that their acceptability declines withincreasing gestational age beyond 9 weeks.5 Second,MVA is quicker than EMA, taking around 10 minutes,but requiring attendance of around 2.5 hours to allowcervical preparation. Third, it is complete at the time,allowing insertion of intrauterine contraception as partof the procedure. Published data show that women fre-quently fail to attend for a deferred fitting appoint-ment following abortion.7 Finally, around 50% ofwomen choosing EMA do not complete their abortionwithin our service and this incurs considerablefollow-up work, which is not needed with MVA.The main cost savings to our service were realised

by replacing surgical procedures in theatre with MVAprocedures. For women there is the added safety ofavoiding general anaesthesia, the convenience thatthey do not need to starve before the procedure andbe ‘recovered’ after it, and that they do not needanother adult to take them home.We feel that patient selection is very important, as

women who have significant difficulty tolerating apelvic examination are unlikely to find the procedureacceptable. We find it much more difficult to predict theminority of women who will not cope well with EMAand this was reflected in the patient experience survey.We were pleasantly surprised that 79% of women

felt the procedure was either not painful at all or com-parable to the level of pain they would experience

Table 3 Choice of contraception

Method EMA % MVA %

Condoms 23 3.5 4 1.3

Oral (COC or POP) 320 47.0 50 16.4

DMPA 122 18.0 24 7.9

Implant 150 22.0 41 13.5

IUD/IUS 55* 8.0 179 58.6

Declined 10 1.5 7 2.3

Total 680 100.0 305 100.0

*We are unable to clarify how many women expressing an intention touse intrauterine contraception following EMA actually underwent a fitting.COC, combined oral contraceptive; DMPA, depot medroxyprogesteroneacetate; EMA, early medical abortion; IUD, intrauterine device; IUS,intrauterine system; MVA, manual vacuum aspiration; POP,progestogen-only pill.

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with a period. There are two elements to the tech-nique that we employed for pain relief. One is extra-amniotic instillation of lidocaine gel. Instillation of5 ml 4% lidocaine through the cervix 3 minutesbefore first-trimester abortion has been shown toprovide significant reduction in pain during cervicaldilation and suction aspiration,8 while instillation of1% lidocaine failed to provide pain relief.9 However,there was a high rate of toxicity with instillation ofthe higher concentration. We instilled 11 ml 2% lido-caine gel, but allowed considerably longer for absorp-tion (20–30 minutes). This technique also provided anopportunity to assess cervical priming and to extendthis where the cervix did not admit the quill or gelwith ease. Extending the duration of priming inpotentially more difficult cases may also have influ-enced pain scores. The second element, paracervicalinjection of mepivicaine, has been studied for a rangeof gynaecological interventions. A recently updatedCochrane review found that deep local anaestheticinjection was associated with significantly less painduring cervical dilatation and uterine interventionthan placebo injection (saline or water) but concludedthat clinically this difference may be unimportant.10

Overall there is a lack of clear evidence on the bestmethod of local anaesthesia for minor gynaecologicalprocedures, including abortion.9–11

We did not include conscious sedation as part ofour procedure as we aimed to introduce a techniquethat is safe and suitable for an outpatient settingwhere anaesthetist support is not available and thatwould allow women to leave the service directly,without requiring a supervising adult.

CONCLUSIONSThe technique we use for MVA is highly effectivethroughout the first trimester, with low pain scores, alow complication rate and high acceptability. It com-bines all the advantages of a surgical procedure with lowcost.Although we did not set out to compare MVA with

medical abortion, our experience with both proceduresindicates that medical methods seem to be less effectiveand more painful compared to first-trimester surgicalabortion with local anaesthetic. Arguably MVA is there-fore a gold standard procedure for the first trimester.

Author affiliations1Consultant in Community Gynaecology andObstetrics, Gloucestershire Care Services NHS Trust,Sexual Health Service, Gloucestershire RoyalHospital, Gloucester, UK2Lead Nurse in Sexual and Reproductive Health,Gloucestershire Care Services NHS Trust, SexualHealth Service, Gloucestershire Royal Hospital,Gloucester, UK3Nurse in Sexual and Reproductive Health,Gloucestershire Care Services NHS Trust, Sexual

Health Service, Gloucestershire Royal Hospital,Gloucester, UK4Associate Specialist in Sexual and ReproductiveHealth, Gloucestershire Care Services NHS Trust,Sexual Health Service, Gloucestershire RoyalHospital, Gloucester, UK5Associate Specialist and General Practitioner,Gloucestershire Care Services NHS Trust, SexualHealth Service, Gloucestershire Royal Hospital,Gloucester, UK6Nurse in Sexual and Reproductive Health,Gloucestershire Care Services NHS Trust, SexualHealth Service, Gloucestershire Royal Hospital,Gloucester, UK

Acknowledgements Dr Julia Shefras contributed to writing thepolicies and patient information leaflet during the setting upphase of the MVA service.

Competing interests None.

Provenance and peer review Not commissioned; externallypeer reviewed.

REFERENCES1 Department of Health. Abortion Statistics England and Wales

2012. July 2012. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/211790/2012_Abortion_Statistics.pdf (accessed 12 December 2013).

2 Pillai M, Shefras J. Experience with Instillagel® forhysterosonography and analgesia in a complex contraceptionclinic: a QIPP initiative. J Fam Plann Reprod Health Care2012;38:110–116.

3 Hamoda H, Flett GM, Ashok PW, et al. Surgical abortion usingmanual vacuum aspiration under local anaesthesia: a pilotstudy of feasibility and women’s acceptability. J Fam PlannReprod Health Care 2005;31:185–188.

4 Milingos DS, Mathur M, Smith NC, et al. Manual vacuumaspiration: a safe alternative for the surgical management ofearly pregnancy loss. BJOG 2009;116:1268–1271.

5 Robson SC, Kelly T, Howel D, et al. Randomised preferencetrial of medical versus surgical termination of pregnancy lessthan 14 weeks’ gestation (TOPS). Health Technol Assess2009;13:1–124, iii–iv.

6 Say L, Kulier R, Gülmezoglu M, et al. Medical versus surgicalmethods for first trimester termination of pregnancy. CochraneDatabase Syst Rev 2005;1:CD003037.

7 Stanek AM, Bednarek PH, Nichols MD, et al. Barriersassociated with the failure to return for intrauterine deviceinsertion following first-trimester abortion. Contraception2009;79:216–220.

8 Edelman A, Nichols MD, Leclair C, et al. Four percentintrauterine lidocaine infusion for pain management infirst-trimester abortions. Obstet Gynecol 2006;107:269–275.

9 Renner RM, Jensen JT, Nichols MD, et al. Pain control in firsttrimester surgical abortion. Cochrane Database Syst Rev2009;2:CD006712.

10 Tangsiriwatthana T, Sangkomkamhang US, Lumbiganon P, et al.Paracervical local anaesthesia for cervical dilatation and uterineintervention. Cochrane Database Syst Rev 2013;9:CD005056.

11 Mercier RJ, Zerden ML. Intrauterine anesthesia forgynecologic procedures: a systematic review. Obstet Gynecol2012;120:669–677.

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transmission: a potential conflict ofpublic health principles’.2

Importantly, through the application ofdifferent frameworks, we came to acommon conclusion: even if a contracep-tive method increased HIV transmissionrisk, restrictions on the use of that contra-ceptive should not be imposed. Contra-ceptive choice should remain with theindividual woman, in consultation withher health care provider.

A limitation with human rights andclinical ethics approaches is that there isno way to adjudicate among competingissues as, in our case, the same principlecan suggest directly contrary actionsand policies. Thus, principlism cannotguide action.3 The human rights frame-work emphasises the point that womenhave the fundamental right to bothHIV prevention and family planning, apoint with which we agree. What thehuman rights perspective does not do isto help policymakers figure out what todo when two human rights claims dir-ectly compete with one another.

While our viewpoint certainly isn’tthe only public health perspective, whatwe tried to provide was a mechanismby which policymakers can determinehow to weigh and balance these com-peting claims and come up with a setof policies that are woman-centeredand satisfy other important principlesof public health such as fairness,accountability and transparency.

Lisa B Haddad,* MS, MPH

Assistant Professor, Department of Gynecology andObstetrics, School of Medicine, Emory University,Atlanta, GA, USA; lisa.haddad@emory.edu

Sean Philpott-Jones, PhD, MSBioethics

Director, Center for Bioethics and ClinicalLeadership, Union Graduate College, Schenectady,NY, USA; philpots@mail.uniongraduatecollege.edu

Toby Schonfeld, PhD

tlschonfeld@gmail.com

*Corresponding author.

Competing interests None.

▸ http://dx.doi.org/10.1136/jfprhc-2015-101176

J Fam Plann Reprod Health Care 2015;41:156–157.doi:10.1136/jfprhc-2015-101204

REFERENCES1 Covshoff E, Sauer U, Pittrof R. Human rights

and clinical ethics are the right framework toaddress the probable DMPA-HIV interaction.J Fam Plann Reprod Health Care 2015;41:156.

2 Haddad LB, Philpott-Jones S, Schonfeld T.Contraception and prevention of HIVtransmission: a potential conflict of publichealth principles. J Fam Plann Reprod HealthCare 2015;41:20–23.

3 Clouser KD, Gert B. A critique ofprinciplism. J Med Philos 1990;15:219–236.

Incidence of fracturedimplants

I read with interest Deepak Khatri’sletter about a fractured Nexplanonimplant in the January 2015 issue ofthis Journal.1 I would like to informreaders of another implant fracture,similar to that described by AlysonElliman in this Journal 2 years ago,2

and subsequent related correspondence.A patient had an uneventful reinser-

tion, and attended 7 months later havingnoticed a ‘dip’ in the implant that hadnot been present post-insertion. Therewas no history of any trauma. Thepatient’s bleeding pattern had beenscanty and irregular, unchanged fromher previous implant bleed pattern.

On examination the implant waseasily palpable at both distal and prox-imal ends, with a noticeable ‘dip’ in thecentre portion. Implant removal andreinsertion was agreed with the patient.The implant was removed without diffi-culty using a ‘pop out’ technique fromthe distal end. Figure 1 shows the ‘teethmarks’ made by a Gillies dissectingforceps on the distal end of the implant.On close inspection the implant wasseen to be fractured in the mid-section,without separation of the two parts,resulting in the angulation that thepatient had noticed.

I informed the drug company andfiled a Medicines and Healthcareproducts Regulatory Agency (MHRA)Yellow Card report online. After severalmonths I was contacted by the implant’smanufacturer for further details of theclinical incident. I have had no furthercorrespondence since then.

It would be interesting to receive clari-fication from the manufacturer about theincidence of reported fractured implants.Do other/all practitioners report theseevents to both the manufacturer and theMHRA, I wonder?

Victoria Hartnell, DFSRH, MRCGP

General Practitioner and Level 2 Sexual HealthProvider, Falmouth Health Centre, Falmouth, UK;vicky.hartnell@nhs.net

Competing interests None.

J Fam Plann Reprod Health Care 2015;41:157.doi:10.1136/jfprhc-2015-101209

REFERENCES1 Khatri D. Fractured Nexplanon® implant.

J Fam Plann Reprod Health Care 2015;41:77.2 Elliman A. Removal of a fractured

Nexplanon®. J Fam Plann Reprod Health Care2013;39:66–67.

Figure 1 Photograph of the implantfollowing removal, showing the fracturedmid-section with clearly visible ‘teethmarks’ made by a Gillies dissectingforceps on the distal end. (Photographkindly supplied by Dr Paul Davoren.)

Correction

doi:10.1136/jfprhc-2013-100700corr1

Pillai M, Welsh V, Sedgeman K, GazetA C, Staddon J, Carter H. Introductionof a manual vacuum aspiration service:a model of service within a NHSSexual Health Service. J Fam PlannReprod Health Care 2015;41:27–32doi:10.1136/jfprhc-2013-100700The lead author would like to apolo-gise for an error in the description ofthe MVA aspirator. The device used intheir service is the Ipas MVA Plus®

Aspirator supplied by Durbin.

Letters to the editor

J Fam Plann Reprod Health Care April 2015 Vol 41 No 2 157