1. Medical Education Series © 2005 National Abortion Federation E A R L Y O P T I O N S A PROVIDER’S GUIDE TO MEDICAL ABORTION

2. E A R L Y O P T I O N S A PROVIDER’S GUIDE TO MEDICAL ABORTION EARLY VACUUM ASPIRATION: EARLY VACUUM ASPIRATION: AN ALTERNATIVE TO & BACKUP FOR MEDICAL ABORTION

3. Objectives Describe methods of early vacuum aspiration Review the technique of manual vacuum aspiration Describe backup techniques necessary for medical abortion services

4. Overview Efficacy and safety Patient and office preparation Technique and postoperative care Role in medical abortion practice

5. Efficacy With modern techniques, early vacuum aspiration has a low failure rate Failure = reaspiration for continuing pregnancy –Manual vacuum aspiration < 6 weeks’ gestation Failure rate: 0.13% Total reaspiration rate: 0.25% –Manual vacuum aspiration < 12 weeks’ gestation Failure rate: 0% Total reaspiration rate: 0.5% Edwards and Creinin. Curr Probl Obstet Gynecol Fertil 1997 Westfall, et al. Arch Fam Med 1998

6. Safety Early vacuum aspiration (< 6 weeks’ gestation) is safe Advances in medical technology –Ultrasound –High-sensitivity urine pregnancy test Complications rare

7. Medical Abortion/Vacuum Aspiration

8. Features of Vacuum Aspiration Compared to medical abortion, vacuum aspiration: Involves inserting instruments into the uterus Can be done in one visit Is completed in 5-10 minutes Has a high reported success rate (99%) Does not require follow-up in all cases Requires patient participation in a single-step procedure Allows the use of sedation for the procedure if desired

9. Features of Medical Abortion Compared to vacuum aspiration, medical abortion: Generally avoids instrumentation and anesthesia Requires two or more visits Abortion occurs within 24 hours of the second medication for most women Has a high success rate (95-99%) Requires follow-up to ensure completion of abortion Requires greater patient participation throughout a multistep process

10. Overview Efficacy and safety Patient and office preparation Technique and postoperative care Role in medical abortion practice

11. Patient Counseling Clarify pregnancy options and decision Patient who opts for abortion: describe medical abortion and vacuum aspiration –Explain steps of the procedure –Help patient prepare for the experience Obtain informed consent

12. Patient Evaluation and Preparation Pre-abortion assessment for vacuum aspiration similar to medical abortion –Confirm pregnancy –Estimate gestational age –Identify conditions that might make the procedure more difficult Screen for sexually transmitted diseases Antibiotic prophylaxis as indicated

13. Office Preparation: Equipment Suitable exam table and lighting Cannulas and suction source: electric and/or manual Instruments: speculum, tenaculum, dilators, curettes, ring forceps Laboratory services Ultrasound availability Emergency equipment and supplies

14. Ipas syringe Cervical dilator (Pratt)Abortion tray Office Preparation

15. Overview Efficacy and safety Patient and office preparation Technique and postoperative care Role in medical abortion practice

16. Technique: Anesthesia Options Local (cervical anesthesia) Local anesthesia + IV sedation Preoperative NSAIDs useful Deep sedation or general anesthesia when medically indicated

17. Manual Vacuum Aspiration (MVA) vs. Electric Vacuum Aspiration (EVA) MVA Inexpensive Small Portable Quiet Specimen likely to be intact May require repeated reloading of suction EVA More costly but longer life Bulky Less portable Noisy Fragmentation of specimen possible Constant suction

18. Vacuum Aspiration Anesthesia as appropriate Gentle cervical dilation as required “No touch” technique Manual or electric vacuum source Appropriate-size cannula Gross tissue examination required to verify presence of gestational sac

19. MVA Technique: Cervical Dilation © Lisa Peñalver

20. MVA Technique: Create Suction © Lisa Peñalver

21. MVA Technique: Cannula Insertion © Lisa Peñalver

22. MVA Technique: Vacuum Aspiration © Lisa Peñalver

23. MVA Technique: Vacuum Aspiration © Lisa Peñalver

24. Ultrasound and Early Vacuum Aspiration Effect on outcomes remains unclear Decision based on provider preference/experience May help: –Confirm gestational age –Guide cervical dilation/uterine evacuation –Confirm removal of gestational sac –Aid in diagnosis of ectopic pregnancy

25. Tissue Examination Small gestational sacs may be hard to detect Techniques –Strain the aspirate –Use backlighting –Float specimen in tap water, saline, or white vinegar –Magnify specimen

26. Tissue Examination

27. Pitfalls in Tissue Examination Villi alone may not confirm success Lack of gestational sac may indicate ongoing intrauterine or ectopic pregnancy Evaluation of insufficient tissue –Transvaginal ultrasound –Serial hCG monitoring

28. Visual Inspection of the Products of Conception Gestational sac Blood clot Decidua

29. Postoperative Care Length of stay varies with type of anesthesia Excessive pain or bleeding requires medical evaluation Start contraception immediately Rh immune globulin as indicated

30. Overview Efficacy and safety Patient and office preparation Technique and postoperative care Role in medical abortion practice

31. Backup for Medical Abortion: The Role of Counseling Initial visit –Explain differences between the methods –Make sure women realize that vacuum aspiration will be necessary if medical abortion is unsuccessful Maintain vacuum aspiration as an option throughout the medical abortion process

32. Vacuum Aspiration in Cases of Unsuccessful Medical Abortion Vacuum aspiration required in event of medical abortion failure MVA or EVA Often does not require dilation Rarely emergent

33. Conclusion Early vacuum aspiration –Is safe and effective as a primary method of abortion –Can be provided in an office setting Vacuum aspiration is important as a “backup” method for completion of medical abortion –Can be provided in an office setting –Rarely emergent

34. E A R L Y O P T I O N S A PROVIDER’S GUIDE TO MEDICAL ABORTION This educational program does not define a standard of care, nor does it dictate an exclusive course of management. It contains recognized methods and techniques of medical care that represent currently appropriate clinical practice. Variations in patient needs and available resources may justify alternative approaches. Laws governing abortion, informed consent, and medical malpractice vary among states. These materials are strictly for informational purposes, and do not constitute legal advice or representation. These materials are not intended as a substitute for the advice of a health care provider. Neither NAF nor its agents are responsible for adverse clinical outcomes that might occur where they are not expressly and directly involved in the role of primary caregiver. This educational program is protected by copyright. Any unauthorized duplication, reproduction, or alteration of the presentations or any part of the presentations contained therein is strictly prohibited. This educational program is intended for the use of the original recipient and his/her agents and cannot be sold, distributed, transmitted or transferred in any form without prior written authorization by the National Abortion Federation. © 2005 National Abortion Federation