European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 197200

Manual vacuum aspiration (MVA) in the management of rst trimester pregnancy loss
Rafet Gazvania,b,*, Emma Honeya, Fiona M. MacLennanb, Allan Templetona
a

Department of Obstetrics and Gynaecology, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK b Aberdeen Maternity Hospital, Aberdeen, UK Received 16 October 2001; received in revised form 16 May 2003; accepted 17 June 2003

Abstract Background: Manual vacuum aspiration is not widely used for the evacuation of retained products of conception in western Europe despite its well-proven success and safety record. Nor is there much information about its use under intravenous (systemic) analgesia or patientcontrolled anaesthesia in modern settings. Aim: To evaluate the use of manual vacuum aspiration for the evacuation of retained products of conception under systemic analgesia or patient-controlled anaesthesia in the management of rst trimester miscarriages. Methods: Fifty-eight women with a diagnosis of rst trimester miscarriage (42 missed and 16 incomplete miscarriages) were treated with manual vacuum aspiration under systemic analgesia or patient-controlled anaesthesia. Success rates and patient satisfaction and acceptability were recorded. Results: Of the 58 women recruited, 42 underwent the procedure under systemic analgesia and 15 under patient-controlled sedation while 1 woman opted for general anaesthesia. Successful evacuation was achieved in all cases. Both analgesic methods were associated with high levels of patient satisfaction and acceptability. Conclusions: Manual vacuum aspiration is an option in the management of all rst trimester pregnancy losses. Comparisons with other treatment options are indicated. # 2003 Elsevier Ireland Ltd. All rights reserved.
Keywords: Manual vacuum aspiration; First trimester miscarriages; Anaesthesia

1. Introduction The incidence of rst trimester pregnancy loss is around 1419% of registered pregnancies, and for over 50 years surgical evacuation, has been the preferred management option [1]. Although a minor procedure, the risks of surgical evacuation include infection, haemorrhage and inadvertent uterine perforation, in addition to the morbidity of general anaesthesia [2]. In order to avoid these complications alternatives to traditional surgical evacuation have been developed for the management of missed and incomplete miscarriages. These options are: (1) medical management using a combination of antiprogesterone and prostaglandin analogue which has a success rate of 95% in all rst trimester miscarriages [1]; (2) expectant management essentially for incomplete miscarriages, which is successful in around 79% of cases [2]; and (3) manual vacuum aspiration (MVA)
* Corresponding author. Present address: Liverpool Womens Hospital, Crown Street, Liverpool, L8 7SS. Tel.: 44-151-708-9988. E-mail addresses: gazvani@hotmail.com (R. Gazvani), allan.templeton@abdn.ac.uk (A. Templeton).

for incomplete miscarriages with success rates up to 98 99% [3]. Of all the methods available for the management of rst trimester miscarriages, MVA is arguably the least commonly used technique in industrialised countries especially in western Europe. In an earlier study in the UK, its use under intravenous (systemic) analgesia where anaesthetic and hypnotic drugs are used without total loss of consciousness (as described in Section 2) was reported to be effective in the management of incomplete miscarriages only [4]. There appears to be no data available regarding the use of MVA in the management of missed miscarriages except for one prospective study from Mexico [5] and one retrospective study from Nigeria [6]. At present, MVA does not appear to be as commonly performed or widely recognised in industrialised countries as an alternative for the management of rst trimester miscarriages (incomplete and missed) despite its well-proven success and safety record. There is also no information regarding its use under systemic analgesia (SA) or patientcontrolled sedation (PCS) in modern settings. With emphasis on individualised treatment and patient choice, an increasing number of women may be reluctant to

0301-2115/$ see front matter # 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0301-2115(03)00320-8

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R. Gazvani et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 197200

accept general anaesthesia or prolonged conservative/medical treatment and wish to explore alternative treatment options. Development of an outpatient surgical procedure in modern settings may therefore offer an additional choice for these women. This preliminary study was planned to assess the use of MVA under SA and PCS in the management of rst trimester miscarriage (incomplete and missed) in women who previously had access only to medical, surgical (under general anaesthesia), or expectant management options.

2. Materials and methods Women admitted to Aberdeen Maternity Hospital with a diagnosis of rst trimester (<13 weeks) miscarriage (missed or incomplete) between the dates of November 1998 and April 2000 were invited to participate. Ethical approval for the study was granted by the Grampian Research Ethics Committee. The diagnosis was conrmed by physical examination and ultrasound scan according to unit protocols. Gestational age was determined by the date of the last menstrual period and by ultrasonographic examination. Women who were haemodynamically unstable, had a history of cervical surgery, as well as those with a known systemic disease including hepatic or renal dysfunction as well as severe asthma, were excluded. All women were administered a rectal dose of 100 mg diclofenac sodium (Voltarol1, Novartis, Surrey, UK) for pain relief and a vaginal dose of 800 mg misoprostol (Cytotec1, Searle, Bucks, UK) for cervical ripening at least 3 h prior to the procedure. MVA was carried out in the operating theatre. During the rst 12 months of the study, women were administered systemic analgesia in the form of intravenous alfentanil (Rapifen1, Janssen-Cilag, UK) (maximum total dose of 500 mg) followed by i.v. midazolam HCl (Midazolam1) titrated against the consciousness level of the woman (maximum total dose of 5 mg). In the last 6 months of the study, women either received SA as described earlier or PCS via a system based on a Graseby1 patient-controlled anaesthesia syringe pump (Sims-Graseby Medical Ltd., Herts, UK). One millilitre of alfentanil (1 mg/ml) was added to 25 ml of propofol (10 mg/ml) (Diprivan1, Zeneca, UK) which was made available in 0.3 ml bolus doses with zero lockout period. An anaesthetist was in attendance in all cases and women were continuously monitored by blood pressure, pulse and oxygenation measurements as well as electrocardiography. Women were asked to lie at throughout the procedure. Following routine cleansing and draping, the cervix was visualised using a Cuscos speculum and paracervical block was achieved by the injection of 5 ml of 0.5% lidocaine hydrochloride (Lignocaine1) via a dental syringe following the induction of analgesia. A Karmann suction curette (6 or

8 mm) was introduced through the cervix, and negative pressure was obtained using a modied 50 ml locking syringe (Rocket1, London, UK). Products of conception were removed using a technique similar to a surgical evacuation. On completion of the procedure, women were transferred to the ward where they were observed for 23 h and assessment of symptoms relating to the operative procedure was made. Acceptability of treatment was assessed using a semantic differential scale [7], together with more open questions. On discharge, all women were offered a hospital followup 2 weeks following the procedure. Alternatively, they were advised to see their general practitioner (GP). Women were also advised to inform the unit should there be any complications specically pyrexia, abdominal pain, vaginal blood loss or discharge. Those women not attending the hospital follow-up were contacted by telephone to identify any post-operative complications. In the presentation of results, normally distributed data were given as mean (standard deviation (S.D.)) and nonnormally distributed data as median (inter-quartile range (IQR)).

3. Results During the recruitment period 58 women elected to undergo MVA as the rst line management option. One woman changed her mind later and opted for general anaesthesia. Of the 57 women who took part in the study, 41 (72%) were diagnosed to have missed miscarriage, and 16 (18%) incomplete miscarriage. The mean gestation was 8.9 weeks (S:D: 1:9 weeks). Forty-two women proceeded with MVA under SA administered by the anaesthetist and 15 women under PCS. Their characteristics are detailed in Table 1. All women undergoing MVA had an apparently successful evacuation of the uterus. Following cervical ripening with prostaglandins, no further dilatation of the cervix was needed except in one case where this was carried out up to 6 mm. The largest diameter of curette used during all procedures was 8 mm, which was adequate to achieve
Table 1 Patient characteristics Systemic analgesia (n 42) Agea Parityb Gestationa Diagnosis Missed miscarriage Incomplete miscarriage
a b

Patient-controlled sedation (n 15) 33 (5.1) 1 (03) 10.4 (2) 14 1

31.8 (5.2) 1 (03) 9.2 (1.8) 27 15

Mean (S.D.). Median (range).

R. Gazvani et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 197200 Table 2 Womens assessment of pain during MVA Systemic analgesia (n 42) Duration of the procedure (min)a Overall procedure pain score (0100)a Most severe pain during the procedure (0100)a Help with pain relief (0100)a Anxiety during the procedure (0100)a Level of pain (%) Very painful Moderately painful Slightly painful Painless Satisfaction (%) Very satisfied Moderately satisfied Dissatisfied Very dissatisfied
a

199

Patientcontrolled sedation (n 15) 6.4 (1.9) 11.9 (15.9) 20.8 (21.3) 89.7 (11.5) 12.3 (14.3) 0 2 (13) 4 (27) 9 (60) 11 (73) 4 (27) 0 0

5.4 (1.6) 12.5 (13) 16.7 (18.5) 86.6 (17.7) 19.8 (23.7) 0 4 (9) 18 (42) 20 (47) 36 (84) 7 (16) 0 0

Mean (S.D.).

complete evacuation of retained products in missed miscarriages up to 12 weeks of gestation. There were no signicant differences between the anaesthetic techniques with respect to patient satisfaction. Low pain scores and high acceptability of MVA by all women regardless of the technique used for the administration of analgesia was conrmed by the satisfaction survey. When offered the choice of method they would recommend to a friend or relative, all 57 said MVA. Operative details and outcome are detailed in Table 2. None of the women needed additional post-operative pain relief and all were discharged within 3 h following the procedure. In the post-operative period, 17 women (30%) attended hospital follow-up whilst 40 (70%) were followed up by their GPs and surveyed by telephone. There was one case of post-MVA intrauterine infection, by group B streptococci, which responded to antibiotic treatment.

4. Discussion To our knowledge, this is the rst study carried out in modern settings, which utilises MVA in the management of all rst trimester miscarriages. In industrialised countries, previous experience with MVA has been limited to the management of incomplete miscarriage and early induced abortion. Furthermore, pain relief and anaesthesia used in previous studies comply with older technology. The ndings of our study suggest that MVA under SA or PCS is a safe, effective and acceptable option for women diagnosed with missed or incomplete miscarriage within the rst trimester. It was evident that MVA provided the benets of an immediate solution to the problem whilst avoiding general anaesthesia. Both anaesthetic methods used in the study

proved to be highly acceptable by all women. Furthermore, PCS allowed women to have complete control over their level of sedation. It appears that by removing the need for general anaesthesia, delays associated with availability of theatre space were also avoided by the use of MVA. World Health Organization [8] has listed MVA as an effective and safe method of uterine evacuation and hence the technique is being employed increasingly in the developing world under minimal anaesthesia or sedation in the management of incomplete miscarriages [915]. However, there is minimal available data regarding its use in missed miscarriages [5,6]. It is important to note that with the advent of ultrasonography and its routine use in early pregnancy, the diagnosis of missed miscarriage has become signicantly more common compared to incomplete miscarriage. Therefore, the possible use of MVA in the management of rst trimester missed miscarriages becomes an even more interesting issue. MVA for early induced abortion up to 9 weeks [1619] as well as 12 weeks of gestation [20,21] has been undertaken successfully as an outpatient procedure in the USA since the early 1970s. An extensive review of the literature on uterine evacuation for induced early abortion (up to 7 weeks of gestation) has documented that MVA was highly efcacious, achieving complete uterine evacuation in over 98% of cases [22]. In cases of rst trimester miscarriages, MVA was suggested to be associated with a low incidence of minor complications (4.5%) comparable to inpatient procedures [23]. The technique has been shown to have high rates of acceptability and success, which is comparable to surgical evacuation under general anaesthesia [3]. It has also been reported that, following the introduction of MVA as the rst line treatment option in early miscarriage, general anaesthesia and its provision was no longer required and the overall need for post-operative pain relief was signicantly reduced. Hospital stay and bed occupancy was also reduced by 20% [15]. During this pilot study, the procedures were carried out in a fully equipped operating theatre to establish its safety and improve condence, as MVA is not a routinely used technique in the UK. In previous studies, when provided in an area other than the operating theatre for the management of incomplete miscarriage, MVA accounted for a 41% cost savings over surgical evacuation performed in an operating room under general anaesthesia. Introduction of MVA was associated with reduced hospital stay by 70% and the procedure time was lowered by 42% [24]. In conclusion, our results suggest that MVA can be a viable alternative to already available options in the management of rst trimester pregnancy losses. It promises signicant improvements in patient care and substantial savings for the health service. Once established in industrialised countries, MVA may also be suitable for populations with limited access to services such as those in remote areas. When available evidence is taken into account, it is surprising that MVA has not

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R. Gazvani et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 197200 [11] Mahomed K, Healy J, Tandon S. A comparison of manual vacuum aspiration (MVA) and sharp curettage in the management of incomplete abortion. Int J Gynaecol Obstet 1994;46:2732. [12] Magotti RF, Munjinja PG, Lema RS, Ngwalle EK. Cost-effectiveness of managing abortions: manual vacuum aspiration (MVA) compared to evacuation by curettage in Tanzania. East Afr Med J 1995;72: 24851. [13] Fawcus S, McIntyre J, Jewkes RK, Rees H, Katzenellenbogen JM, Shabodien R, et al. Management of incomplete abortions at South African public hospitals. National Incomplete Abortion Study Reference Group. S Afr Med J 1997;87:43842. [14] Fonseca W, Misago C, Fenandes L, Coreia L, Silverira D. Use of manual vacuum aspiration in reducing cost and duration of hospitalization due to incomplete abortion in an urban area of northeastern Brazil. Rev Saude Publica 1997;31:4728. [15] Leme VM, Mtimavalye LA, Thole GC, Vula MT. The impact of the manual vacuum aspiration (MVA) technique on health care services at Queen Elizabeth Central Teaching Hospital, Blantyre, Malawi. S Afr Med J 1997;87(Suppl 2):21822. [16] Edwards J, Creinin MD. Surgical abortion for gestations of less than 6 weeks. Curr Probl Obstet Gynecol Infertil 1997;20:119. [17] Creinin MD. Randomized comparison of efficacy, acceptability and cost of medical versus surgical abortion. Contraception 2000;62: 11724. [18] Davis A, Westhoff C, De Nonno L. Bleeding patterns after early abortion with mifepristone and misoprostol and manual vacuum aspiration. J Am Med Womens Assoc 2000;55(Suppl 3):1414. [19] Macisaac L, Darney P. Early surgical abortion: an alternative to and backup for medical abortion. Am J Obstet Gynecol 2000;183(Suppl 2):7683. [20] Westfall JM, Sophocles A, Burggraf H, Ellis S. Manual vacuum aspiration for first-trimester abortion. Arch Fam Med 1998;7:55962. [21] de Jonge ET, Jewkes R, Levin J, Rees H. Randomised controlled trial of the efficacy of misoprostol used as a cervical ripening agent prior to termination of pregnancy in the first trimester. S Afr Med J 2000; 90:25662. [22] Henshaw SK. Induced abortion: a world review. Fam Plann Perspect 1990;122:7689. [23] Farrel RG, Stonington DT, Ridgeway RA. Incomplete and inevitable abortion: treatment by suction curettage in the emergency department. Ann Emerg Med 1982;11:6528. [24] Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynaecol Obstet 1994;45:2617.

been more widely used in Europe. We now envisage that, in the context offutureresearch and clinical application, MVAwill be carried out in a Procedure Room. Larger, prospective, controlled studies utilising various options of analgesia and sedation are now needed to fully assess the use of MVA compared to other treatment options in the management of all cases of rst trimester pregnancy loss. References
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