MVA

Prof. Ashis Kumar Mukhopadhyay Professor, G & O Medical Superintendent-cum-Vice Principal CSS College of Obstetrics & Gynaecology, Kolkata National Chairperson, Medical Education Committee of FOGSI

WHAT IS MVA ? MVA meaning Manual Vacuum Aspiration – a surgical method of TOP to enhance safe abortion within the 1st trimester of pregnancy (WHO-2003). MVA actually is the resurrcation of original MR method by MR syringe & Karman canulae.

With the expectation that MM & Morbidity will be reduced, but on the contrary it is seen that the no. of unsafe abortions have much more increased with a disastrous result on MM & Morbidity.

So new techniques started becoming introduced for safe abortion & MVA is one of them. This method is safe, simple, effective and economical too.

Parivar Seba Sangstha (PSS), a national level NGO for quality abortion and family planning procedures – has experiences on MVA for more than 25 years. They also have the same experience in their Kolkata branch. 95% - MVA 5% - Med. Abortion

Manual Vacuum Aspiration Safe & updated technology for termination of 1st Trimester Pregnancy Recognized by FIGO, WHO, GOI, NAF, USAID for Post Abortion Care and World Bank

Mechanism of Action MVA acts via vacuum extraction of the uterine contents through a cannula Cannula is attached to the vacuum syringe which has been previously charged and locked having created vacuum in the syringe Vacuum extracts the entire contents of the uterus with minimal damage to the lining of the uterus

Origin The Single Valve Syringe, the earlier version originated in the USA in early 70's Karmen (Batelle Labs) Was studied intensively in India and around the world Single valve syringe was originally designed to be a technique of Menstrual Regulation

Double Valve MVA Syringe Designed to evacuate the uterus up to 12 weeks Proven safe and effective for termination of incomplete abortion, endometrial biopsy and backup for medical abortion

MVA - Features Flexible Plastic Cannulae Manual Vacuum Syringe with double valve adapter Portable Non-Electric Practical use in Medical Office, Clinic or Hospital

Summary of Studies Effectiveness of EVA - MVA Patients Efficacy Induced Abortions EVA : 37 MVA : 9 EVA : 385,000 MVA : 15,000 98% Incomplete EVA : 15 MVA : 4 EVA : 3,600 MVA : 1,400 * Effectiveness defined as complete evacuation - Adapted from Greenslade et al., 1993

Recent Clinical Experience Edward 1997 2399 MVA procedures of less than 6 weeks, found to be effective in 99.2% of cases Westfall et al 1998 1677 MVA procedures, of less than 10 weeks, found to be effective in 99.5% of cases FOGSI Multicentric study 2001 926 Cases between 6-12 weeks, found to be effective in 98.6% of cases

Comparison between Two Contemporary Methods Manual Vacuum Aspiration (MVA) Electrical Vacuum Aspiration (EVA) - Takes 1 Second to create 26” (660mm) Hg Vacuum - 360O Rotation possible because of easy maneuverability - Pre-created vacuum gets transferred to the uterine cavity which is highly effective - Takes 1-1.5 minutes to create 26” Hg Vacuum - 180O Rotation possible on either side because of kinking of tubing - Vacuum is created gradually in the uterine cavity, hence less effective

Comparison between Two Contemporary Methods Electrical Vacuum Aspiration (EVA) Manual Vacuum Aspiration (MVA) - Pre created transfer of vacuum helps to find cleavage between the sac and the endometrial lining. This allows sac to get sucked into the aperture of the cannula en mass causing minimum bleeding - Since vacuum takes time to reach 26” of Hg, not possible to create cleavage easily and therefore, material comes in pieces causing more bleeding

Comparison between Two Contemporary Methods Manual Vacuum Aspiration (MVA) Electrical Vacuum Aspiration (EVA) - In case of uterine perforation, the vacuum drops to less than 10mm of Hg and therefore, prevents sucking of mesentery or intestines - In case of perforation, the vacuum creation continues endangering pulling out mesentery or intestines if plugged into the aperture of cannula

EVA Vs MVA Comparison of 5 week’s gestation Removed with electric suction machine (left) and MVA syringe (right) From: Creinin and Edwards, Curr Problems in Obs Gyn Fert, 20 (1) 1997

INSTRUMENTS

MVA Plus Aspirator (recent) Can be autoclave at 1210 c with a pressure of (15 lbs/in2)

Colour coated & graduated canulae – they can also be autoclaved

Close the pinch valve of an assembled syringe Loading the Syringe Close the pinch valve of an assembled syringe Prepare the Syringe Step 1: Close the pinch valve. Begin with the valve buttons open and the plunger pushed all the way into the barrel. Close the valve by pushing the buttons down and forward until they lock into place.

Withdraw plunger till catcher arms locked Creation of Vacuum Create the Vacuum Create the vacuum by grasping the barrel (do not grasp the valve piece) and pulling back on the end of the plunger until the arms of the plunger snap outward at the end of the syringe barrel, holding the plunger in place. Check the stable positioning of the plunger arms. Both plunger arms must be fully extended to the sides and secured over the edge of the barrel. With the arms snapped in this position, the plunger will not move forward and the vacuum is maintained. Incorrect positioning of the arms could allow them to slip back inside the barrel, possibly pushing the contents of the syringe or air into the uterus. Never grasp the syringe by the plunger arms. It is a good idea to check the syringe once it is assembled and before its use. Leave the syringe for several minutes with the vacuum established. Open the pinch valve by releasing the buttons. You should hear a rush of air into the syringe, indicating that there was a vacuum in the syringe. If you do not hear a rush of air, follow instructions in the product literature for lubricating the o-ring and test the vacuum again. Replace the o-ring or use another syringe if the syringe still will not hold a vacuum. Withdraw plunger till catcher arms locked

Serial insertion with gentle rotatory movements Insertion of Cannulae Inserting Cannula Select the cannula size based on the size of the uterus. Some people use a cannula that corresponds to the weeks gestation (e.g., 7mm at 7 weeks); others use a cannula one or two sizes smaller than the weeks gestation (e.g., 6mm at 7 weeks). It is important not to dilate the cervix beyond the size of the appropriate cannula. It is advisable to have several cannulae of several sizes on hand. Insert the cannula into the uterine cavity until it touches the top of the fundus, and then withdraw the cannula slightly. Note uterine depth. Attach syringe, taking care not to push cannula further into uterus OR attach the charged syringe to the cannula prior to inserting the cannula through the cervical os. Serial insertion with gentle rotatory movements

Pinch valve released to create intrauterine vacuum MVA Procedure Pinch valve released to create intrauterine vacuum Releasing the Pinch Valve The pinch valve is opened by releasing both buttons. When the pinch valve is released, the vacuum is transferred through the cannula to the uterus. Blood, tissue, and bubbles will flow through the cannula into the syringe.

Back & forth & rotatory movements of cannula Evacuation of Uterus Back & forth & rotatory movements of cannula Evacuating the Uterus Evacuate the contents of the uterus by moving the cannula gently and slowly back and forth within the uterine cavity, rotating the syringe as you do so. It is important not to withdraw the cannula aperture(s) beyond the cervical os, as this will cause the vacuum to be lost. If this happens, follow the instructions to re-establish the vacuum. Blood and tissue will rush into the MVA syringe barrel. If the barrel becomes full and the procedure is not complete, detach the syringe from the cannula, empty it, reestablish the vacuum, and continue the procedure. While the vacuum is established and the cannula is in the uterus, never grasp the syringe by the plunger arms to ensure that the plunger arms do not move from their locked position on the rim of the barrel. Accidentally allowing the plunger to slip back into the syringe may eject tissue or air back into the uterus.

Care of Instruments Care of instruments comprises of following steps : Decontamination Cleaning High Level Disinfection (HLD) or Sterilization Storage / Reassembly

Processing of the Instruments Syringe & cannulae decontaminated in a bleach solution for 10 minutes (optional) Wash well with detergent and water Soak in 2% Glutaraldehyde (Cidex) or 0.5% chlorine solution for 20 minutes Do not boil the Syringe or use any heat technique or autoclave

Cervical Ripening : For pregnancies up to eight weeks, no priming is required. For pregnancies of 9-12 weeks in nulliparous women and <18 years old. Prostaglandin in cervical ripening Prostodin – 250mcg by intramuscular injection 45 minutes before the procedure. Misoprostol – 400mcg tablet administered either vaginally or sublingually/orally 3-4 hours before the procedure.

The instruments are reusable (disposable in developed countries), provided those are very well maintained. The aspirators described, could be reused from 50-200 times and the new canulae can be reused for 10 – 20 times.

Post Operative Contraception :

For pain control, Para cervical block – all that is necessary for complete evacuation A sedative or anxiolytic may be necessary if the patient is apprehensive

MAJOR COMPLICATIONS OF MVA (12,888) 24,000 (2003-06) D & C 0.15 – 28 Excess bleeding 0.4 0.06% Pelvic infection 0.01 0.01 0.7 – 8 Cervical injury 0.02 0.025% 0.3 – 6.4 Uterine perforation 0.04% 0 – 3.3 Laufe, 1977 PSS (Kolkata) Greenslade et al 1993

EFFICACY : Several authors have shown that the efficacy of MVA in general - 98% Gestation Number Effectiveness Hemin et al 2001, Sweeden <8 wks N = 91 > 97% Fogsi Multicentric Study 2001, India <6-12 wks N = 926 98.6% Edward & Creinin 1997, USA < 6 wks N = 2,399 > 99% Westfall et al. 1998, USA < 12 wks N = 1,677 99% Greenslade, 1993 Within 12 wks N = 15,000 97% PSS, Kolkata, India (2003-2006) 8-12 wks N = 24,000 98.5%

MVA – in Low tech rural & High tech urban : Limited access to medical facilities Non availability of reliable equipment MVA is – portable instrument, can be used as an OPD procedure. Erratic electricity supply High tech urban Accidental perforation – no damage to the abdominal organs because of dropping vacuum. Client friendly procedure – surgeon can continue to speak to the patient. Appreciation of minimally invasive concept. MVA Pilot Project – GOI, FOGSI & WHO

OTHER USES OF MVA There are other uses of MVA and they are:- Endometrial Biopsy / sampling (using 4mm cannulae) Blighted ovum Hydatidiform mole Incomplete abortion

CONCLUSION To conclude, MVA technology can be used as the first line surgical method for uterine evacuation within 1st trimester of pregnancy. MVA is safe, simple and effective & a low cost procedure, reusable for many many times. The method is highly recommended by FIGO, FOGSI, WHO & GOI. MVA today is considered as the NEW GOLD STANDARD for early abortion and there is no place for other traditional method like D & C. (ICPD, WHO, FIGO, 1997)