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Prof. Ashis Kumar Mukhopadhyay Professor, G & O Medical Superintendent-cum-Vice Principal CSS College of Obstetrics & Gynaecology, Kolkata National Chairperson,

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Presentation on theme: "Prof. Ashis Kumar Mukhopadhyay Professor, G & O Medical Superintendent-cum-Vice Principal CSS College of Obstetrics & Gynaecology, Kolkata National Chairperson,"— Presentation transcript:

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2 Prof. Ashis Kumar Mukhopadhyay Professor, G & O Medical Superintendent-cum-Vice Principal CSS College of Obstetrics & Gynaecology, Kolkata National Chairperson, Medical Education Committee of FOGSI

3 WHAT IS MVA ? MVA meaning Manual Vacuum Aspiration – a surgical method of TOP to enhance safe abortion within the 1st trimester of pregnancy (WHO-2003). MVA meaning Manual Vacuum Aspiration – a surgical method of TOP to enhance safe abortion within the 1st trimester of pregnancy (WHO-2003). MVA actually is the resurrcation of original MR method by MR syringe & Karman canulae. MVA actually is the resurrcation of original MR method by MR syringe & Karman canulae.

4 With the expectation that MM & Morbidity will be reduced, but on the contrary it is seen that the no. of unsafe abortions have much more increased with a disastrous result on MM & Morbidity.

5 So new techniques started becoming introduced for safe abortion & MVA is one of them. So new techniques started becoming introduced for safe abortion & MVA is one of them. This method is safe, simple, effective and economical too. This method is safe, simple, effective and economical too.

6 Parivar Seba Sangstha (PSS), a national level NGO for quality abortion and family planning procedures – has experiences on MVA for more than 25 years. They also have the same experience in their Kolkata branch. Parivar Seba Sangstha (PSS), a national level NGO for quality abortion and family planning procedures – has experiences on MVA for more than 25 years. They also have the same experience in their Kolkata branch. 95% - MVA 5% - Med. Abortion

7 Manual Vacuum Aspiration Safe & updated technology for termination of 1st Trimester Pregnancy Safe & updated technology for termination of 1st Trimester Pregnancy Recognized by FIGO, WHO, GOI, NAF, USAID for Post Abortion Care and World Bank Recognized by FIGO, WHO, GOI, NAF, USAID for Post Abortion Care and World Bank

8 Mechanism of Action MVA acts via vacuum extraction of the uterine contents through a cannula MVA acts via vacuum extraction of the uterine contents through a cannula Cannula is attached to the vacuum syringe which has been previously charged and locked having created vacuum in the syringe Cannula is attached to the vacuum syringe which has been previously charged and locked having created vacuum in the syringe Vacuum extracts the entire contents of the uterus with minimal damage to the lining of the uterus Vacuum extracts the entire contents of the uterus with minimal damage to the lining of the uterus

9 Origin The Single Valve Syringe, the earlier version originated in the USA in early 70's The Single Valve Syringe, the earlier version originated in the USA in early 70's Karmen (Batelle Labs) Karmen (Batelle Labs) Was studied intensively in India and around the world Was studied intensively in India and around the world Single valve syringe was originally designed to be a technique of Menstrual Regulation Single valve syringe was originally designed to be a technique of Menstrual Regulation

10 Double Valve MVA Syringe Designed to evacuate the uterus up to 12 weeks Designed to evacuate the uterus up to 12 weeks Proven safe and effective for termination of incomplete abortion, endometrial biopsy and backup for medical abortion Proven safe and effective for termination of incomplete abortion, endometrial biopsy and backup for medical abortion

11 MVA - Features Flexible Plastic Cannulae Flexible Plastic Cannulae Manual Vacuum Syringe with double valve adapter Manual Vacuum Syringe with double valve adapter Portable Non-Electric Portable Non-Electric Practical use in Medical Office, Clinic or Hospital Practical use in Medical Office, Clinic or Hospital

12 Summary of Studies Effectiveness of EVA - MVA Studies PatientsEfficacy Induced Abortions EVA : 37 MVA : 9 EVA : 385,000 MVA : 15,000 98% Incomplete Abortions EVA : 15 MVA : 4 EVA : 3,600 MVA : 1,400 98% * Effectiveness defined as complete evacuation - Adapted from Greenslade et al., 1993

13 Recent Clinical Experience Edward MVA procedures of less than 6 weeks, found to be effective in 99.2% of cases Edward MVA procedures of less than 6 weeks, found to be effective in 99.2% of cases Westfall et al MVA procedures, of less than 10 weeks, found to be effective in 99.5% of cases Westfall et al MVA procedures, of less than 10 weeks, found to be effective in 99.5% of cases FOGSI Multicentric study Cases between 6-12 weeks, found to be effective in 98.6% of cases FOGSI Multicentric study Cases between 6-12 weeks, found to be effective in 98.6% of cases

14 Manual Vacuum Aspiration (MVA) Comparison between Two Contemporary Methods - Takes minutes to create 26 Hg Vacuum O Rotation possible on either side because of kinking of tubing - Vacuum is created gradually in the uterine cavity, hence less effective Electrical Vacuum Aspiration (EVA) - Takes 1 Second to create 26 (660mm) Hg Vacuum O Rotation possible because of easy maneuverability - Pre-created vacuum gets transferred to the uterine cavity which is highly effective

15 Manual Vacuum Aspiration (MVA) - Since vacuum takes time to reach 26 of Hg, not possible to create cleavage easily and therefore, material comes in pieces causing more bleeding Electrical Vacuum Aspiration (EVA) Electrical Vacuum Aspiration (EVA) - Pre created transfer of vacuum helps to find cleavage between the sac and the endometrial lining. This allows sac to get sucked into the aperture of the cannula en mass causing minimum bleeding Comparison between Two Contemporary Methods

16 Manual Vacuum Aspiration Manual Vacuum Aspiration(MVA) -In case of perforation, the vacuum creation continues endangering pulling out mesentery or intestines if plugged into the aperture of cannula Electrical Vacuum Aspiration (EVA) Electrical Vacuum Aspiration (EVA) -In case of uterine perforation, the vacuum drops to less than 10mm of Hg and therefore, prevents sucking of mesentery or intestines Comparison between Two Contemporary Methods

17 Removed with electric suction machine (left) and MVA syringe (right) From: Creinin and Edwards, Curr Problems in Obs Gyn Fert, 20 (1) 1997 EVA Vs MVA Comparison of 5 weeks gestation

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19 MVA Plus Aspirator (recent) Can be autoclave at c with a pressure of (15 lbs/in 2 )

20 Colour coated & graduated canulae – they can also be autoclaved

21 Loading the Syringe Close the pinch valve of an assembled syringe

22 Creation of Vacuum Withdraw plunger till catcher arms locked

23 Insertion of Cannulae Serial insertion with gentle rotatory movements

24 MVA Procedure Pinch valve released to create intrauterine vacuum

25 Evacuation of Uterus Back & forth & rotatory movements of cannula

26 Care of Instruments Care of instruments comprises of following steps : Care of instruments comprises of following steps : Decontamination Decontamination Cleaning Cleaning High Level Disinfection (HLD) or Sterilization High Level Disinfection (HLD) or Sterilization Storage / Reassembly Storage / Reassembly

27 Processing of the Instruments Syringe & cannulae decontaminated in a bleach solution for 10 minutes (optional) Syringe & cannulae decontaminated in a bleach solution for 10 minutes (optional) Wash well with detergent and water Wash well with detergent and water Soak in 2% Glutaraldehyde (Cidex) or 0.5% chlorine solution for 20 minutes Soak in 2% Glutaraldehyde (Cidex) or 0.5% chlorine solution for 20 minutes Do not boil the Syringe or use any heat technique or autoclave

28 Cervical Ripening : For pregnancies up to eight weeks, no priming is required. For pregnancies of 9-12 weeks in nulliparous women and <18 years old. For pregnancies up to eight weeks, no priming is required. For pregnancies of 9-12 weeks in nulliparous women and <18 years old. Prostaglandin in cervical ripening Prostaglandin in cervical ripening Prostodin – 250mcg by intramuscular injection 45 minutes before the procedure. Prostodin – 250mcg by intramuscular injection 45 minutes before the procedure. Misoprostol – 400mcg tablet administered either vaginally or sublingually/orally 3-4 hours before the procedure. Misoprostol – 400mcg tablet administered either vaginally or sublingually/orally 3-4 hours before the procedure.

29 The instruments are reusable (disposable in developed countries), provided those are very well maintained. The aspirators described, could be reused from times and the new canulae can be reused for 10 – 20 times.

30 Post Operative Contraception :

31 For pain control, Para cervical block – all that is necessary for complete evacuation For pain control, Para cervical block – all that is necessary for complete evacuation A sedative or anxiolytic may be necessary if the patient is apprehensive A sedative or anxiolytic may be necessary if the patient is apprehensive

32 MAJOR COMPLICATIONS OF MVA (12,888)24,000( ) D & C 0.15 – 28 Excess bleeding % Pelvic infection – 8 Cervical injury % 0.3 – 6.4 Uterine perforation % 0 – 3.3 Laufe, 1977PSS (Kolkata) Greenslade et al 1993 Greenslade et al 1993

33 EFFICACY : Several authors have shown that the efficacy of MVA in general - 98% AuthorGestationNumberEffectiveness Hemin et al 2001, Sweeden <8 wks N = 91 > 97% Fogsi Multicentric Study 2001, India <6-12 wks N = % Edward & Creinin 1997, USA < 6 wks N = 2,399 > 99% Westfall et al. 1998, USA < 12 wks N = 1,677 99% Greenslade, 1993 Within 12 wks N = 15,000 97% PSS, Kolkata, India ( ) 8-12 wks N = 24, %

34 MVA – in Low tech rural & High tech urban : Low tech rural Limited access to medical facilities Limited access to medical facilities Non availability of reliable equipment Non availability of reliable equipment MVA is – portable instrument, can be used as an OPD procedure. MVA is – portable instrument, can be used as an OPD procedure. Erratic electricity supply Erratic electricity supply High tech urban Accidental perforation – no damage to the abdominal organs because of dropping vacuum. Accidental perforation – no damage to the abdominal organs because of dropping vacuum. Client friendly procedure – surgeon can continue to speak to the patient. Client friendly procedure – surgeon can continue to speak to the patient. Appreciation of minimally invasive concept. Appreciation of minimally invasive concept. MVA Pilot Project – GOI, FOGSI & WHO

35 OTHER USES OF MVA There are other uses of MVA and they are:- There are other uses of MVA and they are:- Endometrial Biopsy / sampling (using 4mm cannulae) Endometrial Biopsy / sampling (using 4mm cannulae) Blighted ovum Blighted ovum Hydatidiform mole Hydatidiform mole Incomplete abortion Incomplete abortion

36 To conclude, MVA technology can be used as the first line surgical method for uterine evacuation within 1st trimester of pregnancy. MVA is safe, simple and effective & a low cost procedure, reusable for many many times. The method is highly recommended by FIGO, FOGSI, WHO & GOI. MVA today is considered as the NEW GOLD STANDARD for early abortion and there is no place for other traditional method like D & C. (ICPD, WHO, FIGO, 1997) To conclude, MVA technology can be used as the first line surgical method for uterine evacuation within 1st trimester of pregnancy. MVA is safe, simple and effective & a low cost procedure, reusable for many many times. The method is highly recommended by FIGO, FOGSI, WHO & GOI. MVA today is considered as the NEW GOLD STANDARD for early abortion and there is no place for other traditional method like D & C. (ICPD, WHO, FIGO, 1997)


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