Manual Vacuum Aspiration (MVA)

Manual Vacuum Aspiration (MVA) is a method of pregnancy termination where a healthcare provider uses a handheld device (an aspirator) to gently remove the contents of the uterus using suction. The procedure is typically performed while the patient is awake. A narrow tube (cannula) attached to a syringe is used to empty the womb through aspiration, which is a process of gentle suction. Local anesthetic is injected into the cervix (neck of the womb) to minimize discomfort during the procedure.

MVA is a preferred, appropriate, and cost-effective method for managing abortion, particularly in resource-limited settings. It is highly effective up to 12 weeks of pregnancy and has demonstrated high efficacy in numerous randomized controlled trials. MVA has largely replaced dilation and curettage (D&C) in many industrialized and developing countries.

Preparation:

• Ensure the patient is prepared, the room is set up correctly, all equipment and supplies are readily available, and an assistant is present.

• Select the appropriate size of the cannula based on the gestational age and size of the uterus.

Requirements for MVA Procedure:

• Trolley (Top Shelf):

  • Sterile MVA set

  • Casco speculum

  • Vulsellum (or tenaculum)

  • Uterine sound

  • Receiver

  • Bowl of cotton swabs

  • Sponge-holding forceps

  • Appropriate-sized cannulas

  • Local anesthetic (Lidocaine or bupivacaine)

  • Syringe and needle

  • KY Jelly

  • Antiseptic solution

• Trolley (Bottom Shelf):

  • Gumboots

  • Buckets

  • Screens

  • Apron

• Bedside Setup:

  • Items for immediate use during the procedure.

Procedure for Manual Vacuum Aspiration:

1. Review Indications: Confirm appropriate indications such as:

   • Inevitable abortion before 16 weeks

   • Incomplete abortion

   • Molar pregnancy

   • Delayed postpartum hemorrhage due to retained placental fragments

2. Provide Emotional Support and Encouragement: Ensure the patient feels supported and reassured throughout the procedure.

3. Offer Pain Relief: Administer paracetamol 30 minutes before the procedure or perform a para-cervical block to numb the area.

4. Prepare the MVA Syringe:

   • Assemble the syringe, close the pinch valve, and pull back on the plunger until the plunger arms lock.

   • For molar pregnancy, have three syringes prepared. For very early pregnancy, insert the cannula without prior cervical dilation.

5. Administer Oxytocin or Ergometrine: Give oxytocin 10 units intramuscularly (IM) or ergometrine 0.2 mg IM to firm the uterine muscle and reduce the risk of perforation.

6. Perform a Bimanual Pelvic Examination: Re-assess the size and position of the uterus and the conditions of the fornices (the spaces around the cervix).

7. Insert Sterile Speculum and Visualize the Cervix: Apply antiseptic solution to the vagina and cervix, particularly around the os (the opening of the cervix).

8. Check the Cervix for Tears or Protruding POC: Remove any visible products of conception (POC) with ring (or sponge) forceps.

9. Gently Grasp the Anterior Lip of the Cervix: Use ring forceps or a single-toothed tenaculum. If using a tenaculum, first inject 1 mL of 0.5% lignocaine solution into the cervix to minimize pain.

10. Dilate the Cervix if Needed: For a missed abortion or prolonged retention of POC, use mechanical or osmotic dilators, or cervical priming with mifepristone or prostaglandin.

11. Insert the Cannula: While applying gentle traction to the cervix, carefully insert the cannula through the cervix into the uterine cavity, just past the internal os.

12. Attach the Prepared MVA Syringe: Hold the ring forceps (or tenaculum) and the end of the cannula in one hand and the syringe in the other. Release the pinch valve(s) to transfer the vacuum to the uterine cavity.

13. Evacuate Remaining Contents: Gently rotate the syringe from side to side and move the cannula back and forth within the uterine cavity to ensure complete evacuation without losing the vacuum.

14. Check for Signs of Completion: Look for signs such as:

    • Red or pink foam without tissue

    • A grating sensation as the cannula moves along the uterine wall

    • The uterus contracting around the cannula

15. Withdraw the Cannula: Detach the syringe, place the cannula in a decontamination solution, and empty the syringe contents into a strainer.

16. Perform a Bimanual Examination: Check the size and firmness of the uterus after the procedure.

17. Inspect the Tissue Removed: Ensure complete evacuation, assess for molar pregnancy, and if needed, strain and rinse the tissue for examination.

18. Address Absence of POC: If no products of conception are seen, consider a complete abortion, breakthrough bleeding, or a possible ectopic pregnancy.

19. Reinsert Speculum and Examine for Bleeding: If there is persistent bleeding or the uterus feels soft, repeat the evacuation procedure.

Post-Procedure Care:

• Administer paracetamol 500 mg as needed for pain relief.

• Consider antibiotics to prevent infection.

• Encourage the patient to eat, drink, and walk.

• Offer other necessary health services.

Discharge Uncomplicated Cases:

• Discharge the patient within 1-2 hours if the case is uncomplicated.

• Provide clear instructions on symptoms that require immediate medical attention.

Precautions for Performing MVA:

• Delay the procedure if conditions such as shock, severe vaginal bleeding, or intra-abdominal injury are present. Stabilize the patient first.

• Stabilization involves providing oxygen, intravenous fluids, antibiotics for sepsis, and blood transfusion if needed.

Shock Management:

• Recognize symptoms such as:

  • Rapid, weak pulse

  • Low blood pressure

  • Pallor

  • Sweatiness

  • Rapid breathing

  • Anxiousness, confusion, or unconsciousness

• Treat with oxygen, intravenous fluids, antibiotics, and blood transfusion if necessary.

Severe Vaginal Bleeding:

• Identify symptoms such as:

  • Heavy, bright red bleeding

  • Pallor

  • Blood-soaked materials

• Assess all sources of bleeding, stabilize the patient, and evacuate POC.

Intra-Abdominal Injury:

• Recognize symptoms such as:

  • Distended abdomen

  • Decreased bowel sounds

  • Rigid abdomen

  • Rebound tenderness

  • Nausea and vomiting

  • Pain, fever, or cramping

• Immediate management involves intravenous fluids, antibiotics, and potential surgery. Perform MVA after stabilization.