BREAK THIS PRACTICE HABIT Uterine aspiration: From OR to office

Compared with uterine aspiration in the OR, an office-based procedure is as safe, less expensive, and more patient centered—all reasons to make it the standard for surgical management of early pregnancy failure

Lauren Thaxton, MD, MBA, and Bri Tristan, MD

CASE Patient with early pregnancy failure advent of manual vacuum aspiration (MVA) opts for surgical management using a 60-mL handheld syringe aspirator, A 36-year-old woman (G3P2) at 9 weeks from office-based treatment of pregnancy failure her last menstrual period presents for an initial has become more widely available. obstetric examination. On transvaginal ultra- In this article we make the case for why, sound, her ObGyn notes an measuring in appropriate clinical situations, office- 9 weeks without cardiac activity. The ObGyn based uterine aspiration, compared with informs her of the early pregnancy failure diag- uterine aspiration in the OR, should be the IN THIS nosis and offers bereavement support, and then standard for surgical management of early ARTICLE reviews the available options: expectant man- pregnancy failure, for these reasons: agement with follow-up in 2 weeks, medical 1. equivalent safety profile Safety, costs of management with and misopro- 2. reduced costs, and office MVA stol, and surgical management with a dilation 3. patient-centered characteristics. and curettage (D&C). The patient is interested page 40 in expedited treatment and thus selects D&C, and the staff books the next available operat- Office-based procedures Patient-centered ing room (OR) slot for her the subsequent week. 1are safe procedure Over the weekend, the patient calls to report Suction curettage is one of the most common page 42 heavy bleeding and passage of clots, and the surgical procedures for a woman to undergo ObGyn’s practice partner takes her to the OR Necessary for a D&C for incomplete . equipment Instant Poll page 44 arly pregnancy failure occurs in about 1 in 5 pregnancies. Treatment options E include expectant, medical, or surgical Do you agree that the standard location for uterine aspiration management. Surgical management is clas- should be in the office? sically offered in the OR via D&C. With the Yes, in appropriate clinical situations Dr. Thaxton is Assistant Professor, Department of Women’s Health, University of Texas at Austin. No Dr. Tristan is Assistant Professor and Residency Program Director, Department of Women’s Tell us at [email protected] Health, University of Texas at Austin. Please include your name and city and state. The authors report no financial relationships relevant to this article.

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during her lifetime, and it has an excellent than 50 days’ , estimated blood safety profile. Authors of a recent systematic loss and severe pain occurred less commonly review found that major surgical compli- during procedures performed using MVA.5 cations, including transfusion and uterine perforation requiring repair, occurred in less than 0.1% of all uterine aspiration proce- Office-based procedures dures.1 Importantly, this complication rate 2 are less expensive did not differ by inpatient or outpatient site There has been a trend in recent decades of procedure. to obtain cost savings by moving appropri- Anesthesia-related complications at the ately selected gynecologic procedures from time of aspiration also are extremely rare, the operative suite to the outpatient setting. and they are less likely to occur in the office Because of MVA’s minimal up-front and on- setting than in surgical centers or hospital- going costs, office-based suction aspiration based clinics (<0.2% and <0.5%, respec- is one of the most cost-effective procedures tively).1 This may be a result of the types of performed in the outpatient setting. anesthesia offered at varying locations, given Dalton and colleagues, for example, dem- that local analgesia or moderate sedation is onstrated that in women diagnosed with early likely used in office-based procedures while pregnancy failure, suction curettage is 50% deep sedation or general anesthesia may be less expensive when performed in the office as employed at other practice locations. compared to in the operating suite.6 Likewise, Studies specifically designed to deter- in a cohort of patients who presented to the mine the safety of suction aspiration by prac- emergency department with an incomplete tice location have yielded similar results. abortion, Blumenthal and colleagues showed FAST Researchers who conducted a systematic a 41% procedural cost reduction by offering TRACK review comparing the safety of procedures D&C in the outpatient setting instead of the done at ambulatory surgical centers with OR.7 Waiting times and mean procedure times Major surgical office-based procedures found no difference also were reduced by nearly half. complications in safety between procedures performed in Recent studies have broadened cost occurred in less these 2 settings.2 These findings were con- analyses beyond the comparison of inpatient than 0.1% of all firmed by results from a large retrospective versus outpatient procedures. A multicenter uterine aspiration cohort study that reviewed more than 50,000 trial of women with first-trimester pregnancy procedures, and aspiration procedures performed in ambula- failure compared the costs of medication the rate did not tory surgical centers versus private offices.3 In management with those of surgical proce- differ by inpatient that study, only 0.32% of women had any ma- dures; as expected, the cost of D&C in the or outpatient site jor adverse event, and there were no statisti- OR was significantly more expensive than of procedure cally significant differences in complication medication management.8 However, MVA in rates between settings.3 the office was less expensive than medication Complication rates based on procedure management, due largely to the increased type are similar for MVA and electric suction cost of managing medication failures. aspiration. Early studies revealed no differ- In addition, a recent, well-designed ence in the need for reaspiration or other decision model study demonstrated that complications for MVA compared with elec- offering women with early pregnancy fail- tric suction.4 This was later confirmed by a ure a greater array of management options systematic review that found no significant decreases costs.9 The study compared the differences in safety by type of suction over- costs when women were offered the most all, and a possible trend toward fewer uterine common options, expectant management perforations with MVA.5 When procedures or uterine evacuation in the OR, versus the were assessed by gestational age, additional costs when additional options were also of- trends toward the safety of MVA emerged. fered. When options were expanded to in- For example, in procedures performed at less clude medication management and MVA

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in the office, costs decreased by nearly 20% below for performing office-based uterine overall.9 aspiration. Clinicians should review their clinic’s protocols prior to implementing such a plan. Office-based procedures Review the patient history and preg- 3 are more patient centered nancy dating. Patients with serious medical The benefits of surgical management of an conditions, such as history of postabortion early pregnancy failure include very high hemorrhage or a bleeding disorder, may success rates (98%) and convenient timing. not be appropriate candidates for an office- Among women who elect surgical manage- based procedure. We perform bedside ultra- ment, a desire to expedite the process in a sonography to confirm pregnancy dating and predictable fashion is a common factor in diagnosis of pregnancy failure. their decision.10,11 It is unsurprising then that Review consent for the procedure and 68% of patients will select an office-based sedation. Risks of office-based uterine -as procedure if they do not perceive that the cli- piration are the same as those for D&C: nician has a setting preference.6 bleeding, uterine perforation, and failure to When surgical management is per- fully evacuate the . Benefits include formed in the OR, scheduling delays are rapid, safe evacuation of the pregnancy. Al- common. Such delays can be clinically im- ternative treatments include expectant or portant: Women progressing to a miscar- medical management. riage while awaiting surgical treatment may For pain management, we start by dis- be at risk for urgent, unplanned interval cussing expectations with the patient. Pro- procedures for incomplete abortion, and viding general anesthesia in the outpatient FAST they may be dissatisfied with the inability setting is not safe; many women are satisfied, TRACK to access the desired management. While however, with local anesthesia with or with- women are highly satisfied after treatment out sedation. Very high for early pregnancy failure in general,6 OR Local anesthesia may be given using a success rates treatment can cause dissatisfaction because paracervical block with 2 mL of 1% and convenient patients miss more work days or need assis- at the tenaculum site followed by 18 mL di- timing are tance at home.12 In a cross-sectional study, vided between the 4 and 8 o’clock positions. 2 benefits patients who elected office-based aspiration In our practice, we are trained providers of of surgical reported less delay to treatment (less than 2 conscious sedation, so additionally we offer management of hours) compared with women who elected IV fentanyl 100 μg and IV midazolam 2 mg an early OR procedures (more than 12 hours), and given prior to the procedure. pregnancy failure shorter time to procedure initiation was a Provide antibiotic prophylaxis. The Amer- satisfier.13 ican College of Obstetricians and Gynecolo- Women also note fear of the hospital gists and the Society for Family Planning setting and general anesthesia, and they recommend doxycycline 200 mg orally as tend to see hospital-based services as more a preoperative prophylaxis for office-based invasive.11 Clinicians can offer anesthesia in uterine aspiration.14,15 Metronidazole is an the outpatient setting with nonsteroidal anti- acceptable alternative for patients who have inflammatory medications and a paracervi- medication allergies. cal block, oral sedation with an anxiolytic, or Prepare the surgical field.To complete in some cases intravenous (IV) sedation with this procedure, you will need the following conscious sedation. equipment: • one MVA kit that includes an aspirator, cu- rettes, and dilators (FIGURE, page 44) Our process for office-based • 20 mL 1% lidocaine, divided into two 10- uterine aspiration mL syringes with a 22-gauge 3.5-inch spi- We follow the step-by-step process outlined nal needle

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FIGURE Manual vacuum description of how to perform the MVA evacuation kit contains procedure using the Ipas MVA Plus As- pirator device is available online at syringe aspirator, curettes, http://provideaccess.org/wp-content and dilators /uploads/2012/09/4Performing-MVA-Us ing-the-Ipas-MVA-Plus.pdf.

A good option for many women A D&C in the OR remains an appropriate op- tion for patients who are clinically unstable due to heavy vaginal bleeding. With highly sensitive home urine pregnancy tests, preg- Used with permission of HPSRx Enterprises, Inc. nancies often are diagnosed before clinically apparent . In fact, many such patients are diagnosed with pregnancy fail- • speculum ure in the office, as was our patient in the • cervical antiseptic prep case scenario. For such women, office-based • single-tooth tenaculum management of early pregnancy failure is • ring forceps. preferred because it is safe, cost-effective, Perform the MVA procedure. A full and patient centered.

References FAST 1. White K, Carroll E, Grossman D. Complications from first- 8. Rausch M, Lorch S, Chung K, et al. A cost-effectiveness TRACK trimester aspiration abortion: a systematic review of the analysis of surgical versus medical management of early literature. Contraception. 2015;92:422-438. pregnancy loss. Fertil Steril. 2012;97:355-360. 2. Berglas NF, Battistelli MF, Nicholson WK, et al. The effect of 9. Dalton VK, Liang A, Hutton DW, et al. Beyond usual care: the A D&C in the facility characteristics on patient safety, patient experience, economic consequences of expanding treatment options in OR remains an and service availability for procedures in non-hospital- early pregnancy loss. Am J Obstet Gynecol. 2015;212:177.e1-6. affiliated outpatient settings: a systematic review. PloS One. 10. Schreiber CA, Chavez V, Whittaker PG, et al. Treatment appropriate option 2018;13:e0190975. decisions at the time of miscarriage diagnosis. Obstet Gynecol. for patients who 3. Roberts SC, Upadhyay UD, Liu G, et al. Association of facility 2016;128:1347-1356. type with procedural-related morbidities and adverse events 11. Smith LF, Frost J, Levitas R, et al. Women’s experiences of are clinically among patients undergoing induced . JAMA. three early miscarriage management options: a qualitative unstable due to 2018;319:2497-2506. study. Br J Gen Pract. 2006;56:198-205. 4. Goldberg AB, Dean G, Kang MS, et al. Manual versus 12. Edwards S, Tureck R, Fredrick M, et al. Patient acceptability of heavy vaginal electric vacuum aspiration for early first-trimester abortion: manual versus electric vacuum aspiration for early pregnancy a controlled study of complication rates. Obstet Gynecol. loss. J Womens Health (Larchmt). 2007;16:1429-1436. bleeding 2004;103:101-107. 13. Dodge LE, Hofler LG, Hacker MR, et al. Patient satisfaction and 5. Wen J, Cai QY, Deng F, et al. Manual versus electric vacuum wait times following outpatient manual vacuum aspiration aspiration for first-trimester abortion: a systematic review. compared to electric vacuum aspiration in the operating room: BJOG. 2008;115:5-13. a cross-sectional study. Contracept Reprod Med. 2017;2:18. 6. Dalton VK, Harris L, Weisman CS, et al. Patient preferences, 14. American College of Obstetricians and Gynecologists. satisfaction, and resource use in office evacuation of early ACOG practice bulletin no. 195: Prevention of after pregnancy failure. Obstet Gynecol. 2006;108:103-110. gynecologic procedures. Obstet Gynecol. 2018;131:e172-e189. 7. Blumenthal PD, Remsburg RE. A time and cost analysis of the 15. Achilles SL, Reeves MF; Society of Family Planning. management of incomplete abortion with manual vacuum Prevention of infection after induced abortion. Contraception. aspiration. Int J Gynaecol Obstet. 1994;45:261-267. 2011;837:295–309.

The “Break This Practice Habit” series is spearheaded by Dr. Lauren Demosthenes, who makes overarching high value cost decisions in her role as Medical Director of High Value Care and Innovation, Department of ObGyn at Greenville Health System in Greenville, South Carolina. Watch for quarterly case presentations of low value, low evidence practices that should be questioned in current day, followed by reasons why that practice should be abandoned. If you would like to contribute to this series, please submit your query to Dr. Demosthenes at [email protected].

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