Manual Vacuum Aspiration (MVA)
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Is done in an out-patient setting.
Indications
Any uterus with retained products & without a fetus in situ up to 14-16 weeks size (operator dependant) can (should) be emptied by MVA. If the fetus is present the skill required is greater & incomplete evacuation is more likely. When a fetus is present at 9-10 weeks MVA is relatively easily achieved.
The os must be open, naturally or with the aid of misoprostol (single tablet 200mcg pre procedure), since dilatation at MVA is not easy nor is it well tolerated.
Analgesia
A gentle but adequate & well directed technique will reduce patient discomfort. Nonsteroidal anti-inflammatory agents such as diclophenac 75mg IM or Indomethacin 100 mg suppository may be given but are inadequate alone. Additives or alternatives include midazolam 2 mg IV or Pethidine 50 mg im or Morphine 5mg. Sedating drugs should be used & the patient must be observed during & after the procedure & should be discharged accompanied if possible.
Pre-procedure assessment
- Check the details of the patient – parity, LMP, history of current pregnancy, medications so far given, medical history, clinical & scan findings
- Ultrasound scan unless it has recently been done; if the products are less, less needs to be removed (does the procedure need to be performed?) if more, more is expected
- Advise the patient of the procedure
- Ask her to empty the bladder in the toilet if she has not done so
Procedure
- Ensure all instruments are correct & present. Learn how to assemble the MVA set & to create a vacuum
- Place the patient in lithotomy position. In certain situations, e.g. an unwell patient in a medical ward (too unwell for formal curettage), this is not completely essential
- Inspect the vulva, vagina, & cervix, & perform a gentle bimanual examination (size, axis, adnexa), & check that the os is open
- If the cervical os is closed, give further misoprostol sublingually (see above) or insert a Lamicel, or do evacuation under GA or spinal anaesthesia
- The diameter of the MVA catheter chosen should be a little less in mm than the gestation in weeks. The largest easily passing catheter is better
- Insertion without a vulsellum is ideal. If required, apply one (single toothed) to the anterior of the cervix. You can use a ml of local first
- Push the catheter to the fundus gently, release the vacuum & withdraw the instrument in a spiralling motion. Repeat at least once.
- Antibiotics are optional. Give if indicated
- If there are doubts about the emptiness of the cavity, do an ultrasound
- If the patient cannot tolerate MVA, be understanding. Scan the cavity again. If significant products are present, book for evacuation in theatre