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Advantages of MVA
Complications of MVA
A 29-year old woman G1P0+0 with a history of
amenorrhea for 3 months and a positive home urine
Presented with PV bleeding or lower abdominal pain of 2/7
duration and intends to continue the pregnancy, though it
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
Clinical assessment of incomplete miscarriage was made.
Plan : Manual Vacuum Aspiration after stabilizing.
Manual vacuum aspiration (MVA) is an aseptic
procedure that involves the evacuation of
uterine contents by the use of a hand-held
Used commonly in both developed and
Approximately one in four women will
experience a miscarriage in her lifetime.
First trimester (≤12Weeks)
– Mifepristone(RU 486)- Antagonist to progesterone
– Mifepristone & Misoprostol
– Misoprostol alone
– Dilatation & Curettage (now obsolete)
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
4. Ideal for performing procedures in the
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)
1. Treatment of incomplete abortion for GA up to
2. First trimester abortion(menstrual regulation)
3. Missed abortion GA ≤ 12weeks
4. Gestational trophoblastic diseases-molar
5. Septic abortion ≤12 weeks GA
6. Inevitable abortion ≤ 12 weeks GA
7. Blighted ovum or anembryonic gestation.
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)
1. TOP > 12 weeks GA because, bony tissue
and other body tissue is formed which is
difficult to be evacuated via suction.
1. Purulent cervicitis and pelvic infection
2. Coagulation disorders
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
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.
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.
1. Privacy should be maintained (screen or
2. All the articles are arranged near procedure
3. All the ornaments, finger rings, bangles etc
4. Put on all universal protective
5. Scrub and wear sterile gloves
6. Assemble the aspirator
Goal: reduce pain and anxiety.
Choice may be based on woman’s individual
needs or presentation.
1. Psychological pain: anxiety, fear,
2. Cervical pain due to dilatation
3. Uterine cramping due to manipulation
Drug must be most effective at the time of
Administer drugs 30-45 minutes before the
Gentle, respectful interaction and
Verbal support and reassurance
Gentle, smooth operative technique
Can supplement but not replace
Anxiolytics/sedatives relieve anxiety
Analgesics to relieve pain such as
local anaesthesia (for paracervical
block)using lidocaine or pethidine.
Ask the woman to empty
Clean adequately and
Clean vagina and vulva
Assist her in lithotomy
Conduct a bimanual
exam to confirm uterine
size and position
Insert speculum and
conduct speculum exam
to confirm findings of
Position the plunger all
the way inside the
Have collar stop in place
with tabs in the cylinder
Push valve buttons down
and forward until they
Pull plunger back until
arms snap outward and
catch on cylinder base (2)
Negative pressure (600-
660mmHg) is created in
Technique- no instrument
that enters the uterus can
surfaces, including vaginal
walls, before insertion
through the cervix
sponge to clean cervical os.
Start at os and spiral
outward without retracing
Continue until os has been
completely covered by
Paracervical block is
mechanical dilatation is
required with MVA.
Using local protocols,
block (at 2,4,8,10 o’
clock sites) and place
Use lowest anaesthetic
dose possible to avoid
toxicity-e.g if using
lidocaine, the lowest
recommended dose is
less than 200mg
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.
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
The size of cannula is
roughly the number of
gestational weeks i.e
Attach the prepared aspirator
to the cannula if the cannula
and aspirator were not
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-
Re-charge aspirator if
When the procedure is
finished, depress the buttons
and withdraw the instruments.
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
3. The uterus contracts around or grips the
4. The patient complains of cramping or pain,
indicating that the uterus is contracting.
Empty the contents of
the aspirator into a
Strain material, float in
water or vinegar and
view with a light from
Inspect tissue for the
evacuation and molar
Send products for
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.
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
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.
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.
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
4. Reproductive and other health services
provided in the facility or referral
5. Community and service provider partnership-
mobilizing resources to ensure timely care.
Warm-baths, compresses for cramping
Light menstrual-like bleeding or spotting
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
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).
Maternal death is lowest (about 0.6/100000
procedures) in first trimester termination
specially with MVA.
Scheduled before discharge from facility
Timing varies; usually scheduled within one
May not be at same facility
Woman may be referred to provider in her
1. High Level Disinfection in 0.5% Chlorine
2. HLD by boiling (abt 20mins)
3. HLD in cidex
4. Sterilization using Autoclave (1210c for
5. Sterilization using Etylene oxide(ETO).
Aspirator-discard or replace if:
◦ Cylinder is brittle or cracked or mineral deposits inhibit
◦ 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
Early pregnancy failure is a distressing
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.
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