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Manual Vacuum Aspiration: a Safe and Effective Treatment for Early Miscarriage

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Manual Vacuum Aspiration: a Safe and Effective Treatment for Early Miscarriage Manual vacuum aspiration: A safe and effective treatment for early miscarriage Surgical management of early pregnancy loss has advantages over medical treatment. For one, patients benefit from a brief procedure using local anesthesia. Here, pearls for office-based surgery as well as other treatment options. Piyapa Praditpan, MD, MPH, and Anne R. Davis, MD, MPH CASE Miscarriage in a 29-year-old woman intervention. The management options A woman (G0P0) presents to her gynecologist include surgical, medical, and expectant. with amenorrhea for 3 months and a positive Women should be offered all 3 of these, and home urine pregnancy test. She is 29 years clinicians should explain the risks and bene- of age. She denies any bleeding or pain and fits of each approach. But while each strategy IN THIS intends to continue the pregnancy, though it ARTICLE can be safe, effective, and acceptable, many was unplanned. Results of office ultrasonogra- women, as well as their health care provid- Advantages of phy to assess fetal viability reveal an intrauter- ers, will benefit from office-based uterine office-based MVA ine gestation with an 8-mm fetal pole but no aspiration. In this article, we present the data page 39 heartbeat. The diagnosis is miscarriage. available on office-based manual vacuum as- piration (MVA) as well as procedure pointers his case illustrates a typical miscar- and urge you to consider MVA in your prac- Medical riage diagnosis; most women with tice for your patients. management T miscarriage are asymptomatic and page 40 without serious bleeding requiring emergency Surgical management Current diagnostic Surgical management of miscarriage offers criteria Dr. Praditpan is Fellow in Family several clear advantages over medical and page 42 Planning, Department of Obstetrics and Gynecology, Columbia University expectant management. Perhaps the most Medical Center, New York, New York. important advantage to patients is that sur- gery offers rapid resolution of miscarriage with the shortest duration of bleeding.1,2 When skilled providers perform electric Dr. Davis is Associate Professor of vacuum aspiration (EVA) or MVA in outpa- Clinical Obstetrics and Gynecology and Director of the Family Planning tient or emergency department settings, suc- Fellowship, New York Presbyterian/ cessful uterine evacuation is completed in a Columbia University Medical Center, single medical encounter 99% of the time.1 By comparison, several follow-up visits and The authors report no financial relationships relevant to additional ultrasounds may be required dur- this article. ing medical or expectant management. Uter- ine aspiration rarely requires an operating 38 OBG Management | November 2015 | Vol. 27 No. 11 obgmanagement.com room (OR). Such a setting should be limited an OR spent a mean total of 290 minutes at to cases in which the clinical picture reflects: the hospital.5 • hemodynamic instability with active uter- Patients’ satisfaction with care provided ine bleeding in the OR was comparable to patients’ sat- • serious uterine infection isfaction with care provided in a medical • the presence of medical comorbidities in office. In fact, the median total satisfaction patients who may benefit from additional score was high among women who had a blood bank and anesthesia resources. procedure in either setting (office score, 19 of 20; OR score, 20 of 20). Office-based MVA Cost and equipment for in-office MVA Office-based MVA is well tolerated when Office-based surgical management of mis- performed using a combination of verbal carriage is more cost-effective than OR- distraction and reassurance, oral nonsteroi- based management. In 2006, Dalton and dal anti-inflammatory drugs (NSAIDs), and colleagues conducted a cost analysis and a paracervical block with or without intrave- found that average charges for office-based nous sedation. MVA were less than half the cost of charges Evidence on managing pain at MVA. for a dilation and curettage (D&C) in the OR Multiple studies have assessed preprocedure ($968 vs $1,965, respectively).5 and postprocedure pain using NSAIDs, oral More recently, these researchers found anxiolytics, and local anesthesia at the time that usual care (expectant or OR manage- of EVA or MVA.3,4 Renner and colleagues ment) was more costly than a model that found that women who received a paracervi- also included medical and office-based sur- cal block prior to MVA or EVA reported mod- gical options. They found that the expanded erate levels of pain, according to a 100-point care model—with use of the OR only when visual analogue scale (VAS), at the time of needed—cost $1,033.29 per case. This was cervical dilation (mean, 42) and uterine as- compared with $1,247.58 per case when Office-based MVA 4 piration (mean, 63). In this same study, pa- management options did not include medi- can be performed 6 tients’ willingness to treat a future pregnancy cal and office-based surgical treatments. with local anesthesia with EVA or MVA using local anesthesia and The cost of supplies needed to initiate and is faster their overall satisfaction with the procedure MVA services within an established outpa- than surgical was high (mean, 90 on 100-point VAS). tient gynecologist’s office is modest. Equip- management in In-office advantages over the OR. Women ment includes manual vacuum aspirators; an OR and clinicians can avoid the extensive sched- disposable cannulae of various sizes; reus- uling delays associated with ORs, as well as able plastic or metal dilators; supplies for the complications associated with medical disinfection, allowing reuse of MVA aspira- and expectant management, if office-based tors; and supplies for examination of prod- EVA and MVA services are readily available. ucts of conception (POC; FIGURE 1, page 40). Compared with surgical management of According to WomanCare Global, man- miscarriage in an OR, office-based EVA and ufacturer of the IPAS MVA Plus, equipment MVA are faster to complete. For example, should be sterilized after each use with soap Dalton and colleagues compared patients and water, medical cleaning solution (such undergoing first-trimester procedures in an as Cidex, SPOROX II, etc.), or autoclaving.7 office setting with those undergoing a pro- If 2 reusable aspirators are purchased along cedure in an OR. The mean procedure time with dilators, disposable cannulae, and tools for women treated in an office was 10 min- for tissue assessment, the price of supplies is utes, compared with 19 minutes for wom- estimated at US $500.8 WomanCare Global en treated in the OR. In addition, women also offers prepackaged, single-use aspirator treated in an office setting spent a mean total kits, which may be ideal for the emergency of 97 minutes at the office; women treated in department setting.9 CONTINUED ON PAGE 40 obgmanagement.com Vol. 27 No. 11 | November 2015 | OBG Management 39 Manual vacuum aspiration CONTINUED FROM PAGE 39 FIGURE 1 MVA equipment The risk of endometritis after surgical management of miscarriage is low. Antibi- otic prophylaxis prior to MVA or EVA should be considered. Experts recommend giving a single dose of doxycycline 200 mg orally at least 1 hour prior to uterine aspiration.2,10 Use of EVA or MVA for outpatient man- agement of miscarriage yields the opportu- nity to conduct immediate gross examination of the evacuated tissue and to verify the presence of complete POC. The process is simple: rinse the specimen through a sieve with water or saline, placed in a clear glass container under a small water bath and backlit on a light box. This allows clinicians The required equipment for office-based MVA includes a reusable vacuum to separate uterine decidua and pregnancy aspirator (with disinfection supplies), reusable plastic or metal dilators, and tissues. “Floating” tissue in this manner is supplies for examination of products of conception. especially useful in patients with pregnancy of unknown location, as immediate confir- The procedure mation of a gestational sac rules out ectopic To view a video on the MVA device and pro- pregnancy. cedure, including step-by-step technique Examine evacuated tissue for macro- (FIGURE 2), local anesthesia administration, scopic evidence of pregnancy. Chorionic choosing cannula size, and cervical dilation, villi, which arise from syncytiotrophoblasts, visit the Managing Early Pregnancy Loss can be seen with the naked eye. Immediate Web site (http://www.earlypregnancyloss evaluation of POC is also useful for patients resources.org) and access “Videos.” The vid- who desire diagnostic testing to ascertain a eo “Uterine aspiration for EPL” is available cause of their miscarriage because evacu- under password protection and broken into ated tissue stored in saline may be sent to a chapters for viewing ease. laboratory for cytogenetic analysis. FIGURE 2 MVA procedure Medical management Management of miscarriage with misopro- stol is also safe and acceptable to women, though it has a lower success rate than surgi- cal management. Comparing efficacy: Medical vs surgical management. The Management of Early Pregnancy Failure Trial (MEPF) is the larg- est randomized controlled trial comparing medical management of miscarriage to sur- gical management. This multicenter study compared treatment with office-based EVA or MVA to vaginal misoprostol 800 µg. A re- If the cannula is already inside the uterus, suction should be created in the peat dose of vaginal misoprostol was offered syringe and then the syringe should be attached to the cannula. Suction is 48 hours
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