Manual Vacuum Aspiration

(Published June 2008)

Clinical Components of the MVA Procedure

MVA Instruments and Supplies¹

• MVA aspirator
• Silicone lubrication
• Cannulae (4–12 mm)
• Adaptor for cannulae
• Specula
• Tenaculum (sharp-toothed or atraumatic)
• Ring forceps
• Antiseptic solution, gauze, and small bowl
• Mechanical dilators
• Syringe, needle, and anesthetic agent for cervical block

MVA Aspirator Selection

There are nine brands of manual uterine aspirators available worldwide. Preference for brand is often determined by the needs of a particular setting.² In the United States, the IPAS TM double-valve manual aspiration syringe is the most commonly used product. The product is now designed to allow for steam autoclaving sterilization. Several US manufacturers produce cannulae that fit the IPAS syringe.³

Prevention of Infection

Use of a no-touch technique and prophylactic antibiotics can help to avoid infection. The first dose should ideally be administered 30 minutes before the procedure. The one regimen that is best supported in the medical literature is Doxycycline 100 mg, one hour before abortion, and 200 mg 30 minutes afterward.⁴

Cervical Anesthesia and Dilation of the Cervix

A paracervical or intracervical block is commonly used for vacuum aspiration abortions in North America. Deep injections using the Glick technique can be more effective than superficial injections and injecting slowly has been found to be less painful than injecting quickly.^5,6 The cervix should be dilated in accordance with the size of the pregnancy and the cannula the clinician plans to use. Excessive force in dilation of the cervix can cause cervical or uterine injury. In addition, overdilation should be avoided with MVA because it can compromise the vacuum pressure. Women experiencing early pregnancy loss or incomplete abortion may already have sufficient cervical dilation for the procedure. Women undergoing termination of an early pregnancy may be dilated using mechanical or plastic dilators or misoprostol.

Performance of the Procedure

The procedure is considered complete once the uterus feels empty to the clinician. (Note: If MVA is used for completion of incomplete or medical abortion, a sac may not be present.) The syringe must be emptied an average of one to three times to complete the procedure.⁷

Postprocedure Patient Monitoring

Postprocedure the patient should be monitored for signs of pain and bleeding. A clinician should be notified in the event of fever or prolonged, worsening, or severe pain or bleeding.⁸

Postoperative Tissue Examination

It is critical to examine the products of conception (POC) after completion of the procedure. Examining the tissue helps ensure that the procedure is complete. For very early gestations, POC are less likely to be disrupted during the aspiration when using MVA as compared to EVA; thus, the POC may be more easily identified.^9-11 Lack of complete POC identification may indicate an ongoing or ectopic pregnancy. Patients should be evaluated carefully to identify the appropriate diagnosis.

A common technique for early tissue examination includes the following steps:

• Wash the aspirate in a fine-mesh metal strainer under running water to remove blood and clots.
• Transfer the remaining tissue into a clear glass dish containing about 0.5 inch of water or saline solution.
• Place the dish on a radiograph box or photographic slide viewer, as backlighting greatly facilitates differentiation of the pregnancy elements.¹⁰ A flashlight may provide some additional lighting if these resources are not available in the office.

Additional Issues Regarding Tissue Identification:

• A woman experiencing early pregnancy loss (i.e., miscarriage) may have already expelled the pregnancy, and thus only limited tissue may be present.
• POC from a very early pregnancy (< 6 weeks) may be difficult to identify without specialized training.
• MVA may be unsuccessful. A congenital abnormality in uterine shape, for example, may make cannula placement difficult or impossible. In such cases, the patient will need another option for clinical management.

References

1. Ipas. MVA Training in the Outpatient Setting—Binder. Lincoln Medical and Mental Health Center, March 18-19, 2003. Chapel Hill, NC: Ipas.
2. Girvin S, Ruminjo J. An evaluation of manual vacuum aspiration instruments. Int J Gynaecol Obstet. 2003;83(2):219-32.
3. Orbach D, Schaff E. Which cannulae fit the Ipas manual vacuum aspiration syringe? Contraception. 2004;69(2):171-3.
4. Levallois P, Rioux JE. Prophylactic antibiotics for suction curettage abortion: results of a clinical controlled trial. Am J Obstet Gynecol. 1988 Jan;158(1):100-5.
5. Castleman L, Mann C. ManualVacuum Aspiration (MVA) for Uterine Evacuation: Pain Management. Chapel Hill, NC: Ipas, 2002.
6. Maltzer DS, Maltzer MC, Wiebe ER, Halvorson-Boyd G, Boyd C. Pain management. In: NAF’s A Clinician’s Guide to Medical and Surgical Abortion. Philadelphia: Churchill Livingstone, 1999.
7. Dean G, Cardenas L, Darney P, Goldberg A. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception. 2003;67:201-6.
8. Dalton V, Castleman L. Manual vacuum aspiration for treatment of early pregnancy loss. Postgrad Obstet Gynecol. 2002;22(19):1-5.
9. Edwards J, Creinin MD. Surgical abortion for gestations of less than six weeks. Curr Probl Obstet Gynecol Fertil. 1997;Jan/Feb:11-19.
10. MacIsaac L, Darney P. Early surgical abortion: an alternative to and backup for medical abortion. Am J Obstet Gynecol. 2000;183:S76-83.
11. Paul M, Lackie E, Mitchell C, Rogers A, Fox M. Is pathology examination useful after early surgical abortion? Obstet Gynecol. 2002;99:567-71.