Clinical Review

Manual vacuum aspiration: A safe and effective treatment for early miscarriage

OBG Manag. 2015 October;27(10):38-43

References

1. Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. N Eng J Med. 2005;353(8):761−769.

2. Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, Creinin MD, eds. Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care. Oxford, United Kingdom: Wiley-Blackwell; 2009.

3. Edelman A, Nichols MD, Jensen J. Comparison of pain and time of procedures with two first-trimester abortion techniques performed by residents and faculty. Am J Obstet Gynecol. 2001;184(7):1564−1567.

4. Renner RM, Nichols MD, Jensen JT, Li H, Edelman AB. Paracervical block for pain control in first-trimester surgical abortion: a randomized controlled trial. Obstet Gynecol. 2012;119(5):1030−1037.

5. Dalton VK, Harris L, Weisman CS, Guire K, Castleman L, Lebovic D. Patient p, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol. 2006;108(1):103−110.

6. Dalton VK, Liang A, Hutton DW, Zochowski MK, Fendrick AM. Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss. Am J Obstet Gynecol. 2015;212(2):177.e171−177.e176.

7. Ipas. Ipas start-up kit for integrating manual vacuum aspiration (MVA) for early pregnancy loss into women’s reproductive healthcare services. Chapel Hill, NC: Ipas; 2009.

8. MVA Products page. HPSRx Web site. http://www.hpsrx.com/mva-products.html. Accessed October 13, 2015.

9. Kinariwala M, Quinley KE, Datner EM, Schreiber CA. Manual vacuum aspiration in the emergency department for management of early pregnancy failure. Am J Emerg Med. 2013;31(1):244−247.

10. The American College of Obstetricians and Gynecologists. Practice Bulletin No. 150: early pregnancy loss. Obstet Gynecol. 2015;125(5):1258−1267.

11. Meckstroth KR, Whitaker AK, Bertisch S, Goldberg AB, Darney PD. Misoprostol administered by epithelial routes: drug absorption and uterine response. Obstet Gynecol. 2006;108(3 Part 1):582−590.

12. Davis AR, Hendlish SK, Westhoff C, et al. Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial. Am J Obstet Gynecol. 2007;196(1):31.e31−31.e37.

13. Luise C, Jermy K, May C, Costello G, Collins WP, Bourne TH. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ. 2002;324(7342):873−875.

14. Bardos J, Hercz D, Friedenthal J, Missmer SA, Williams Z. A national survey on public perceptions of miscarriage. Obstet Gynecol. 2015;125(6):1313−1320.

15. The Practice Committee of the American Society for Reproductive Medicine. Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertil Steril. 2012;98(5):1103−1111.

16. Doubilet PM, Benson CB, Bourne T, Blaivas M. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Eng JMed. 2013;369(15):1443−1451.

17. Abdallah Y, Daemen A, Kirk E, et al. Limitations of current definitions of miscarriage using mean gestational sac diameter and crown–rump length measurements: a multicenter observational study. Ultrasound Obstet Gynecol. 2011;38(5):497−502.

FIGURE 1 MVA equipment The required equipment for office-based MVA includes a reusable vacuum aspirator (with disinfection supplies), reusable plastic or metal dilators, and supplies for examination of products of conception.

According to WomanCare Global, manufacturer of the IPAS MVA Plus, equipment should be sterilized after each use with soap and water, medical cleaning solution (such as Cidex, SPOROX II, etc.), or autoclaving.⁷If 2 reusable aspirators are purchased along with dilators, disposable cannulae, and tools for tissue assessment, the price of supplies is estimated at US $500.⁸ WomanCare Global also offers prepackaged, single-use aspirator kits, which may be ideal for the emergency department setting.⁹

The procedure
To view a video on the MVA device and procedure, including step-by-step technique (FIGURE 2), local anesthesia administration, choosing cannula size, and cervical dilation, visit the Managing Early Pregnancy Loss Web site (http://www.earlypregnancylossresources.org) and access “Videos.” The video “Uterine aspiration for EPL” is available under password protection and broken into chapters for viewing ease.

FIGURE 2 MVA procedure If the cannula is already inside the uterus, suction should be created in the syringe and then the syringe should be attached to the cannula. Suction is generated when the valves are released. Once the vacuum is activated, the cannula is maneuvered in the uterus with a combination of rotation and in and out movements between the fundus and internal os.

The risk of endometritis after surgical management of miscarriage is low. Antibiotic prophylaxis prior to MVA or EVA should be considered. Experts recommend giving a single dose of doxycycline 200 mg orally at least 1 hour prior to uterine aspiration.^2,10

Use of EVA or MVA for outpatient management of miscarriage yields the opportunity to conduct immediate gross examination of the evacuated tissue and to verify the presence of complete POC. The process is simple: rinse the specimen through a sieve with water or saline, placed in a clear glass container under a small water bath and backlit on a light box. This allows clinicians to separate uterine decidua and pregnancy tissues. “Floating” tissue in this manner is especially useful in patients with pregnancy of unknown location, as immediate confirmation of a gestational sac rules out ectopic pregnancy.

Examine evacuated tissue for macroscopic evidence of pregnancy. Chorionic villi, which arise from syncytiotrophoblasts, can be seen with the naked eye. Immediate evaluation of POC is also useful for patients who desire diagnostic testing to ascertain a cause of their miscarriage because evacuated tissue stored in saline may be sent to a laboratory for cytogenetic analysis.

Medical management
Management of miscarriage with misoprostol is also safe and acceptable to women, though it has a lower success rate than surgical management.

Comparing efficacy: Medical vs surgical management. The Management of Early Pregnancy Failure Trial (MEPF) is the largest randomized controlled trial comparing medical management of miscarriage to surgical management. This multicenter study compared treatment with office-based EVA or MVA to vaginal misoprostol 800 µg. A repeat dose of vaginal misoprostol was offered 48 hours after the initial dose if a gestational sac was present on ultrasound.

Findings from the MEPF trial revealed a 71% complete uterine evacuation rate after  1 dose of misoprostol and an 84% rate after  2 doses.¹ The average (SD) reported pain score documented within 48 hours of treatment with misoprostol or MVA/EVA was moderate (5.7 cm [2.4] on 10-cm VAS). The rate of infection or hospitalization was less than 1% in both treatment groups.

These data should provide patients who are clinically stable and who wish to avoid an invasive procedure reassurance that using medication for the management of miscarriage is a reasonable option.

Misoprostol. Use of misoprostol is associated with a longer median duration of bleeding compared with suction aspiration. After misoprostol, bleeding usually begins after several hours and may continue for weeks.¹¹ Based on 2-week prospective bleeding diary entries from the MEPF trial, women who used misoprostol for management of miscarriage were more likely to have any bleeding during the 2 weeks after initiation of treatment, compared with women who had suction aspiration.¹²

Clinically significant changes in hemoglobin levels are more common in women treated with misoprostol than in those who choose EVA or MVA; however, these differences rarely require hospitalization or transfusion.¹ Women who are considering use of misoprostol should be aware of common adverse effects, including nausea, vomiting, diarrhea, and low-grade temperature.

Medical management of miscarriage requires multiple office visits with repeat ultrasounds or serum beta–human chorionic gonadotropin (β-hCG) levels to confirm treatment success. In cases of medication failure (persistent gestational sac with or without bleeding) or suspected retained POC (endometrial stripe greater than  30 mm measured on ultrasound or persistent vaginal bleeding remote from treatment), women should be prepared for surgical resolution of pregnancy and clinicians should be able to perform an office-based procedure.