MANUAL VACUUM ASPIRATION

By Laston Kastom, BscBMS(RH),Dip.Clin.Med

INTRODUCTION

It is the method of using suction to remove the tissues from the uterine cavity through a cannula with a
minimal scraping of the uterine wall. This procedure has been in use since early 80’s in industrialized
countries. Apart from a manual vacuum aspiration that uses a specialized syringe we have other types of
vacuum aspirations that use electricity or a foot pump.

INDICATIONS FOR MANUAL VACUUM ASPIRATION

Treatment of incomplete abortion of less than 16 weeks

Treatment of a septic abortion

Collection of endometrial sample for histopathology

Traditional D&C like in the treatment of condition such as endometriosis

Treatment of molar pregnancy

BENEFITS OF USING THE MVA

The risk of complications is reduced

The access to services is increased

The cost of postabortal care services is reduced

The resources used in postabortal care are reduced

MVA Instrument Kits

Basic MVA instruments kits for emergency treatment of incomplete abortion contain either a single-
valve or a double valve 60cc syringe with other accessories like locking valve, plunger handle, collar stop,
and silicone for lubricating the syringe ring, sterile flexible cannulae, cannulae in single valve kits come
in two sizes, 5mm and 6mm in diameter. Those in double valve kits come in six sizes, 6-10 mm and
12mm, with a set of color-coded adapters to fit each cannula to a syringe.

Choice of Equipment

The single and double valve syringes may be used with 5 or 6mm cannulae for treatment of incomplete
abortion up to 8 weeks from LMP.

The double-valve syringe may be used with cannulae up to the 12mm size for treatment of incomplete
abortion within the first trimester
Minimizing the Risk of Infections during MVA

Do hand washing with soap and water before and after each MVA procedure

Use sterile or high level disinfected instruments and gloves on both hands

Clean the cervix and vagina with an effective antiseptic before inserting any instrument through the
cervix and into the uterine cavity.

Use of non touch technique for the MVA procedure

PROCEDURE

Provide emotional support and encouragement, and you give oral, I.M or I.V medication for pain and
wait for a few minutes for the drug to begin the effect. You may sometimes use paracervical block.

Prepare the MVA syringe

 Assemble the syringe

 Close the pinch valve

 Pull back on the plunger until the plunger arms lock.

 Prepare more than one syringe if you are expecting complication like bleeding or more tissues.

Even if bleeding is slight, give oxytocin 10 units IM or ergometrine 0.2mg IM before the procedure, to
make the myometrium firmer and reduce the risk of perforation.

Perform a bimanual pelvic examination to assess the size and position of the uterus and the condition of
the fornices.

Insert a speculum or vaginal retractor into the vagina.

Apply antiseptic solution to the vagina and cervix, especially the os.

Check the cervix for tears or protruding products of conception. If products are protruding or are
present in the vagina or cervix, remove them using a ring or sponge forceps.

Gently grasp the anterior or posterior lip of the cervix with a vulsellum or single toothed tenacullum. If it
is an incomplete abortion, ring or sponge forceps is recommended as it is less likely than the tenacullum
to tear the cervix with traction and does not require the use of lignocaine for placement.

If using tenacullum to grasp the cervix, first inject 1ml of 0.5% lignocaine solution into the anterior or
posterior lip of the cervix which has been exposed by the speculum.

Dilatation is needed only in cases of missed abortion or when products of conception have remained in
the uterus for several days or in molar pregnancy or in endometrial tissue biopsy.
Gently introduce the widest gauge suction cannula

Take care not to tear the cervix or create a false opening.

While gently applying traction to the cervix, insert the cannula through the cervix into the uterine cavity
just past the internal os. Rotating the cannula while gently applying pressure often helps the tip of the
cannula pass through the cervical canal.

Slowly push the cannula into the uterine cavity until it reaches or touches the fundus, but not more than
10cm. Measure the depth of the uterus by dots visible on the cannula and then withdraw the cannula
slightly.

Attach the prepared MVA syringe to the cannula by holding the vulsellum or tenacullum and the end of
the cannula in one hand and the syringe on the other.

Release the pinch valve or valves on the syringe to transfer the vacuum through the cannula to the
uterine cavity.

Evacuate the remain uterine contents by gently rotating the syringe from side to side and then gently
moving the cannula back and forth within the uterine cavity.

To avoid losing the vacuum, do not withdraw the cannula opening past the os of the cervix. If the
vacuum is lost or if the syringe is more than half full, empty it and then re-establish another vacuum.

Avoid grasping the syringe by plunger arms while the vacuum is established and the cannula is in the
uterus. If the plunger arms becomes unlocked, the plunger may accidently slip back into the syringe,
pushing material back into the uterus.

Continue evacuating until you have noted the signs of completion.

SIGNS OF COMPLETION

Red or pinkish foam but no more tissue is seen in the cannula

A grating sensation is felt as the cannula passes over the surfaces of the evacuated uterus.

The uterus contracts around the cannula or grips the cannula.

AFTER COMPLETION

Withdraw the cannula, detach the syringe and place the cannula in decontamination solution.

With the valve open, empty the contents of the MVA syringe into a receiver by pushing on the plunger.
Do not put the syringe into the decontamination solution until you are sure that the procedure is
complete

Remove the speculum or retractors and perform a bimanual examination to check the size and firmness
of the uterus
Quickly inspect the tissues removed from the uterus

 For quantity and presence of the products of conception.

 To assure complete evacuation

 To check for a molar pregnancy

 Tissue specimen can also be sent for histopathology

If you don’t see the products of conception then think of these issues

 All of the products of conception may have been passed before the MVA was performed.

 The uterine cavity may appear to be empty but may not have been emptied completely. Repeat
the evacuation.

 The vaginal bleeding may have not been due to incomplete abortion

 The uterus may be abnormal ( may be the uterus was inserted in the non-pregnant side of the
double uterus)

 May be it is an ectopic pregnancy

So it is required that you rule out these possibilities first.

POST-PROCEDURE CARE

Give paracetamol per os if needed.

Encourage the woman to eat, drink and walk about as she wishes

Offer other services, if possible, including tetanus prophylaxis, counseling or providing family planning
method.

Discharge the uncomplicated cases in one to two hours.

Advise the woman to watch for signs and symptoms requiring immediate attention

 Prolonged cramping ( for more than a few days )

 Prolonged bleeding (more than two weeks)

 Bleeding more than normal menstrual bleeding

 Severe or increased pain

 Fever, chills or malaise

 Fainting
COMPLICATIONS OF MVA

Uterine perforation

Cervical perforation

Severe bleeding (hemorrhage)

Air embolism

PROCESSING OF THE MVA INSTRUMENTS

The basic four steps for processing MVA equipment are decontamination, cleaning, sterilization and
storage or reassembling

Decontamination

Soak all instruments in a 0.5% chlorine solution for ten minute before cleaning. Use gloves when
handling these instruments.

Cleaning

After decontamination, thoroughly wash all instruments including the syringes and cannulae in
lukewarm water with detergent or liquid soap to remove all organic material. And after cleaning you
have to rinse the instrument with clean running water. Always wear gloves.

Sterilization or High level Disinfection

Do not use the steam (autoclaving) or dry heat sterilization on plastic MVA instruments, they may melt.

Chemical sterilants should be used, and these chemical sterilants include Glutaraidehyde 2-4%, it is also
called Cidex. The instruments should be put in this chemical for a minimum of 10 hours. This sterilant is
formaldehyde 8%, and the instruments should be put in this chemical for a minimum of 24 hours.

The metal instruments such as sponge forceps can be autoclaved or boiled or steamed.

Storage and Reassembly

Sterile packs or containers should be labeled with an expiration date and used within 1 week.

When packing the instruments handle with sterile forceps and handle the end of the instrument that
does not an immediate contact with the patient during the time of use.

Store sterile packs or containers in areas with enclosed shelves off the floor to protect them from dust
and debris.

If not used within one week the instrument should be recleaned and resterilised.