Transcript What`s an incomplete? - University of Washington

Manual Vacuum Aspiration (MVA)
for Early Pregnancy Loss
Sarah Prager, MD
Department of Obstetrics and Gynecology
University of Washington
Adapted from the Association of
Reproductive Health Professionals,
Washington, DC, USA
Incidence of Early
Pregnancy Loss
≤ 20 weeks’
gestation
12%–24% of
pregnancies
600,000
to 800,000
annually
Griebel CP, et al. Am Fam Physician. 2005.; Everett C. BMJ. 1997.
Smith NC. Contemp Rev Obstet Gynecol. 1988.; Stirrat GM. Lancet. 1990.
What Is a Manual Vacuum
Aspirator?
•Has locking valve
•Is portable and reusable
•Vacuum is equivalent to
electric pump
•Efficacy is same as electric
vacuum (98%–99%)
•Has semi-flexible plastic cannula
Creinin MD, et al. Obstet Gynecol Surv. 2001.; Goldberg AB, et al. Obstet Gynecol.
2004.’ Hemlin J, et al. Acta Obstet Gynecol Scand. 2001.
Comparison of EVA to MVA
EVA
MVA
Vacuum
Electric pump
Manual aspirator
Noise
Variable
Quiet
Portable
Not easily
Yes
Cannula
4–16 mm
4–12 mm
Capacity
350–1,200 cc
60 cc
Suction
Constant
Decreases to 80% (50 mL) as
aspirator fills
Dean G, et al. Contraception. 2003.
Clinical Indications for MVA
 Uterine evacuation in the first trimester:
• Induced abortion
• Spontaneous abortion




Incomplete medication abortion
Uterine sampling
Post-abortal hematometra
Hemorrhage
Creinin MD, et al. Obstet Gynecol Surv. 2001.; Edwards J, Creinin MD. Curr Probl Obstet Gynecol
Fertil.1997.; Castleman LD et al. Contraception. 2006; MVA Label. Ipas. 2007.
Using MVA for treatment/completion
of spontaneous abortion




Treatment for spontaneous abortion
Ensures POC are fully evacuated
Comfortable for woman due to low noise level
Portable for use in physician office familiar to the
woman
 Women very satisfied with method
• Very few studies on MVA in spontaneous abortion
MVA Label. Ipas. 2007.
MVA Instruments
Steps for Performing MVA
A step-by-step, onepage poster
is available from the manufacturer to
guide clinicians through the procedure
Products of Conception (POC)
Procedure is complete when POC are identified
Electric Suction
Machine
Edwards J, et al. Am J Obstet Gynecol. 1997.
MacIsaac L, et al. Am J Obstet Gynecol. 2000.
MVA
Aspirator
Moving Out of the
Operating Room
Miscarriage Management:
Why the OR?
Current practices developed when
•
•
•
•
Abortion was illegal
Uterine evacuation was an emergency
Antibiotics were not available
Access to blood transfusion was very limited
“Puerperal (childbed) fever was the scourge of
nineteenth-century obstetrics and abortion.”
- Joffe 1999
Advantages of Moving Treatment from
OR to Outpatient Setting
• Avoid the repeated exams that often occur in
the hospital
• Simplify scheduling and reduce wait time
 Average OR waiting time in U.K.-based study:
14 hours, with 42% of women not satisfied
• Save resources
• Avoid cumbersome OR protocols
 Prolonged NPO requirements & discharge
criteria
Demetroulis 2001; Lee and Slade 1996
Advantages of Moving Treatment from
OR to Outpatient Setting (continued)
• Office affords more treatment options
•
•
•
•
 Vacuum aspiration or misoprostol
 Pain management choices
Improved patient autonomy and
privacy
Convenience
Personalized care
Patient education
Lee and Slade 1996
Moving Incomplete Abortion to an
Outpatient Setting: Johns Hopkins
Methods
• N = 35, incomplete first-trimester
abortion
• Compared treatment with MVA in
labor and delivery vs. conventional
care (suction curettage in OR)
Blumenthal and Remsburg 1994
Moving Incomplete Abortion to
Outpatient Setting: Johns Hopkins
Results
• Decreased anesthesia requirements
• Decreased overall hospital stay, from 19 to
6 hours
• Decreased patient waiting time by 52%
• Decreased procedure time, from 33 to 19
minutes
• Decreased costs per case:
 $1,404 in OR
 $827 in L&D
 $200 or less in ER
Blumenthal 1994
Moving Incomplete Abortion to
Outpatient Setting: Johns Hopkins
Cost Comparisons
Charges
Admission
Supplies
Anesthesiology
___________________
Total Hospital Charges
Outpatient
MVA
OR Procedure
Mean ($) Mean ($)
10
58
6
137
125
85
_______
________
$ 827
$1404
$577 saved per procedure with MVA
Blumenthal 1994
Use Caution in Women
with…
•
•
•
•
•
Uterine anomalies
Coagulation problems
Active pelvic infection
Extreme anxiety
Any condition causing the patient to
be medically unstable
Complications with MVA
 Very rare
 Same as EVA
 May include:
•
•
•
•
•
MVA Label. Ipas. 2004.
Incomplete evacuation
Uterine or cervical injury
Infection
Hemorrhage
Vagal reaction
MVA vs. EVA Complication
Rates
Methods
 Vacuum aspiration for abortion up to 10 wks
LMP
 Retrospective cohort analysis
 Choice of method (MVA vs. EVA) up to
physician
 n = 1,002 for MVA; n = 724 for EVA
 Charts reviewed for complications
more…
Goldberg AB, et al. Obstet Gynecol. 2004.
MVA vs. EVA Complication
Rates (continued)
Complications
• 2.5% for MVA
• 2.1% for EVA (p = 0.56)
• No significant difference
*Elective not spontaneous studies
Goldberg AB, et al. Obstet Gynecol. 2004.
more…
MVA vs. EVA Complication
Rates (continued)
Choice of MVA vs EVA in
procedures
• Attendings:
52% MVA
• Gyn residents: 59% MVA
• Other residents: 76% MVA
(p<0.001)
Goldberg AB, et al. Obstet Gynecol. 2004.
Early Abortion with MVA:
Study
• Methods
• 2,399 MVA procedures, < 6 weeks LMP
• Meticulous inspection of POC immediately after
MVA
• Results
• 99.2% effective in terminating pregnancy
• 6 repeat aspirations (0.25%)
• 14 ectopic pregnancies (0.6%) diagnosed and
treated
Edwards J, Creinin MD. Curr Probl OIbstet Gynecol Fertil. 1997.
MVA and POC: Study
• In group overall
• n = 1,726, up to 10 weeks LMP
• Complication rates between MVA and EVA
• 37 patients at < 6 weeks’ gestation
• In 35 of 37, provider chose MVA
• No re-aspirations needed in patients < 6 weeks
more…
Goldberg AB, et al. Obstet Gynecol. 2004.
MVA and POC: Study (continued)
“…Significantly more re-aspirations for
inability to accurately identify the
pregnancy occurred in electric group.”
Goldberg AB et al.
Obstet Gynecol, 2004
Goldberg AB, et al. Obstet Gynecol. 2004.
Patient Satisfaction
• Both EVA and MVA groups were highly
satisfied
• No differences in:
•
•
•
•
•
Pain
Anxiety
Bleeding
Acceptability
Satisfaction
• More EVA patients were bothered by noise
Bird ST, et al. Contraception. 2003.; Dean G, et al. Contraception. 2003.;
Edelman A, et al. Am J Obstet Gynecol. 2001.
MVA Safety and Efficacy:
Summary
• MVA is simple
• Easily incorporated into office setting
• Training/Practice Issues
•
•
•
•
•
Expanding pain management options
Ultrasound as needed
No sharp curettage
Patient-provider interaction
Instrument processing for multiple use (new
guidelines)
MVA and Pain
Pain is made worse by:
 Fearfulness
 Anxiety
 Depression
Belanger E, et al. Pain. 1989.; Smith GM, et al. Am J Obstet Gynecol. 1979.
Hansen GR, Streltzer J. Emerg Med Clin N Am. 2005.
Effective Pain Management
 Respectful, informed, and supportive
staff
 Warm, friendly environment
 Gentle operative technique
 Women’s involvement
 Effective pain medications
Pain Management
Techniques
With addition of:
• Focused breathing: 76%
• Visualization: 31%
• Localized massage: 14%
General or nitrous
10%
32%
Local
+ IV
58%
Local
Lichtengerg ES, et al. Contraception. 2001.
Good M, et al. Pain Manag Nurs. 2002.
Paracervical Block
Regular Injection
Castleman L, Mann C. 2002.
Maltzer DS, et al. 1999.
Deep Injection
Efficacy of Ancillary
Anesthesia
• Importance of psychological preparation
and support
• Music as analgesia for abortion patients
receiving paracervical block
• 85% who wore headphones rated pain as “0,”
compared with 52% of controls
• Verbicaine (“Vocal Local”)/Distraction
Therapy
Shapiro AG, Cohen H. Contraception. 1975.
Stubblefield PG.Suppl Int J Gynecol Obstet. 1989.
Sharp Curettage and Pain
 Often requires
increased
dilatation
 Often painful
 More difficult to
reduce
anesthesia
Forna F, Gulmezoglu AM. Cochrane Library. 2002.
Sharp Curettage and MVA
 Generally not indicated
 Not routinely recommended after MVA
more…
WHO. 2003
Ultrasound and MVA
 Not required for
MVA
 Used by some
providers routinely
 Use contingent on
provider
preference and
experience
Word Health Organization. 2003.
Counseling for MVA
Effective counseling occurs
before, during, and after the
procedure
•Woman-centered
•Structured completely
around the women’s needs
and concerns
more…
Breitbart V, Repass DC. J Am Med Womens Assoc. 2000.; Hogue CJ, et al.
Epidemiol Rev. 1982; Steward FH, et al. 2004. Hyman AG, Castleman L.
2005
Counseling for MVA (continued)
• Prepare women for
procedure-related effects
• Address women’s concerns
about future desired
pregnancies
more…
Breitbart V, Repass DC. J Am Med Womens Assoc. 2000.; Hogue CJ, et al.
Epidemiol Rev. 1982; Steward FH, et al. 2004. Hyman AG, Castleman L.
2005
Counseling for MVA (continued)
Quality of
counseling
Picker Institute. 1999.
Patient
satisfaction
with care
Post-Procedure Care
• Observe for complications
• Bleeding
• Pain
• Monitor pain and treat accordingly
 Monitor vital signs
 Check bleeding and pain
more…
Post-Procedure Care (continued)
 Give instructions for aftercare/follow-up
 Discuss contraception, if appropriate
 Discharge patient
• Tolerates oral intake (general anesthesia only)
• Vital signs are normal
• Bleeding is minimal
Lichtenberg ES, Shott S. Obstet Gynecol. 2003.
Instructions for Aftercare
 Warning signs to call a
clinician
 Pain management options
 Prophylactic antibiotics
• Many regimens effective
 When to return to normal
activities
Lichtenberg ES, Shott S. Obstet Gynecol. 2003.
When Women Should Contact
Clinician
 Heavy bleeding with dizziness,
lightheadedness
 Worsening pain not relieved with
medication
 Flu-like symptoms lasting >24 hours
 Fever or chills
 Syncope
 Any questions
For more information on
EPL
• Association of Reproductive Health
Professionals (ARHP) archived webinar:
Options for Early Pregnancy Loss: MVA and
Medication Management
www.arhp.org/healthcareproviders/cme/webc
me/index.cfm
• Ipas WomanCare Kit for Miscarriage
Management
www.ipaswomancare.com
Questions?
Papaya Model Demonstration and
Practice to Follow