Transcript Manual Vacuum Aspiration

Management of Early Pregnancy
Failures in the Outpatient Setting
Emily Godfrey MD MPH
Michelle Forcier MD MPH
ARHP National Conference 2006
Pre-Conference Workshop
ARHP
Objectives
• Appreciate the historical context regarding
terminology, diagnosis, and management of early
pregnancy failure and how it has evolved
• Recognize the various presentations and
classifications of early pregnancy failure
• List new and different treatment options currently
available for early pregnancy failure
• Describe new data suggesting a role for misoprostol
in the management of early pregnancy failure
• Describe the current standard treatment using MVA
for early pregnancy failure
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Early Pregnancy Failures
• Incidence:
– 15-20% clinically recognized pregnancies
– Estimated 30% if non-clinically recognized
pregnancies are included*
• 80% occur in first trimester
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* Wilcox NEJM 1988
Types of Early Pregnancy Failure
• Threatened
• Inevitable*
– Uterine cramping
– Dilated cervical os
• Incomplete*
– Inevitable with passage of some POCs
• Missed*
– Closed os
– Uterine cramping
• Septic
• Complete
– No uterine cramping
– Cervical os closed
– Complete passage of tissue
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* Early Pregnancy Failure
History of the Management of EPF
• Pre 1880
– Less is better
• Post 1880
– Development of curette
– Reduction of hemorrhage
– Reduction of infection
– Intervention advocated because high rates of
infection accompanying illegal abortion
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Management of EPF
• Today
– D & C still remains the standard of care despite decreased incidence of
septic abortion
– Potential complications
• Risk of anesthesia
• Uterine perforation
• Intrauterine adhesions
• Cervical trauma
• Pelvic Pain
• Increased risk of ectopic pregnancy (subsequent)
• Alternative treatment options
– Manual vacuum aspiration
– Medical management with prostaglandin analogues (i.e. Misoprostol)*
– Expectant management
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Expectant management
• In the setting of incomplete abortion expectant
management is successful 82-96% of the time
• Average time to completion is 9 days
• Success rate is less for embryonic death or
anembryonic gestations (missed abortions) (25-76%)
• First trimester miscarriages may be expectantly
managed indefinitely if without hemorrhage or
infections
Griebel AFP 2005
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Success of expectant management
Group
N
Complete
day 7
Complete
day 14
Success
day 49
Incomplete
221
117 (53%)
185 (84%)
201 (91%)
Missed
138
41 (30%)
81 (59%)
105 (76%)
Anembryonic
92
23 (25%)
48 (52%)
61 (66%)
TOTAL
451
181 (40%)
314 (70%)
367 (81%)
Luise C. BMJ 2002
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Misoprostol (Cytotec)
• Prostaglandin E1
• FDA approved for
prevention and treatment of
gastric and duodenal ulcers
• Heat stable (does not need
refrigeration)
• Inexpensive
• Widely available
• Oral preparation
– 100 g (non-scored) & 200 g
(scored) tablets
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Misoprostol: Physiologic Effects
Uterine:
Stimulate contractions
Cervical
Softens and primes cervix
Gastrointestinal:
Prevents/treats ulcers
Nausea
Vomiting
Diarrhea
Systemic:
Fever
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Routes of Administration
Oral
Vaginal
Buccal
Sublingual
Rectal
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Vaginal Use
• Manufactured and approved for oral use only
• Greater effects on reproductive tract with
vaginal dosing*
• Decreased gastrointestinal side effects with
vaginal dosing*
*Danielsson 1999
Creinin 1993
Toppozada 1997
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Buccal & Sublingual Use
• Mostly been studied with the use of induced
medical abortion
• Sublingual has faster absorption than buccal*
• Buccal as effective as vaginal in induced
medical abortion up to 56 days’ gestation
• Sublingual as effective as vaginal misoprostol
in induced medical abortion up to 63 days’
gestation
*Schaff, EA et al. 2005
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*Tang, OS et al 2006
Middleton, T et al 2005
Surgical options
• Sharp curettage (D and C) no longer an
acceptable option due to higher complication
rates
• Vacuum aspiration includes manual vacuum
aspiration (MVA) vs. electrical pump aspiration
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MVA Instruments and Supplies
•
•
•
•
•
Inexpensive
Small
Portable
Quiet
Specimen likely
to be intact
• May require repeated reloading of suction
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Literature Review
• Standard dosage and dosing intervals have
not been well established
• Studies difficult to compare
– Various patient populations and dosing regimens
– Different routes of administration
– Varying definitions of success
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Incomplete and Missed AB
•
•
•
•
•
Demetroulis et al, 2001
Prospective RCT
80 women w/missed AB or incomplete AB
Misoprostol vs. Surgical evacuation
Results:
– 82.5% successful in Misoprostol group
– Failure rate higher for Missed AB patients (23% v.
7%)
Demetroulis. Human Reproduction, 2001
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Missed Abortion
• Wood et al, 2002
• Double blind randomized controlled trial (Type I
study)
• 50 women
– Ultrasound dx of missed ab
– Absence of cramping and bleeding
– Less than 12 weeks uterine size
• 800 g misoprostol – up to 2 doses
– Vaginal versus placebo
• Follow-up
– 24 hours, 48 hours, 1 week
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Wood and Brain, Obstet Gynecol 2002
Missed Abortion
• Misoprostol
–
–
–
–
15 of 25 completed after first dose @ 24h
21 of 25 completed after second dose @ 48h
2 had on-going bleeding
1 had retained tissue
• Placebo
– 1 of 25 completed after @ 48h
– 4 of 25 completed @ 1 week
• No significant change in hemoglobin levels
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Wood and Brain, Obstet Gynecol 2002
Comparison of surgical with medical
management: EPF
• Zhang et al, 2005
• Prospective, RCT
• 652 w/ 1st trimester pregnancy failure
–
–
–
–
Anembryonic
Embyronic or fetal death
Incomplete
Inevitable
• Misoprostol 800 g, repeat day 3
– Vaginal versus surgical evacuation
• Complications
– Surgical treatment for the miso group
– Repeat surgical procedure within 30 days
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Zhang. NEJM 2005
Comparison of surgical with medical
management: EPF
• Results
– Misoprostol Group
• 71% complete by Day 3
• 84% complete by Day 8
– Treatment Failure
• 16% Misoprostol group
• 3% Surgical group
• Conclusions
– Treatment of EPF with Miso is safe and works about 84%
of the time
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Zhang. NEJM 2005
Missed Abortion Using Sublingual
Misoprostol
• Tang, et al, 2006
• Prospective randomized controlled trial
• 180 women
– Ultrasound dx of missed ab
– Absence of cramping and bleeding
– Less than 13 weeks uterine size
• 600 g sublingual misoprostol Q 3 hours x 3 vs 400 g
sublingual misoprostol daily x 1 week
• Results at 1 week
– 92% completed in SL x 3 group
– 93% complete in SL x 3 + daily group
• Greater side effects reported in the SL x 3 + daily group
Tang. Hum Reprod 2006
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Early Pregnancy Failure Treatment
Using Mifepristone/Misoprostol
•
•
•
•
Trinder, et al, 2006
Prospective randomized controlled trial
Miscarriage Treatment Trial (MIST)
1200 women
– Less than 13 weeks gestation
– Incomplete miscarriage, Anembryonic, Missed abortion
•
•
•
•
•
Expectant vs. Medical vs. Surgical
Incomplete: 800 miso only vaginal
Anembyronic/Missed: 200 mife + 800 miso 24-48 hr
Primary outcome: infection within 14 days
Secondary outcome: efficacy (no D & C within 8 weeks)
Tinder. BMJ 2006
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Early Pregnancy Failure Treatment
Using Mifepristone/Misoprostol
• Results
– Gynecological Infection
• No difference between the groups
– Anembyronic/Missed
• 6% Surgical group
• 38% Medical group
• 50% Expectant group
• Conclusions
– Infection rates did not differ between groups
– Surgical Management is more treatment option than
medical or expectant management
Tinder. BMJ 2006
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Meta-analysis of Expectant, Surgical and
Medical
• Comparison of expectant, medical and
surgical treatment of 1st trimester
spontaneous abortion
• 28 studies eligible for analysis
• Medical v. expectant: expectant was 39%
successful.
• Medical 3 times more likely to be successful
Sotiriadis. Obstet Gynecol 2005
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Meta-analysis of Expectant, Surgical and
Medical, cont.
• Surgical v. expectant: expectant was 79%
• Surgical more likely to be successful than
expectant
• Surgical v. medical: surgical was 1.5 times
more successful than medical
• Pt satisfaction did not differ significantly
between surgical and medical, although trend
favored medical management
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Sotiriadis, Obstet Gynecol 2005
Conclusion
• Early pregnancy failure is common
• Expectant, medical and surgical management can
be done safely in an outpatient setting
• Study findings vary because of lack of uniformity of
study populations
• Patients should be counseled accordingly so they
can choose best treatment option
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CASES
Discussions about Outpatient
Management of Miscarriage
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Case 1
You see a 18-year old woman, G2P1001, whose
last period was 8 weeks ago. She had a positive
home pregnancy test 3 weeks ago. Her first
prenatal appointment is scheduled with another
provider. She has not had an ultrasound during
this pregnancy.
Three days ago, she began to spot. Today, her
bleeding has increased, like a very heavy period
with some clots. She began cramping last night
and now reports that the cramping is severe. She
comes to your clinic today for assessment and
treatment if required.
ARHP
Case 1
Her medical history includes a spontaneous
vaginal delivery 2002. She is otherwise healthy.
On exam, she appears comfortable and is able to
walk around the room and talk easily. Her vital
signs:
BP 110/70, Pulse 90, Temp 97.8
At this point, how would you proceed with
evaluation?
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Case 1
The examination reveals the following
– Abdomen: soft, nontender
– Vaginal vault: scant amount of blood, consistent with a
menses
– Cervix: os open, tissue at os noted
– Bimanual exam: uterus enlarged, approx. 8 weeks size,
nontender
• Her hemoglobin is 12.2.
• Urine pregnancy test: positive
What tests do you think you should order now?
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Case 1
The ultrasound reveals an intrauterine gestational
sac, and thickened endometrial stripe.
What is the diagnosis?
What are the treatment options available for this
patient?
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Case 1 Key Concepts
Incomplete/Inevitable Abortion
• 600-800 mcg effective dose without too many
side effects
• May give vaginally, orally, sublingual (not well
studied)
• May repeat
• More effective for incomplete abortions than
for missed abortions
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Case 2
41 yo G1P1 presents to the Clinic for her first
prenatal visit in a very desired pregnancy. Her
LMP was 10 weeks ago and she is certain of her
dates. The pregnancy has been uncomplicated
except for a small amount a bleeding she had
about 1 week ago. You evaluate the patient and
finds that her BM exam is consistent with a 7 wk
IUP, os is closed.
What other information might you be interested in
knowing about?
What might you order to get a diagnosis?
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Case 2
Fortunately, your Clinic has a portable
ultrasound, and you are able to supervise the
resident with a vaginal probe ultrasound. You
see a well-circumscribed, though empty
gestational sac.
What are your differential diagnoses? What do
you tell the patient?
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Case 2
The patient returns 5 days later with further
spotting and cramping. A 2nd serum β-hCG is
done, as well as a repeat ultrasound. The
ultrasound now shows a large irregular shaped
gestational sac. The serum β-hCG level has
dropped.
What is your assessment?
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Case 2
The patient decides to opt for medical treatment.
What regimen do you use?
How do you advise her? What can she expect?
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Case 2 Key Concepts
Anembryonic Pregnancy
• Consider the emotional aspects of miscarriage
• Element of choice in patient satisfaction
• Effectiveness of medication methods as well
as surgical methods
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Case 3
26 yo G2P2002 LMP uncertain because of
irregular periods well known to you presents to
your office with spotting x 4 days. She denies
any pain. Her urine pregnancy test is positive,
her cervical os closed. Her uterus is retroverted.
She has a remote history of Chlamydia infection
about 10 years ago.
What is your differential diagnosis?
What tests would you order now?
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Case 3
You perform an ultrasound and you see small
echolucent area, which could be a small
gestational sac or a pseudosac.
What should you do now?
What is your diagnosis? What are you options for
treatment?
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Case 3 Key Concepts
Ectopic Pregnancy
• Ectopic vs early pregnancy may be hard to
differentiate
• Methotrexate an option for early & stable
patients
• MVA can help evaluate POC in clinic, guiding
diagnosis & referral decisions
ARHP
MVA for
Miscarriage Management in the
Out-Patient Setting
ARHP Workshop
September 6, 2006
ARHP
Emily Godfrey, MD MPH
Michelle Forcier, MD MPH
Updates in Miscarriage Management
• To discuss issues in evaluation & management of
early miscarriage
• To discuss the evidence behind the options for
miscarriage management
• To review manual vacuum aspiration (MVA) for
miscarriage management
– Summarize the safety and efficacy of MVA
– Discuss pain management in out-patient settings
– Discuss moving miscarriage management out of OR
• To demonstrate technique or update your skills in
MVA for uterine evacuation
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What is MVA?
•Manual vacuum aspirator
•Semi-flexible plastic
cannula
•Portable & reusable
Goldberg 2004; Creinin 2001; Hemlin 2001
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•Efficacy = electric vacuum
(98-99%)
Indications for MVA
• Uterine evacuation first trimester
– Induced abortion
– Spontaneous abortion or early pregnancy
failure (EPF)
• Complications management
– Incomplete medical abortion
– Post-abortal hematometra
• Uterine sampling
– Endometrial biopsy
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MVA Safety & Efficacy
• Hale 1979 (MVA in 1st trimester, gynecology office, Hawaii)
• Edwards 1997 (MVA at < 6 weeks gestation, women’s clinic,
Texas)
• Westfall 1998 (MVA in 1st trimester, family practice office,
Colorado)
• Hemlin 2001 (EVA vs. MVA at < 8 weeks gestation, hospital
operating room, Sweden)
• Paul 2002 (EVA and MVA at < 6 weeks, Planned Parenthood,
Massachusetts)
• Goldberg 2004 (EVA vs. MVA up to 10 weeks, University of
California, San Francisco)
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Early Abortion with MVA
Author
Date
N
Paul et al.
2002
1,132 (MVA+EVA)
<6
98%
Edwards &
Carson
1997
1,530 MVA
<6
99%
Edwards &
Creinin
1997
2,399 MVA
<6
99%
Hemlin & Moller
2001
91 MVA
<8
98%
Laufe
1977
12,888
“About 6”
98%
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Gestational Efficacy
Age
Adapted from Baird and Flinn 2001
MVA vs EVA
MVA
•
•
•
•
•
•
Manual aspirator
Inexpensive
Quiet
Portable
Capacity: 60 cc
Suction decreases as
aspirator fills
• POCs likely intact
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EVA
•
•
•
•
•
•
•
Electric pump
Costly but longer life
Variable noise level
Not easily portable
Capacity: 350-1,200 cc
Constant suction
Fragmentation of
POCs
Complications with MVA
• Rare
• Same as for EVA
– Incomplete evacuation
– Uterine or cervical injury
– Infection
– Hemorrhage
– Vaso-vagal reaction
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MVA for Miscarriages
• Aspiration recommended if
– Prolonged or excessive bleeding
– Signs of infection
– Patient preference
• Advantages
– Portable & low cost device
– Suitable for outpatient services
– Applications to variety of settings (primary care,
ob/gyn office, ER)
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Patient Satisfaction
• Both EVA and MVA groups highly satisfied
• No difference reported in
– Pain
– Anxiety
– Bleeding
– Acceptability & satisfaction
• More EVA patients bothered by noise (p=0.03)
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Bird et al. 2003, Dean et al. 2003, Edelman et al. 2001
MVA Instruments
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MVA: Key Benefits
• Safety & efficacy equivalent
to EVA
•Portable
•Low tech
•Low-cost
•Small and quiet
 Significant implications for
incorporating services into the
office setting
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Dalton and Castleman 2002; Goldberg et al. 2004
MVA: Essentials for Providers
•
•
•
•
•
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Pain management for awake patient
Counseling & rapport
Ultrasound
Identifying products of conception
Instrument processing
Video of MVA Procedure
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MVA Video- Important Points?
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Video – Important Points
• Actual patient from local outpatient clinic
• Ibuprofen and paracervical block only
• In procedure room time ~10-15 minutes
• Actual time for uterine evacuation ~1-2 minutes
• Recovery time ~30 minutes
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Pain Management
In the
Out Patient Setting
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Pain Management in Outpatient Settings
• Staff often express concern that uterine evacuation
requires general or conscious sedation
• Many uterine evacuations done under
paracervical (local) block
• Definite ways you can improve pain management
in your outpatient setting
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Pain Management Techniques
General or
nitrous 10%
Local + IV
32%
With Addition Of:
•Focused breathing: 76%
•Visualization: 31%
•Localized massage: 14%
Local 58%
ARHP
Lichtenberg 2001
Importance of Pain Management
• Most common concern expressed by patient
• Highly linked to patient satisfaction
• Whose perspective?
– Patients
– Clinician
– Counselor/bedside assistant
• What are we trying to do?
– Minimize risk / maximize benefit
– Take away all pain/all feeling
– Get through it
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Effective pain management
• What worsens pain?
– Pre-procedure fearfulness
– Anxiety
– Depression
• What reduces pain?
–
–
–
–
–
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Respectful, informed and supportive staff
Warm and friendly environment
Gentle operative technique
Women’s involvement & sense of control
Effective pain medications
Belanger 1989; Smith 1979
Other Influences on Pain
• Provider
– The clinician has a profound effect on pain score,
independent of anesthetic (Rawling 1998 and 2001)
• Patient’s sense of control
– “The idea that I could manage the miscarriage
myself with guidance available whenever I needed
it…I felt calmer, more confident, less medicated and
out of control.”(Wiebe 1999)
ARHP
Role Play- Patient Centered Care
•
•
•
•
23 yro G1P0 miscarrying at EGA 8 weeks
Very desired pregnancy
Bleeding and cramping x 24 hrs
No fetal heart activity & CRL only measuring 5
weeks
ARHP
Paracervical Block
ARHP
Maltzer 1999; Castleman 2002
Options for Anesthesia
• Local
• Conscious sedation
• Other
– Psychological
• Information, preparation & support
– Music as analgesia
• 85% abortion patients wearing headphones
rated pain as “0” compared to 52% controls
– Distraction
ARHP
Stubblefield 1989
Shapiro 1974
Curettage and Pain
• Using the curette often
requires increased
dilatation
• Curetting hurts! Makes
reducing anesthesia more
difficult
 Sharp curettage generally
not indicated & not
routinely recommended
following MVA
ARHP
Forna 2002
In Conclusion . . .
• No pain panacea
–
–
–
–
Affirm the patient’s existing viewpoint wherever possible
Avoid glib reassurances
Advise the patient that her fears are widely shared
Help the patient to differentiate between emotional and
physical pain
• Women want to be involved in developing their pain
management plan
• Curette check hurts - usually not needed
• Pre-procedure preparation & psychological support
reduce anxiety & improve overall experience
ARHP
Other Clinical Benefits of MVA
POCS are easier to visualize & inspect
– Often more intact
– Easier detection of early EGA
• Fewer re-aspirations in MVA vs EVA group
(Goldberg 2004)
– Can still send to pathology for genetics
Goldberg 2004; MacIsaac 2000; Edwards 1997
ARHP
MVA POC Check: Benefits for EPL
What is
that?
There
it is!
Electric Suction Machine
ARHP
MVA Aspirator
Creinin and Edwards 1997
MOVING OUT OF THE
OPERATING ROOM
ARHP
Uterine evacuation- Why the OR?
• OR was necessary when emptying the
uterus was an emergency
– Abortion was illegal
– Antibiotics were not available
– Access to blood transfusion limited
“Puerperal (childbed) fever was the scourge of nineteenth century
obstetrics and abortion.” Joffe 1999
• Today, out patient care safe, convenient,
cost effective option for stable patients
ARHP
OR to Out Patient Clinic – Benefits
•
Simplify scheduling
•
•
Avoid cumbersome OR protocols
•
•
Prolonged NPO requirements & discharge
criteria
Save resources
•
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Reduce waiting and repeat exams
Outpatient saves materials required,
costs/charges, personnel
Demetroulis 2001
Out Patient - Benefits to your Patients
Why some patients want MVA
• Control/autonomy while awake during procedure
• Convenience & time
– Single appointment
– Rapid recovery time
• Personalized care by single provider
• Improved patient education, attitudes,
accommodations in out patient setting (Lee 1996)
ARHP
Moving Miscarriage Management to
Outpatient Setting – Johns Hopkins Study
Results
ARHP
– Decreased anesthesia requirements
– Decreased overall hospital stay from 19 to 6
hours
– Decreased patient waiting time by 52%
– Decreased procedure time from 33 to19
minutes
– Decreased costs per case
$1404 in OR
$827 in L&D
Blumenthal 1994
$200 or less in ER
Moving Abortion to an Outpatient Clinic -
Bellevue Hospital
Methods
• Compared costs, staff, complications: OR vs. Outpatient
• N = 967; Patients undergoing first trimester pregnancy
termination in outpatient procedure room (2000-2002)
Results
Outpatient
Operating
MVA
Room
$1268
Cost per
$167
$1,435
Procedure
savings
Staff
2
5
No reported complications with outpatient MVA
ARHP
Bellevue Hospital Improvement Reports, Masch 2002
Moving Abortion to an Outpatient Clinic-
University of Michigan
Results: 60 women chose clinic, 29
women chose OR
MVA: 91% would choose again
• “get home soon,” “avoid GA”
• 69% less patient time
• 50% shorter procedure time
Cost savings of moving out of the OR of
$3,000 per case
Dalton 2003
ARHP
Medications/Supplies Needed
• Analgesia
• Anesthetic
• Silver nitrate or ferric
subsulfate
• Uterotonic agent
• Rhogam
ARHP
• Urine pregnancy tests
• Emergency cart
• Pharmacologic agents
for cervical ripening
(optional)
Equipment Needed
PROCEDURE
• Aspirators
• Cannulae
• Speculae
• Sharp-toothed and/or
atraumatic tenaculae
• Antiseptic solution
• Mechanical dilators
• 20-cc syringe for local
anesthesia
ARHP
TISSUE EXAMINATION
• Basin for POC
• Fine-mesh kitchen
strainer
• Back light
• Tools to grasp tissue
and POC
• Specimen containers
Finances Behind Out Patient Tx
• Diagnosis code: 637.9 (Spontaneous Abortion,
without mention of complication)
• CPT Billing codes for in office management vs in
patient management
– 59812 – Treatment of incomplete abortion, any trimester,
completed surgically
– 59820 – Treatment of missed abortion, completed
surgically, first trimester
• Reimbursement issues
ARHP
Conclusions
Evidence demonstrates
• Uterine evacuation can be managed
safely in an out-patient clinic setting
• Moving out of the operating room
– Saves both time, money, resources
– Offers significant both choice & advantages to
both women & clinicians
ARHP
“Never, ever, think outside the box.”
ARHP
CASES
Discussions about MVA
For Outpatient Management of
Miscarriage
ARHP
Case 1 continued
The same 18 yro G2P1001, experiencing mildmoderate cramping with mild-moderate bleeding
in your clinic, and an ultrasound evidence of an
incomplete abortion elects an MVA procedure as
she wants to take care of this as soon as
possible.
You are performing the MVA-all seems to be
going well. However, the aspirator is only about
one-quarter full and you remember from this
course that at this gestational age, you would
expect more tissue than this. You are not sure
whether or not you are done.
ARHP
Case 1 continued
How can you tell if you are done? List 4 signs
suggesting completion.
What do you do?
For “bonus” credit---at what pregnancy age
does the volume of POC become more than 60
cc (equivalent to the volume of the aspirator)?
ARHP
MVA Key Concepts
• MVA safe & effective for early pregnancy loss
in first trimester
• Allows for care that day, in the office, with their
primary provider
• Any uterine evacuation’s efficacy is improved
by systematically checking for completion
ARHP
Case 2 continued
41 yo G2P1001 with an LMP suggesting a 10 week
pregnancy but ultrasound findings revealing
anembryonic pregnancy. The patient decided to
opt for medical treatment.
She took both mifepristone and misoprostol and
is now seeing you for her routine follow-up visit,
scheduled 2 weeks after she took mifepristone.
She has been having persistent spotting, and
says that she is really “sick of it.” Vaginal
ultrasound reveals a non-viable, persistent
gestational sac. Specifically, there is no evidence
of growth but the sac is still present.
ARHP
Case 2 continued
You counsel her about options, including
observation, repeating misoprostol, and surgical
completion. The woman has significant childcare
problems and wants to minimize the number of
visits she must make to your clinic. Therefore,
she requests surgical completion.
ARHP
Case 2 continued
You perform MVA and are partway through the
aspiration when you note that the cannula seems to
be sliding back and forth over the uterine lining too
easily; it feels like nothing is happening.
What could be going on?
What do you do to test your answer to question #1?
How might MVA on this patient be different from
that performed on surgical abortion patients who
have not received mifepristone or misoprostol?
ARHP
MVA Key Concepts
• Helpful to trouble shoot & know how to solve
common MVA problems
• Lack of suction can caused by
– Device not assembled or working properly
– Clogged cannula
• Can never go wrong by stopping & reassessing
ARHP
Case 3 continued
26 yo G2P2002 LMP uncertain because of
irregular periods is at your office for pregnancy
termination with either early intrauterine versus
ectopic pregnancy in the differential. She would
like to deal with it today and with you if possible.
You want to make sure it is not an ectopic
pregnancy….
ARHP
Case 3 continued
Initially, dilitation of the cervix seems slightly
more difficult than usual. However, after the first
two dilator passes, it then progresses
uneventfully. A 6 mm cannula is placed in the os,
the aspirator is connected, and only scant blood
is obtained. Dilitation for correct placement is
attempted again. Again, only scant blood is
obtained.
What do you think is happening?
What do you do now?
ARHP
MVA Key Concepts
• Checking device & placement helpful when not
getting scant or no products back
• Ultrasound helps assess placement of cannula
• MVA can be help diagnose ectopic pregnancy
• Floating products of conception very helpful in
assessing uterine contents (and is easy to do)
ARHP