2Prof. Ashis Kumar Mukhopadhyay Professor, G & OMedical Superintendent-cum-Vice PrincipalCSS College of Obstetrics & Gynaecology, KolkataNational Chairperson,Medical Education Committee of FOGSI
3WHAT 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 actually is the resurrcation of original MR method by MR syringe & Karman canulae.
4With 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.
5So new techniques started becoming introduced for safe abortion & MVA is one of them. This method is safe, simple, effective and economical too.
6Parivar 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% - MVA5% - Med. Abortion
7Manual Vacuum Aspiration Safe & updated technology for termination of 1st Trimester PregnancyRecognized by FIGO, WHO, GOI, NAF, USAID for Post Abortion Care and World Bank
8Mechanism of ActionMVA acts via vacuum extraction of the uterine contents through a cannulaCannula is attached to the vacuum syringe which has been previously charged and locked having created vacuum in the syringeVacuum extracts the entire contents of the uterus with minimal damage to the lining of the uterus
9OriginThe Single Valve Syringe, the earlier version originated in the USA in early 70'sKarmen (Batelle Labs)Was studied intensively in India and around the worldSingle valve syringe was originally designed to be a technique of Menstrual Regulation
10Double Valve MVA Syringe Designed to evacuate the uterus up to 12 weeksProven safe and effective for termination of incomplete abortion, endometrial biopsy and backup for medical abortion
11MVA - Features Flexible Plastic Cannulae Manual Vacuum Syringe with double valve adapterPortable Non-ElectricPractical use in Medical Office, Clinic or Hospital
12Summary of Studies Effectiveness of EVA - MVA PatientsEfficacyInducedAbortionsEVA : 37MVA : 9EVA : 385,000MVA : 15,00098%IncompleteEVA : 15MVA : 4EVA : 3,600MVA : 1,400* Effectiveness defined as complete evacuation- Adapted from Greenslade et al., 1993
13Recent Clinical Experience Edward MVA procedures of less than 6 weeks, found to be effective in 99.2% of casesWestfall et al MVA procedures, of less than 10 weeks, found to be effective in 99.5% of casesFOGSI Multicentric study Cases between 6-12 weeks, found to be effective in 98.6% of cases
14Comparison between Two Contemporary Methods Manual Vacuum Aspiration(MVA)Electrical Vacuum Aspiration (EVA)- Takes 1 Second to create 26” (660mm) Hg Vacuum- 360O Rotation possible because of easy maneuverability- Pre-created vacuum gets transferred to the uterine cavity which is highly effective- Takes minutes to create 26” Hg Vacuum- 180O Rotation possible on either side because of kinking of tubing- Vacuum is created gradually in the uterine cavity, hence less effective
15Comparison between Two Contemporary Methods Electrical Vacuum Aspiration (EVA)Manual Vacuum Aspiration(MVA)- 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- Since vacuum takes time to reach 26” of Hg, not possible to create cleavage easily and therefore, material comes in pieces causing more bleeding
16Comparison between Two Contemporary Methods Manual Vacuum Aspiration(MVA)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- In case of perforation, the vacuum creation continues endangering pulling out mesentery or intestines if plugged into the aperture of cannula
17EVA Vs MVA Comparison of 5 week’s gestation Removed with electric suction machine (left)and MVA syringe (right)From: Creinin and Edwards, Curr Problems in Obs Gyn Fert, 20 (1) 1997
19MVA Plus Aspirator (recent) Can be autoclave at 1210 c with a pressure of (15 lbs/in2)
20Colour coated & graduated canulae – they can also be autoclaved
21Close the pinch valve of an assembled syringe Loading the SyringeClose the pinch valve of an assembled syringePrepare the SyringeStep 1: Close the pinch valve. Begin with the valve buttons open and the plunger pushed all the way into the barrel. Close the valve by pushing the buttons down and forward until they lock into place.
22Withdraw plunger till catcher arms locked Creation of VacuumCreate the VacuumCreate the vacuum by grasping the barrel (do not grasp the valve piece) and pulling back on the end of the plunger until the arms of the plunger snap outward at the end of the syringe barrel, holding the plunger in place. Check the stable positioning of the plunger arms. Both plunger arms must be fully extended to the sides and secured over the edge of the barrel. With the arms snapped in this position, the plunger will not move forward and the vacuum is maintained.Incorrect positioning of the arms could allow them to slip back inside the barrel, possibly pushing the contents of the syringe or air into the uterus. Never grasp the syringe by the plunger arms.It is a good idea to check the syringe once it is assembled and before its use. Leave the syringe for several minutes with the vacuum established. Open the pinch valve by releasing the buttons. You should hear a rush of air into the syringe, indicating that there was a vacuum in the syringe. If you do not hear a rush of air, follow instructions in the product literature for lubricating the o-ring and test the vacuum again. Replace the o-ring or use another syringe if the syringe still will not hold a vacuum.Withdraw plunger till catcher arms locked
23Serial insertion with gentle rotatory movements Insertion of CannulaeInserting CannulaSelect the cannula size based on the size of the uterus. Some people use a cannula that corresponds to the weeks gestation (e.g., 7mm at 7 weeks); others use a cannula one or two sizes smaller than the weeks gestation (e.g., 6mm at 7 weeks). It is important not to dilate the cervix beyond the size of the appropriate cannula. It is advisable to have several cannulae of several sizes on hand.Insert the cannula into the uterine cavity until it touches the top of the fundus, and then withdraw the cannula slightly.Note uterine depth.Attach syringe, taking care not to push cannula further into uterus OR attach the charged syringe to the cannula prior to inserting the cannula through the cervical os.Serial insertion with gentle rotatory movements
24Pinch valve released to create intrauterine vacuum MVA ProcedurePinch valve released to create intrauterine vacuumReleasing the Pinch ValveThe pinch valve is opened by releasing both buttons.When the pinch valve is released, the vacuum is transferred through the cannula to the uterus.Blood, tissue, and bubbles will flow through the cannula into the syringe.
25Back & forth & rotatory movements of cannula Evacuation of UterusBack & forth & rotatory movements of cannulaEvacuating the UterusEvacuate the contents of the uterus by moving the cannula gently and slowly back and forth within the uterine cavity, rotating the syringe as you do so. It is important not to withdraw the cannula aperture(s) beyond the cervical os, as this will cause the vacuum to be lost. If this happens, follow the instructions to re-establish the vacuum.Blood and tissue will rush into the MVA syringe barrel. If the barrel becomes full and the procedure is not complete, detach the syringe from the cannula, empty it, reestablish the vacuum, and continue the procedure.While the vacuum is established and the cannula is in the uterus, never grasp the syringe by the plunger arms to ensure that the plunger arms do not move from their locked position on the rim of the barrel. Accidentally allowing the plunger to slip back into the syringe may eject tissue or air back into the uterus.
26Care of Instruments Care of instruments comprises of following steps : DecontaminationCleaningHigh Level Disinfection (HLD) or SterilizationStorage / Reassembly
27Processing of the Instruments Syringe & cannulae decontaminated in a bleach solution for 10 minutes (optional)Wash well with detergent and waterSoak in 2% Glutaraldehyde (Cidex) or 0.5% chlorine solution for 20 minutesDo not boil the Syringe or useany heat technique or autoclave
28Cervical Ripening :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 ripeningProstodin – 250mcg by intramuscular injection 45 minutes before the procedure.Misoprostol – 400mcg tablet administered either vaginally or sublingually/orally 3-4 hours before the procedure.
29The 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.
31For pain control, Para cervical block – all that is necessary for complete evacuation A sedative or anxiolytic may be necessary if the patient is apprehensive
32MAJOR COMPLICATIONS OF MVA (12,888)24,000( )D & C0.15 – 28Excess bleeding0.40.06%Pelvic infection0.01– 8Cervical injury0.020.025%0.3 – 6.4Uterine perforation0.04%0 – 3.3Laufe, 1977PSS (Kolkata)Greenslade et al 1993
33EFFICACY : Several authors have shown that the efficacy of MVA in general - 98% GestationNumberEffectivenessHemin et al 2001, Sweeden<8 wksN = 91> 97%Fogsi Multicentric Study 2001, India<6-12 wksN = 92698.6%Edward & Creinin 1997, USA< 6 wksN = 2,399> 99%Westfall et al. 1998, USA< 12 wksN = 1,67799%Greenslade, 1993Within 12 wksN = 15,00097%PSS, Kolkata, India ( )8-12 wksN = 24,00098.5%
34MVA – in Low tech rural & High tech urban : Limited access to medical facilitiesNon availability of reliable equipmentMVA is – portable instrument, can be used as an OPD procedure.Erratic electricity supplyHigh tech urbanAccidental perforation – no damage to the abdominal organs because of dropping vacuum.Client friendly procedure – surgeon can continue to speak to the patient.Appreciation of minimally invasive concept.MVA Pilot Project – GOI, FOGSI & WHO
35OTHER USES OF MVA There are other uses of MVA and they are:- Endometrial Biopsy / sampling (using 4mm cannulae)Blighted ovumHydatidiform moleIncomplete abortion
36CONCLUSIONTo 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)