Manual Vacuum Manual Vacuum Aspiration with Aspiration with

local anaesthesialocal anaesthesia

Marijke Alblas,MDMarijke Alblas,MD

Western Cape Western Cape Department of HealthDepartment of Health

Use of MVA: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 Goal of presentation to show that: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 MVA is a safe and simple procedureprocedure

• 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’!--But: don’t do a ‘curette check’!-->to check with a curette for >to check with a curette for complete evacuation adds complete evacuation adds

unnecessary risksunnecessary 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 Can help to decentralize the service and therefore make it service and therefore make it

more accessiblemore 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 Make use of the right instruments and handle them instruments and handle them gently: the woman is awake!!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 VacuumCreate 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.

9

Selecting the cannulaSelecting the cannula

Adapters for the double-valve aspirator are color-coded to the dots on the corresponding cannula

7 to 10 mm____________________10/12 mm

10 to 12 LMP____________________13 to 14 LMP

6 to 7 mm8 to 9 LMP

4 to 6 mm5 to 8 LMP

Approximate size of the cannula

Approximate uterine size(weeks LMP)

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Paracervical blockParacervical block::

---

Insert cannulaInsert cannula

Releasing the Pinch ValveReleasing 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 MVA Technique: Vacuum AspirationAspiration

© Lisa Penalver

MVA Technique: Vacuum MVA Technique: Vacuum AspirationAspiration

© Lisa Penalver

Dilation cervix while doing Dilation cervix while doing suction: using different sizes of suction: using different sizes of

cannulacannula

• 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.)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 tissueInspecting the tissue17

• 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

Tissue ExaminationTissue Examination

Visual Inspection of the Visual Inspection of the Products of ConceptionProducts of Conception

Gestational sac

Blood clot

Decidua

Types of ComplicationsTypes of Complications

Early Complications:– Cervical Injury– Uterine injury– Haemorrhage– (Pre-existing) infection– Uterine rupture– Anaesthesia related complications

Recognising and Recognising and managing uterine managing uterine

perforationperforationSigns:• Instruments inserted beyond the fundus• Excessive bleeding• Fat or organfragments maybe in the

aspirated tissueTreatment:• Usually seals itself off as uterus contracts• If fat or organfragments:needs

laparoscopy or laparotomy

SummarySummary

• 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)Manual Vacuum Aspiration(MVA)vs. Electric Vacuum Aspiration(EVA)vs. Electric Vacuum Aspiration(EVA)

MVA• Inexpensive/re-usable• Small • Portable • Quiet• Specimen likely

to be intact• Requires repeated

reloading of suction

EVAMore costly but longer lifeBulkyLess portableNoisyFragmentation of specimen possibleConstant suction