Review for indications (inevitable abortion before 16 weeks, incomplete abortion, molar pregnancy or delayed PPH due to retained placental fragments).
Review general care principles.
Provide emotional support and encouragement and give paracetamol 30 minutes before the procedure. Rarely, a
paracervical block may be needed.
Prepare the MVA syringe:
- Assemble the syringe;
- Close the pinch valve;
- Pull back on the plunger until the plunger arms lock.
Note: For molar pregnancy, when the uterine contents are likely to be copious, have three syringes ready for use.
Even if bleeding is slight, give oxytocin 10 units IM or ergometrine 0.2 mg 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
Apply antiseptic solution to the vagina and cervix (especially the
Check the cervix for tears or protruding products of conception. If
products of conception are present in the vagina or cervix, remove them using ring (or sponge) forceps.
Gently grasp the anterior lip of the cervix with a vulsellum or single-toothed
Note: With incomplete abortion, a ring or sponge forceps is preferable as it is less likely than the tenaculum to tear the cervix with traction and does not require the use of
lignocaine for placement.
using a tenaculum to grasp the cervix, first inject 1 mL of 0.5% lignocaine solution into the anterior or posterior lip of the cervix which has been exposed by the speculum (the 10
o’clock or 12 o’clock position is usually used).
Dilatation is needed only in cases of missed abortion or when products of conception have remained in the uterus for several days:
- Gently introduce the widest gauge suction
- Use graduated dilators only if the cannula will not pass. Begin with the smallest dilator and end with the largest dilator that ensures adequate dilatation (usually 10–12 mm)
- Take care not to tear the cervix or to create a false opening.
Inserting the cannula
Slowly push the cannula into the uterine cavity until it touches the
fundus, but not more than 10 cm. 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
tenaculum) and the end of the cannula in one hand and the syringe in the other.
Release the pinch valve(s) on the syringe to transfer the vacuum through the cannula to the uterine cavity.
Evacuate remaining contents by gently rotating the syringe from side to side (10 to 12 o’clock) and then moving the cannula gently and slowly back and forth within the uterine
cavity (Fig P-36).
Note: To avoid losing the vacuum, do not withdraw the cannula opening past the cervical os. If the
vacuum is lost or if the syringe is more than half full, empty it and then
re-establish the vacuum.
Note: Avoid grasping the syringe by the plunger arms while the vacuum is established and the cannula is in the uterus. If the plunger arms become unlocked, the plunger may
accidentally slip back into the syringe, pushing material back into the uterus.
Evacuating the contents of the uterus
- Red or pink foam but no more tissue is seen in the
- A grating sensation is felt as the cannula passes over the surface of the evacuated uterus;
- The uterus contracts around (grips) the
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 strainer by pushing on the plunger.
Note: Place the empty syringe on a high-level disinfected tray or container until you are certain the procedure is complete.
- for quantity and presence of products of conception;
- to assure complete evacuation;
- to check for a molar pregnancy (rare).
If necessary, strain and rinse the tissue to remove excess blood clots, then place in a container of clean water, saline or weak acetic acid (vinegar) to examine. Tissue specimens
may also be sent to the pathology laboratory, if indicated.
- All of the products of conception may have been passed before the MVA was performed (complete abortion);
- The uterine cavity may appear to be empty but may not have been emptied completely. Repeat the evacuation;
- The vaginal bleeding may not have been due to an incomplete abortion (e.g. breakthrough bleeding, as may be seen with hormonal contraceptives or uterine fibroids);
- The uterus may be abnormal (i.e. cannula may have been inserted in the nonpregnant side of a double uterus).
Note: Absence of products of conception in a woman with symptoms of pregnancy raises the strong possibility of
Give paracetamol 500 mg by mouth as needed.
Encourage the woman to eat, drink and walk about as she wishes.
Offer other health services, if possible, including tetanus prophylaxis,
counselling or a family planning method.
Discharge uncomplicated cases in 1–2 hours.
Advise the woman to watch for symptoms and signs requiring immediate attention:
- prolonged cramping (more than a few days);
- prolonged bleeding (more than 2 weeks);
- bleeding more than normal menstrual bleeding;
- severe or increased pain;
- fever, chills or malaise;
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