1. Manual Vacuum Aspiration with local anaesthesia Marijke Alblas,MD Western Cape Department of Health

2. Use of MVA: Induced abortion up to 14 weeks Incomplete abortions uterine size up to 14 weeks As a back-up for failed medical abortion Missed abortion Endometrial biopsy Molar pregnancy

3. Goal of presentation to show that: MVA is a safe and simple procedure Safer, cheaper and more effective than D&C Can help to decentralize the service and make it more accessible Can be done by mid-level providers Has a very low failure rate

4. MVA is a safe and simple procedure Priming of cervix with misoprostol(2 or 3 tablets) 2 to 3 hours before procedure Local anaesthesia By properly trained HCP With the proper instruments In the right setting: as an out-patient procedure

5. But: don’t do a ‘curette check’!-->to check with a curette for complete evacuation adds unnecessary risks Increases pain and vagal reactions Increases chance of perforation Increases bleeding Many studies have demonstrated that using only suction has an effectiveness rate of 98%

6. Can help to decentralize the service and therefore make it more accessible Take it out of the theaters/ hospital-->OPD or office setting Minimal emergency equipment necessary MVA needs no ‘expensive’ instruments: no electrical suction machine, sets are re-usable Beds are not really necessary(not for first trimester) Only one trained ‘specialist’ necessary If allowed make use of mid-level provider Woman recover and return home quicker

7. Make use of the right instruments and handle them gently: the woman is awake!! Use the right size speculum Use ‘long’ needles for para-cervical block or needle extender Use the ‘right’ size of cannula; dilate with the different sizes of cannulae Avoid to use too big size of cannula: be aware that woman is awake!!! Don’t continue too long with the suction

8. Create the Vacuum Pull the plunger back until its arms snap outward over the end of the aspirator barrel. Make sure the plunger arms are positioned over the wide edges of the barrel.

9. 9 Selecting the cannula Adapters for the double-valve aspirator are color-coded to the dots on the corresponding cannula 7 to 10 mm ____________________ 10/12 mm 10 to 12 LMP ____________________ 13 to 14 LMP 6 to 7 mm8 to 9 LMP 4 to 6 mm5 to 8 LMP Approximate size of the cannula Approximate uterine size (weeks LMP) 9

10. Paracervical block : ---

11. Insert cannula

12. Releasing the Pinch Valve 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 aspirator.

13. MVA Technique: Vacuum Aspiration © Lisa Penalver

14. MVA Technique: Vacuum Aspiration © Lisa Penalver

15. Dilation cervix while doing suction: using different sizes of cannula Misoprostol has been given according to established protocol ( 2 to 3 hours before procedure) Gently dilate with cannula of increasing size taking care not to traumatise the cervix.

16. Dilation (cont.) With every cannula do suction and continue until the appropriate cannula for the procedure: POC are passing through the cannula In between empty syringe in kidney basin Dilatation of the cervix only necessary when the cervical canal will not allow passage of appropriate cannula

17. Inspecting the tissue 17 Strain and rinse the tissue Using a transparent container, inspect the material by examining it with a light from behind Make sure all the tissue has been withdrawn

18. Tissue Examination

19. Visual Inspection of the Products of Conception Gestational sac Blood clot Decidua

20. Types of Complications Early Complications: –Cervical Injury –Uterine injury –Haemorrhage –(Pre-existing) infection –Uterine rupture –Anaesthesia related complications

21. Recognising and managing uterine perforation Signs: Instruments inserted beyond the fundus Excessive bleeding Fat or organfragments maybe in the aspirated tissue Treatment: Usually seals itself off as uterus contracts If fat or organfragments:needs laparoscopy or laparotomy

22. Summary MVA is Simple to Use Safe and Effective Versatile and Cost Effective Is used for Endometrial Biopsy and Uterine Evacuation Suction is the method advised for 1 st Trimester surgical terminations by the World Health Organisation.

23. Manual Vacuum Aspiration(MVA) vs. Electric Vacuum Aspiration(EVA) MVA Inexpensive/re-usable Small Portable Quiet Specimen likely to be intact Requires repeated reloading of suction EVA More costly but longer life Bulky Less portable Noisy Fragmentation of specimen possible Constant suction