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Manual vacuum aspiration

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Manual vacuum aspiration

  1. 1. Presented by DR OBAIKE ABBA ADAMS
  2. 2.  Case presentation  Introduction  Advantages of MVA  Indications  Contraindications  MVA equipments  Precautions  Procedure  Complications of MVA  Conclusion  References
  3. 3.  A 29-year old woman G1P0+0 with a history of amenorrhea for 3 months and a positive home urine pregnancy test.  Presented with PV bleeding or lower abdominal pain of 2/7 duration and intends to continue the pregnancy, though it was unplanned.  O/E: Pale, afebrile  V/E: NVV, cervical os open, smeared with altered blood.  Results of urgent ultrasonography to assess fetal viability reveal an intrauterine gestation with a fetal pole but no cardiac activity.  Clinical assessment of incomplete miscarriage was made.  Plan : Manual Vacuum Aspiration after stabilizing.
  4. 4.  Manual vacuum aspiration (MVA) is an aseptic procedure that involves the evacuation of uterine contents by the use of a hand-held plastic aspirator.  Used commonly in both developed and developing countries.  Approximately one in four women will experience a miscarriage in her lifetime.
  5. 5. First trimester (≤12Weeks) 1. Medical – Mifepristone(RU 486)- Antagonist to progesterone – Mifepristone & Misoprostol – Misoprostol alone 2. Surgical – MVA – EVA – Dilatation & Curettage (now obsolete)
  6. 6.  The World Health Organisation recommends Manual Vacuum Aspiration for uterine evacuation because it is: 1. Safe, high-quality, affordable 2. Easy to learn, Easy to use 3. Small, portable, quiet, no electricity required 4. Ideal for performing procedures in the outpatient setting.
  7. 7. 1. Less pain therefore less need for analgesia 2. Reduced risk of complications-bleeding 3. Less post abortal morbidity 4. Less hospital stay 5. Less time (about 10-15 minutes)
  8. 8.  Therapeutic 1. Treatment of incomplete abortion for GA up to 12 weeks 2. First trimester abortion(menstrual regulation) when indicated. 3. Missed abortion GA ≤ 12weeks 4. Gestational trophoblastic diseases-molar pregnancy 5. Septic abortion ≤12 weeks GA 6. Inevitable abortion ≤ 12 weeks GA 7. Blighted ovum or anembryonic gestation.
  9. 9.  Diagnostic 1. Endometrial biopsy 2. Dysfunctional uterine bleeding 3. Retained product of conception (2o PPH) 4. Confirmatory test for ovulation 5. Molar pregnancy (up to 24 weeks)
  10. 10.  ABSOLUTE 1. TOP > 12 weeks GA because, bony tissue and other body tissue is formed which is difficult to be evacuated via suction.  RELATIVE 1. Purulent cervicitis and pelvic infection 2. Coagulation disorders
  11. 11. 1. MVA Kit: ◦ Karman syringes (MV aspirator) ◦ Cannulae 2. Instruments: ◦ Vulsellum or Tenacullum ◦ Sponge holding forceps ◦ Kidney dish ◦ Hegar’s dilators ◦ Uterine sound ◦ Cusco or sim’s speculum
  12. 12. 3. Drugs used: ◦ 1% Lidocaine (xylocaine) ◦ Diazepam ◦ Pentazocine/Tramadol ◦ Normal saline ◦ Oxytocin 4. Others: ◦ Cotton swabs ◦ Vaginal/perineal pads ◦ Vaginal drapes ◦ Sterile gloves ◦ Syringes(10mls) ◦ Light source
  13. 13. 1. Any serious medical conditions such as shock, haemorrhage, cervical or pelvic infection, sepsis, as may occur with incomplete miscarriage be addressed immediately (e.g Urgent PCV,BGXM ). 2. Uterine aspiration/uterine evacuation is often an important component of definitive management in these cases and once the patient is stabilized, the procedure should not be delayed.
  14. 14. 3. In cases where the woman has a history of a blood-clotting disorder, the aspirators and cannulae should be used only with extreme caution and only in facilities where full emergency back-up care is available. 4. The procedure may be done with local anaesthesia or under analgesia with sedation.
  15. 15. 1. Explain procedure to patient and obtain a written or verbal consent. 2. Priming the cervix with agents such as a prostaglandin (inserted into the vagina or taken sublingually) around 3 hours prior to procedure reduces the risk of cervical trauma and haemorrhage.
  16. 16. 1. Privacy should be maintained (screen or closed room) 2. All the articles are arranged near procedure site. 3. All the ornaments, finger rings, bangles etc are removed. 4. Put on all universal protective devices(apron, boots). 5. Scrub and wear sterile gloves 6. Assemble the aspirator
  17. 17.  Goal: reduce pain and anxiety.  Choice may be based on woman’s individual needs or presentation. 1. Psychological pain: anxiety, fear, apprehension 2. Cervical pain due to dilatation 3. Uterine cramping due to manipulation  TIMING:  Drug must be most effective at the time of the procedure  Administer drugs 30-45 minutes before the procedure.
  18. 18.  Non Pharmacological I. Gentle, respectful interaction and communication II. Verbal support and reassurance III. Gentle, smooth operative technique IV. Can supplement but not replace medications
  19. 19.  Pharmacological I. Anxiolytics/sedatives relieve anxiety Diazepam (IM) II. Analgesics to relieve pain such as Ibuprofen, Pentazocine(IV) III. local anaesthesia (for paracervical block)using lidocaine or pethidine.
  20. 20.  Ask the woman to empty her bladder  Clean adequately and drape.  Clean vagina and vulva  Assist her in lithotomy position.  Conduct a bimanual exam to confirm uterine size and position  Insert speculum and conduct speculum exam to confirm findings of clinical assessment
  21. 21.  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 (1)  Pull plunger back until arms snap outward and catch on cylinder base (2)  Negative pressure (600- 660mmHg) is created in the cylinder.
  22. 22.  Follow No-Touch Technique- no instrument that enters the uterus can contact contaminated surfaces, including vaginal walls, before insertion through the cervix  Use antiseptic-soaked sponge to clean cervical os.  Start at os and spiral outward without retracing areas.  Continue until os has been completely covered by antiseptic
  23. 23.  Paracervical block is recommended when mechanical dilatation is required with MVA.  Using local protocols, administer paracervical block (at 2,4,8,10 o’ clock sites) and place tenaculum.  Use lowest anaesthetic dose possible to avoid toxicity-e.g if using lidocaine, the lowest recommended dose is less than 200mg
  24. 24.  Dilatation of the cervix is required to allow a canula to pass into the uterine cavity, and the greater the gestation of the pregnancy, the greater the amount of dilatation required.  Dilate cervix to allow a cannula approximate to the GA to fit snugly through the os.  If cervix is insufficiently dilated, use mechanical dilators or progressively larger canulae to dilate.
  25. 25.  While applying traction to tenaculum, sound the uterus then insert 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  The size of cannula is roughly the number of gestational weeks i.e 7wks=7mm cannula
  26. 26.  Attach the prepared aspirator to the cannula if the cannula and aspirator were not previously attached  Release the vacuum by pressing the buttons  Evacuate the contents of the uterus by gently and slowly rotating the cannula 180o in each direction, using an in- and-out motion.  Re-charge aspirator if necessary.  When the procedure is finished, depress the buttons and withdraw the instruments.
  27. 27. 1. Red or pink foam without tissue is seen passing through the cannula 2. A gritty sensation is felt as the cannula passes over the surface of the evacuated uterus. 3. The uterus contracts around or grips the cannula. 4. The patient complains of cramping or pain, indicating that the uterus is contracting.
  28. 28.  Empty the contents of the aspirator into a container.  Strain material, float in water or vinegar and view with a light from beneath  Inspect tissue for the products of conception, complete evacuation and molar pregnancy.  Send products for histology.
  29. 29.  STEP 9: Perform any concurrent procedure  When procedure is complete, proceed with contraception or other procedures, such as IUD insertion or cervical tear repair.  STEP 10: Process Instruments  Immediately process or discard all instruments, according to local protocol.
  30. 30. 1. Apply perineal pad and ensure that the woman is resting comfortably 2. Monitor vital signs and blood loss for at least 2 hours. 3. Pain is moderate and relieved by analgesics. 4. Verify and update tetanus immunization if unsafe abortion is suspected + Rhogam if Rh-ve. 5. Run IV Normal saline + Oxytocin(5-10IU) to help contract uterus. 6. Document your findings for legal purposes. 7. Patient can go home if vitals are stable, if she can walk and counselled.
  31. 31.  Is part of post-abortal care.  This is the package of care given to women who have undergone an abortion to prevent the complications which arises from it.
  32. 32. 1. Treatment of any complications. 2. Counselling -to identify and respond to woman’s emotional and physical health needs. 3. Contraceptive and family planning service to help her prevent future unwanted pregnancies or miscarriages. 4. Reproductive and other health services provided in the facility or referral 5. Community and service provider partnership- mobilizing resources to ensure timely care.
  33. 33.  Warm-baths, compresses for cramping  Light menstrual-like bleeding or spotting (few days).  Next menses:4-8 weeks  Pregnancy is advised after 2-3 consecutive normal menstrual cycles.  Give antibiotics, haematinics and analgesics before discharge home.  Advice on hygiene; no vaginal douches
  34. 34. 1. Fever, chills, fainting, vomiting. 2. Swollen, tender abdomen. 3. Foul discharge. 4. Bleeding more than normal menses or more than 2 weeks. 5. Delay in resumption of menstruation(more than 8 weeks).
  35. 35. EARLY LATE 1. Primary haemorrhage 2. Retained products 3. Pelvic infection 4. Uterine perforation 5. Genital tract laceration 6. Incomplete evacuation 7. Air embolism 8. Haematometra 9. Vagal reaction 1. Ashermann’s syndrome 2. Sepsis 3. Chronic pelvic pain 4. Chronic PID 5. Ectopic pregnancy 6. Infertility
  36. 36.  Maternal death is lowest (about 0.6/100000 procedures) in first trimester termination specially with MVA.
  37. 37.  Scheduled before discharge from facility  Timing varies; usually scheduled within one week  May not be at same facility  Woman may be referred to provider in her community.
  38. 38. 1. High Level Disinfection in 0.5% Chlorine solution 2. HLD by boiling (abt 20mins) 3. HLD in cidex 4. Sterilization using Autoclave (1210c for 30mins). 5. Sterilization using Etylene oxide(ETO).
  39. 39.  Aspirator-discard or replace if: ◦ Cylinder is brittle or cracked or mineral deposits inhibit plunger movement ◦ Valve parts are cracked, bent or broken ◦ Buttons are broken ◦ Plunger arms do not lock ◦ Aspirator no longer holds a vacuum  Cannulae-discard or replace if: ◦ Has become brittle ◦ Cracked, twisted or bent, particularly at the aperture. ◦ Cleaning the cannula does not completely remove tissue.
  40. 40.  Early pregnancy failure is a distressing situation  The physician needs to be sympathetic to patients who suffer miscarriage and take prompt actions when cases that require MVA present in emergency to mitigate bleeding and other complications.  It is important to keep an MVA checklist to ensure safety and effectiveness of procedure.
  41. 41.  Thank You For Listening
  42. 42. 1. Monga A.,Dobbs S., Gynaecology by Ten Teachers.2011.Hodder Arnold .19th Ed.pp96-98. 2. Ameh A.B., A Management Guide to Gynaecology.2012.Aboki .1st Ed.pp38-48. 3. Agboola A.,Textbook of Obstetric and Gynaecology for Medical Students.2006.2nd Ed.pp95-100 4. Konar H.,DC Duttal Textbook of Obstetrics.2015.Jaypee.8th Ed.pp-203- 207,644-646,753. 5. Manual vacuum aspiration (slideshare.net) 6. Mona S.,Manual vacuum aspiration:an outpatient alternative for surgical management of miscarriage.The Obstetrician and Gynaecologist.Vol 17(3).pub 25th July,2015.https://doi.org/10.1111/tog.12198 7. MVA:Performing uterine evacuation with Ipas MVA plus aspirator and easygrip cannulae.2007.Essential obstetric and newborn care.Chapter 9. 2nd Ed.http;//medicalguidelines.msf.org 8. MVA:Indications for MVA use.Association of Reproductive Health Professionals.Pub June 2008. 9. Piyapa P., and Anne R.D.,MVA:A safe and effective treatment for early miscarriage.OBG Management.Vol 27 No 11.Pub Nov 2015.

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