Faster, cheaper. Blumenthal and Remsburg demonstrated that MVA in an outpatient setting decreases anesthesia requirements, hospital stay times, patient waiting times, and procedure times when compared with aspiration done in the OR. They showed a substantial saving, with the cost of uterine evacuation in the OR estimated at $1404 vs $827 per case when the aspiration was done as an outpatient procedure in the labor and delivery suite.41 The MVA syringe costs about $30 and is reusable after appropriate cleaning through sterilization or high-level disinfectant. The disposable plastic suction cannulas cost less than $3 each.
Pain management. A combination of an oral nonsteroidal anti-inflammatory (NSAID) medication and a paracervical block is a practical approach to managing the pain of this procedure. No published reports demonstrate that 1 type of local anesthetic is better than another, and many different techniques and combinations of medicines used for the paracervical block have been described.42
To minimize the effects of accidental blood vessel injection, the lowest anesthetic dose should be used, usually 10 to 20 mL of a 0.5% to 1% lidocaine or 0.25% bupivacaine solution. A common technique is to inject 8 to 10 cc of 1% lidocaine with epinephrine or vasopressin at 4 and 8 o’clock at the cervicovaginal reflection after careful aspiration to ensure the needle is not in a blood vessel.
Oral narcotics. Clinicians can also choose to manage pain with oral narcotics, benzodiazepines, or intravenous conscious sedation. Moderate cramping during and immediately after the procedure is common and can often be alleviated with verbal support.
For patients whose anxiety level is high, conscious sedation or general anesthesia may be the most appropriate choice. Your patient’s preference and your evaluation of her medical risk and emotional state together determine the most appropriate course.43 The technique for MVA is described inTABLE W2, available at jfponline.com.
Which approach is best for your patient?
Because all 3 approaches to managing EPL are effective and safe, family physicians can empower patients to make the choice themselves. Counseling about treatment options should include consideration of the patient’s support at home, availability of transportation in case of emergency, her desire to avoid surgery, and her need for a definitive resolution.
Counseling should also include information on the likely efficacy of each option, given the type of EPL the patient has experienced. For example, women who have had a missed abortion (embryonic demise or anembryonic gestation) are less likely to complete with expectant management than women with an incomplete abortion. Efficacy rates for different types of EPL are shown in TABLE W1, available at jfponline.com.
There’s time for your patient to change her mind
A woman may opt for 1 approach to start with, but choose a different option later. She may chose expectant management for a week, and then if the pregnancy has not passed on its own, decide that she wants to try misoprostol. If that fails, too, she may want a uterine aspiration procedure.
How did our 3 patients fare?
CASE 1: At first, Janet was content to wait and see whether her miscarriage would pass without further intervention. But when a week went by and nothing happened, she wanted to get it over with. She asked to try MVA, under conscious sedation. The procedure was successful. Now, a year later, she’s very happy to be pregnant again and confidently awaits a happy outcome.
CASE 2: By the time Lizbeth called, you suspected her abortion was complete. Your examination confirmed that diagnosis. She required no treatment, and a year later was ready to try again.
CASE 3: Lola was shocked when she learned her fetus had died in utero. But once she and her husband had taken in the sad news, they wanted to know what options were available. They talked it over and chose treatment with misoprostol. The miscarriage was completed 8 days later. They are content with their current family size and have decided not to try for another pregnancy.
CORRESPONDENCE Emily M. Godfrey, MD, MPH, UIC Department of Family Medicine, 1919 W. Taylor Ave., Room 145, M/C 663, Chicago, IL 60612; egodfrey@uic.edu