1. Emergency Treatment Module 2 - Session 2 Uterine Evacuation Methods

2. Module 2 - Session 2 Objectives At the end of this session, participants will be able to: 1.Describe how each method of uterine evacuation works 2.List main advantages/disadvantages of each method 3.Identify the instruments (or parts) used in each method 4.Describe any indications, contraindications and precautions as applicable for each method 5.Describe the counseling appropriate during any uterine evacuation procedure 2

3. Uterine Evacuation Because most complications result from retained products of conception (POC), removal of the contents of the uterus (uterine evacuation) is one of the primary components of emergency treatment. 3

4. Uterine Evacuation Methods The main methods for treatment of first and second trimester incomplete abortion are vacuum aspiration (VA), sharp curettage (SC) and pharmacological methods. Vacuum aspiration is generally preferred to sharp curettage (or D&C) due to lower minor complications rate and reduced need for surgical facilities (WHO, 1994). 4

5. Vacuum Aspiration (VA) Safe and effective method that works by applying suction to remove uterine contents Used in industrialized countries for more than 20 years Suction is produced by a manual syringe, foot pump or electric pump, via a cannula (tube) placed into the cervix 5

6. Manual Vacuum Aspiration (MVA) A safe, effective and low-cost method of uterine evacuation A hand-held vacuum syringe is used to empty the uterus Syringes come as no-valve, single-valve, double-valve and MVA Plus: –No-valve syringes not recommended: Do not create a vacuum until cannula is inserted, increasing risk of uterine perforation 6

7. Single-Valve Syringe with Cannulae 7

8. Double-Valve Syringe with Cannulae 8

9. MVA Plus 9

10. Foot Pump Suction Evacuation (FSE) An alternative device for uterine evacuation. Uses flexible cannulae and is operated by the provider performing the uterine evacuation procedure. Vacuum can be easily obtained. The provider controls the vacuum by digitally occluding with the thumb a small venting port at the point of attachment of the cannulae to the suction tubing. 10

11. Foot Pump Suction Evacuator 11

12. Comparison of MVA and Foot Pump Suction Evacuation A study published in the South Africa Medical Journal compared the foot pump suction evacuator with the manual vacuum aspirator for uterine evacuation. Findings showed that the FSE and MVA were similar in effectiveness and outcomes. The time to perform the FSE was not significantly different in operative blood loss estimation or the time needed to perform the procedure. There were no cases of uterine perforation, cervical injuries or blood transfusions. Both techniques were easy to use. 12 Adapted from: Gaertner et al.,1998.

13. Electric Vacuum Aspiration (EVA) Uses an electric pump and cannulae to evacuate the uterus by providing either intermittent or continuous suctioning. Most devices provide a continuous level of suction. However, newer models may also provide intermittent suction. 13

14. Electric Vacuum Aspiration (EVA) (2) The EVA method has about the same effectiveness as the manual device: –No evidence showing a significant difference in the rate of complications between the two methods. Patient satisfaction is also comparable, aside from the noise level. Due to the electricity requirements and the initial high cost of the machine, EVA may not be the most suitable method where resources are limited. 14

15. Electric Vacuum Aspiration Machine 15

16. Vacuum Aspiration: Advantages MVA and FSE do not require electricity and can be used in remote settings, extending a woman’s access to emergency treatment. EVA, MVA and FSE have the same effectiveness rate. There is no evidence showing a significant difference in the rate of complications. Patient satisfaction for EVA and MVA is also comparable. Flexible cannula (MVA, FSE): –Can reach deep into the uterus even when it is anteverted or retroverted –Rounded tip and narrow width requires little dilatation 16

17. Vacuum Aspiration: Advantages Though VA and sharp curettage (SC) are equally effective for treatment of incomplete abortion, women undergoing VA procedures experience less blood loss and less incidence of uterine perforation than those undergoing SC. 17

18. Vacuum Aspiration: Contraindications (MVA, FSE) Contraindicated for use in clients with: A uterine size over 12 weeks LMP (MVA) Acute cervicitis or pelvic infection, except in an emergency Large fibroids unless emergency back-up is available 18

19. Vacuum Aspiration: Precautions In the following cases, VA should be used with caution, and only in facilities with full emergency backup. Clients with: –History of bleeding disorders Risk of excessive bleeding or hemorrhage –History or suspicion of prior uterine perforation: Risk of injuring the bowel –Severe anemia: Risk of severe shock and death 19

20. Vacuum Aspiration: Precautions (2) Hemodynamic instability (hemorrhage/shock, cardiac disease): –Risk of severe shock and death Uterine fibroids: –Risk of perforation In the presence of infection, proceed only with antibiotic coverage (initiate antibiotics before starting procedure): –The client may require referral to a higher level of care 20

21. Dilatation and Curettage (D&C) Sharp Curettage (SC) WHO recommends that this method be used only when vacuum aspiration is not available. Uses a curette or a similar metal surgical instrument to empty the uterus. Usually performed under general or regional anesthesia, or heavy sedation. Recent studies show that it can be performed as an outpatient procedure in hospitals/some health centers. 21

22. Comparison of Vacuum Aspiration and Dilatation and Curettage CharacteristicsVacuum Aspiration (EVA) Dilatation and Curettage (D&C) Effectiveness Rate98%99% PainLess painIncreased pain ComplicationsFewer minor complications than D&C Increased bleeding (may be due to use of anesthesia) 22

23. Comparison of VA and SC MVA: Vacuum suction with plastic cannula, lowering the risk of uterine perforation Minimal cervical dilatation required Analgesia, light sedation and/or local anesthesia can be used Can be performed by midwife, general MD or other trained health provider Outpatient procedure, reducing the need for hospital stay 23 D&C: Scraping with sharp, metal curette, increasing the risk of uterine perforation Mechanical dilatation often required Heavy sedation, analgesia and/or general anesthesia often used Usually performed only by trained gynecologist or general MD Operating theater procedure, often requiring hospital stay

24. D&C Instruments 24 Source: www.HealthAtoZ.com 2004.

25. Indications for Sharp Curettage (SC) Sharp curettage has been effectively used for many conditions. Some of the indications include: –Excessive vaginal bleeding –Abnormal vaginal bleeding –Polyps –Incomplete abortion: When VA not available –Molar pregnancy: Risk of uterine perforation is high with SC; VA may be safer and associated with less blood loss –Diagnostic: Endometrial cancer Determine cause of vaginal bleeding 25

26. Pharmacological Methods of Uterine Evacuation: Misoprostol A prostaglandin initially developed to treat gastrointestinal problems: –Prostaglandins are a group of chemicals made by nearly all of the body's cell membranes. Different prostaglandins have different effects on the body: –They can help treat inflammation and pain, raise or lower blood pressure, affect the immune system and stimulate uterine contractions and labor. 26

27. Pharmacological Methods of Uterine Evacuation: Misoprostol (2) Research indicates that 600 ug of misoprostol (oral) is an effective dosage for use in postabortion care. Studies for sublingual dosage amounts for use in postabortion care are ongoing. WHO has included misoprostol on its list of essential medicines for miscarriage and incomplete abortion. 27

28. Expectant Management Spontaneous abortion with partial expulsion of POC sometimes resolves itself as part of the natural process. Over time, the remaining uterine contents will be expelled without any intervention. Expectant management is allowing this process to take place. During this time, the provider must monitor the client for signs of complications and make sure the complete evacuation of uterine contents has occurred. 28

29. Indications for Expectant Management Expectant management should be carried out only under the following circumstances: –Clients with uncomplicated spontaneous abortions –Availability of skilled care and emergency services in case of complications –If possible, ultrasound and hCG monitoring capability should be available 29

30. Uterine Evacuation: Integrating Counseling Counseling should be integrated throughout postabortion care (before, during, after). The content, context and timing of counseling will differ from client to client. Explain all counseling and health care information in the language that the client understands. Explain any medical terms and always encourage the client to ask questions or express any concerns she may have. 30