1. Management of Early Pregnancy Failures in the Outpatient Setting
Emily Godfrey MD MPH
Michelle Forcier MD MPH
ARHP National Conference 2006
Pre-Conference Workshop

2. Objectives
Appreciate the historical context regarding terminology, diagnosis, and management of early pregnancy failure and how it has evolved
Recognize the various presentations and classifications of early pregnancy failure
List new and different treatment options currently available for early pregnancy failure
Describe new data suggesting a role for misoprostol in the management of early pregnancy failure
Describe the current standard treatment using MVA for early pregnancy failure

3. Early Pregnancy Failures
Incidence:
15-20% clinically recognized pregnancies
Estimated 30% if non-clinically recognized pregnancies are included*
80% occur in first trimester
* Wilcox NEJM 1988

4. Types of Early Pregnancy Failure
Threatened
Inevitable*
Uterine cramping
Dilated cervical os
Incomplete*
Inevitable with passage of some POCs
Missed*
Closed os
Septic
Complete
No uterine cramping
Cervical os closed
Complete passage of tissue
* Early Pregnancy Failure

5. History of the Management of EPF
Pre 1880
Less is better
Post 1880
Development of curette
Reduction of hemorrhage
Reduction of infection
Intervention advocated because high rates of infection accompanying illegal abortion
In the 1880s there were no antibiotics nor means for blood transfusions. The doctors during this time it was best to leave the patient alone and let nature take its course and for her to naturally rid the products of pregnancy.
After 1880, the curette was developed. At this point, doctors started to intervene in the treatment of spontaneous abortion. They found that more women survived because the quicker they treated the women, the less they bled and the less they developed uterine infections. Infection was fairly common in the United States when abortion was restricted because women often self-induced with unclean instruments.
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6. Management of EPF Today Alternative treatment options
D & C still remains the standard of care despite decreased incidence of septic abortion
Potential complications
Risk of anesthesia
Uterine perforation
Intrauterine adhesions
Cervical trauma
Pelvic Pain
Increased risk of ectopic pregnancy (subsequent)
Alternative treatment options
Manual vacuum aspiration
Medical management with prostaglandin analogues (i.e. Misoprostol)*
Expectant management
Surgical curettage is still the most commonly used treatment for miscarriage. However d and c of the uterus under anesthesia has certain morbidity such as the risk of anesthesia, uterine perforation, intrauterine adhesions (Asherman’s Syndrome) cervical trauma and infections leading to infertility, pelvic pain and increased chance of ectopic pregnancy. In addition, the patients occupy beds, operating room, contributing to substantial cost to treatment.
Currently, there are alternative treatments to spontaneous AB:
MVA . The manual vacuum is a 60 cc syringe with a plastic cannula that is inexpensive and useful alternative to the electric vacuum. It was first described for the treatment of incomplete abortion in It can be used in the out-patient setting with local anesthesia. The procedure takes about 5 minutes.
A cost analysis using the MVA versus D & C was done on 35 women less than 12 weeks gestation with spontaneous ab. They found a 41% reduction in cost with MVA use in the out-patient setting compared with D & C in the operating room.
I will discuss further spontaneous AB with misoprostol
Expectant management has been well documented that in hemodynamically stable without signs of infection patients, it can be just as effective as D & C. These patients are usually managed symptomatically and with serial Beta HCGs. Several studies have showed fewer perforations, infection
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7. Expectant management
In the setting of incomplete abortion expectant management is successful 82-96% of the time
Average time to completion is 9 days
Success rate is less for embryonic death or anembryonic gestations (missed abortions) (25-76%)
First trimester miscarriages may be expectantly managed indefinitely if without hemorrhage or infections
Griebel C, Halvorsen J, Golemon T and Day A, Management of Spontaneous Abortion, AFP October
Griebel AFP 2005
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8. Success of expectant management
Group N
Complete day 7
Complete day 14
Success day 49
Incomplete
221
117 (53%)
185 (84%)
201 (91%)
Missed
138
41 (30%)
81 (59%)
105 (76%)
Anembryonic 92
23 (25%)
48 (52%)
61 (66%)
TOTAL
451
181 (40%)
314 (70%)
367 (81%)
Luise C. BMJ 2002

9. Misoprostol (Cytotec)
Prostaglandin E1
FDA approved for prevention and treatment of gastric and duodenal ulcers
Heat stable (does not need refrigeration)
Inexpensive
Widely available
Oral preparation
100 g (non-scored) & 200 g (scored) tablets
Belong to family of Eicosanoids, which are active metabolites of arachidonic acied
In the prostaglandins, the E-series (for example dinoprostone and sulprostone) and F-series are the most important. E-series are more uteroselective and are superior in cervical ripening.
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10. Misoprostol: Physiologic Effects
Uterine: Stimulate contractions
Cervical Softens and primes cervix
Gastrointestinal: Prevents/treats ulcers
Nausea
Vomiting
Diarrhea
Systemic: Fever
Acts on smooth muscle receptors
In contrast to oxytocin, prostaglandins not only have an effect on myometrial contractility, but they also accelerate the phsiological cervical ripening.
Prostaglandin receptors are always present in myometrial tissue, whereas oxytocin receptors develop during the later part of pregnancy.
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11. Routes of Administration
Oral
Vaginal
Buccal
Sublingual
Rectal

12. Vaginal Use Manufactured and approved for oral use only
Greater effects on reproductive tract with vaginal dosing*
Decreased gastrointestinal side effects with vaginal dosing*
*Danielsson 1999
Creinin 1993
Toppozada 1997

13. Buccal & Sublingual Use
Mostly been studied with the use of induced medical abortion
Sublingual has faster absorption than buccal*
Buccal as effective as vaginal in induced medical abortion up to 56 days’ gestation
Sublingual as effective as vaginal misoprostol in induced medical abortion up to 63 days’ gestation
*Schaff, EA et al. 2005
*Tang, OS et al 2006
Middleton, T et al 2005

14. Surgical options
Sharp curettage (D and C) no longer an acceptable option due to higher complication rates
Vacuum aspiration includes manual vacuum aspiration (MVA) vs. electrical pump aspiration

15. MVA Instruments and Supplies
Inexpensive
Small
Portable
Quiet
Specimen likely to be intact
May require repeated reloading of suction
MVA Instruments and Supplies
This slide shows MVA instruments and cannulae from several manufacturers. The MVA technique described in this slide presentation uses a double valve syringe, shown here in the upper right. Refer to directions for use with each manufacturer’s product.
Necessary equipment includes:
MVA syringe
Cannulae
Speculum
Tenaculum
Dilators or misoprostol.
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16. Literature Review
Standard dosage and dosing intervals have not been well established
Studies difficult to compare
Various patient populations and dosing regimens
Different routes of administration
Varying definitions of success
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17. Incomplete and Missed AB
Demetroulis et al, 2001
Prospective RCT
80 women w/missed AB or incomplete AB
Misoprostol vs. Surgical evacuation
Results:
82.5% successful in Misoprostol group
Failure rate higher for Missed AB patients (23% v. 7%)
Demetroulis. Human Reproduction, 2001

18. Missed Abortion Wood et al, 2002
Double blind randomized controlled trial (Type I study)
50 women
Ultrasound dx of missed ab
Absence of cramping and bleeding
Less than 12 weeks uterine size
800 g misoprostol – up to 2 doses
Vaginal versus placebo
Follow-up
24 hours, 48 hours, 1 week
Population: ultrasound diagnosis- embryonic fetal pole greater than 7mm without cardiac activity, irregular gestational sac with a mean size greater than 16 mm2, or 15 mm gestational sac without fetal pole
Wood and Brain, Obstet Gynecol 2002
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19. Missed Abortion Misoprostol Placebo
15 of 25 completed after first 24h
21 of 25 completed after second 48h
2 had on-going bleeding
1 had retained tissue
Placebo
1 of 25 completed 48h
4 of 25 1 week
No significant change in hemoglobin levels
Population: ultrasound diagnosis- embryonic fetal pole greater than 7mm without cardiac activity, irregular gestational sac with a mean size greater than 16 mm2, or 15 mm gestational sac without fetal pole
Wood and Brain, Obstet Gynecol 2002
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20. Comparison of surgical with medical management: EPF
Zhang et al, 2005
Prospective, RCT
652 w/ 1st trimester pregnancy failure
Anembryonic
Embyronic or fetal death
Incomplete
Inevitable
Misoprostol 800 g, repeat day 3
Vaginal versus surgical evacuation
Complications
Surgical treatment for the miso group
Repeat surgical procedure within 30 days
Zhang. NEJM 2005
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21. Comparison of surgical with medical management: EPF
Results
Misoprostol Group
71% complete by Day 3
84% complete by Day 8
Treatment Failure
16% Misoprostol group
3% Surgical group
Conclusions
Treatment of EPF with Miso is safe and works about 84% of the time
Zhang. NEJM 2005
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22. Missed Abortion Using Sublingual Misoprostol
Tang, et al, 2006
Prospective randomized controlled trial
180 women
Ultrasound dx of missed ab
Absence of cramping and bleeding
Less than 13 weeks uterine size
600 g sublingual misoprostol Q 3 hours x 3 vs 400 g sublingual misoprostol daily x 1 week
Results at 1 week
92% completed in SL x 3 group
93% complete in SL x 3 + daily group
Greater side effects reported in the SL x 3 + daily group
Population: ultrasound diagnosis- embryonic fetal pole greater than 7mm without cardiac activity, irregular gestational sac with a mean size greater than 16 mm2, or 15 mm gestational sac without fetal pole
Tang. Hum Reprod 2006
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23. Early Pregnancy Failure Treatment Using Mifepristone/Misoprostol
Trinder, et al, 2006
Prospective randomized controlled trial
Miscarriage Treatment Trial (MIST)
1200 women
Less than 13 weeks gestation
Incomplete miscarriage, Anembryonic, Missed abortion
Expectant vs. Medical vs. Surgical
Incomplete: 800 miso only vaginal
Anembyronic/Missed: 200 mife miso hr
Primary outcome: infection within 14 days
Secondary outcome: efficacy (no D & C within 8 weeks)
Population: ultrasound diagnosis- embryonic fetal pole greater than 7mm without cardiac activity, irregular gestational sac with a mean size greater than 16 mm2, or 15 mm gestational sac without fetal pole
Tinder. BMJ 2006
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24. Early Pregnancy Failure Treatment Using Mifepristone/Misoprostol
Results
Gynecological Infection
No difference between the groups
Anembyronic/Missed
6% Surgical group
38% Medical group
50% Expectant group
Conclusions
Infection rates did not differ between groups
Surgical Management is more treatment option than medical or expectant management
Tinder. BMJ 2006
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25. Meta-analysis of Expectant, Surgical and Medical
Comparison of expectant, medical and surgical treatment of 1st trimester spontaneous abortion
28 studies eligible for analysis
Medical v. expectant: expectant was 39% successful.
Medical 3 times more likely to be successful
Sotiriadis. Obstet Gynecol 2005

26. Meta-analysis of Expectant, Surgical and Medical, cont.
Surgical v. expectant: expectant was 79%
Surgical more likely to be successful than expectant
Surgical v. medical: surgical was 1.5 times more successful than medical
Pt satisfaction did not differ significantly between surgical and medical, although trend favored medical management
Sotiriadis, Obstet Gynecol 2005

27. Conclusion Early pregnancy failure is common
Expectant, medical and surgical management can be done safely in an outpatient setting
Study findings vary because of lack of uniformity of study populations
Patients should be counseled accordingly so they can choose best treatment option
The results of this report, together with those of earlier reports,6,7,8,9,10,11,12 provide clinicians with information they need to use this medication responsibly for the management of early pregnancy failure. However, some questions remain.
Existing studies demonstrate that the use of misoprostol is more effective than expectant management (nonintervention) for early pregnancy failure, the other main alternative to immediate surgical treatment.6,7,8 Missed abortion appears to be slightly less easily and less successfully resolved with the use of misoprostol therapy than is incomplete abortion.5,13 This finding suggests that whereas surgery is more of a "one size fits all" proposition for treating early pregnancy failure, medical treatment may not be. In addition, the lowest effective dose of misoprostol for each condition for which it is used is not yet clear, and this dose may turn out to be different for different categories of pregnancy loss.5,7 We also do not know whether repeated doses of misoprostol consistently result in greater efficacy than a single dose followed by sufficient time for it to work.9
Questions also remain about the route of administration, with almost every imaginable variant having been used. (Oral, vaginal, rectal, buccal, and sublingual use have all been reported.) Some studies suggest that vaginal application of misoprostol increases the success rate and reduces side effects as compared with oral or other routes, whereas the results of other studies indicate that the various routes are equally efficacious and have similar rates of side effects.10,11,12 Many studies of vaginal administration have used misoprostol tablets developed and registered for oral use. But the normal procedures of drug registration will make it impossible for a pharmaceutical company to register an oral tablet for vaginal use without considerable additional expenditure on studies and, possibly, reformulation of the tablet. So far, no company has made such an investment, in part because it would be almost impossible for such a product to compete successfully with the inexpensive misoprostol tablets currently available.
Although the study by Zhang et al. was conducted in the United States, the development of nonsurgical treatments for early pregnancy failure may have the most importance outside our country. In resource-constrained environments, high-quality surgical care is not readily available to all. The consequences of unsafe abortion are estimated to account for about 13 percent of all maternal deaths worldwide, almost all of which occur in developing countries.14 Misoprostol therapy as an alternative to surgery appears to be highly acceptable to women wherever it has been tested,5,10 and recent evidence shows clearly that using misoprostol instead of aspiration in an outpatient setting reduces the cost of services.15 It is likely that women offered misoprostol can be treated and discharged more promptly than those who undergo surgery.5 In addition, treatment with pills does not require the immediate availability of sterilized equipment, operating rooms, or surgically skilled personnel.
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28. Discussions about Outpatient Management of Miscarriage
CASES
Discussions about Outpatient Management of Miscarriage

29. Case 1
You see a 18-year old woman, G2P1001, whose last period was 8 weeks ago. She had a positive home pregnancy test 3 weeks ago. Her first prenatal appointment is scheduled with another provider. She has not had an ultrasound during this pregnancy.
Three days ago, she began to spot. Today, her bleeding has increased, like a very heavy period with some clots. She began cramping last night and now reports that the cramping is severe. She comes to your clinic today for assessment and treatment if required.

30. Case 1
Her medical history includes a spontaneous vaginal delivery She is otherwise healthy. On exam, she appears comfortable and is able to walk around the room and talk easily. Her vital signs:
BP 110/70, Pulse 90, Temp 97.8
At this point, how would you proceed with evaluation?
Clinically stable patient suspicious for early pregnancy loss or miscarriage
Many options available for clinically stable patient including:
Watch/wait
Medication evacuation
Surgical/aspiration evacuation
Proceed by diagnostic evalauation: serum Bhcg, hb, ultrasound, pelvic exam
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31. Case 1 The examination reveals the following Her hemoglobin is 12.2.
Abdomen: soft, nontender
Vaginal vault: scant amount of blood, consistent with a menses
Cervix: os open, tissue at os noted
Bimanual exam: uterus enlarged, approx. 8 weeks size, nontender
Her hemoglobin is 12.2.
Urine pregnancy test: positive
What tests do you think you should order now?
Still no evidence of instability, infection, anemia
Ultrasound is next diagnostic step
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32. Case 1
The ultrasound reveals an intrauterine gestational sac, and thickened endometrial stripe.
What is the diagnosis?
What are the treatment options available for this patient?
How do the dates by LMP compare with the dates by sac size?
When do you expect to see a fetus or measure a CRL? What about the yolk?
Incomplete abortion in a stable patient has 3 treatment options:
Observant management
Medication management
Surgical management
Discuss medication options
mcg dose, sometimes repeated up to max of 3 q 3-24hrs
Range 50%-96% effective depending on the study;
average effectiveness to quote for incomplete ~ up to 95% effective
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33. Case 1 Key Concepts Incomplete/Inevitable Abortion
mcg effective dose without too many side effects
May give vaginally, orally, sublingual (not well studied)
May repeat
More effective for incomplete abortions than for missed abortions

34. Case 2
41 yo G1P1 presents to the Clinic for her first prenatal visit in a very desired pregnancy. Her LMP was 10 weeks ago and she is certain of her dates. The pregnancy has been uncomplicated except for a small amount a bleeding she had about 1 week ago. You evaluate the patient and finds that her BM exam is consistent with a 7 wk IUP, os is closed.
What other information might you be interested in knowing about?
What might you order to get a diagnosis?
Cramping, fever?
β-HCG? Ultrasound?
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35. Case 2
Fortunately, your Clinic has a portable ultrasound, and you are able to supervise the resident with a vaginal probe ultrasound. You see a well-circumscribed, though empty gestational sac.
What are your differential diagnoses? What do you tell the patient?
What size does sac measure?
Pseudo sac of ectopic pregnancy (not at fundus, centered midline in stripe, no decidualized reaction)
Anembryonic pregnancy (typical sac features but may be off dates and has no yolk or CRL to measure)
Options include 3: expectant, medical, surgical
Bhcg levels helpful in diagnosis of desired pregnancy and expectant management
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36. Case 2
The patient returns 5 days later with further spotting and cramping. A 2nd serum β-hCG is done, as well as a repeat ultrasound. The ultrasound now shows a large irregular shaped gestational sac. The serum β-hCG level has dropped.
What is your assessment?
Anembryonic pregnancy
3 options, each with good results
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37. Case 2 The patient decides to opt for medical treatment.
What regimen do you use?
How do you advise her? What can she expect?
Mife + miso 98% effective
Miso only
Sortiriadis 2005 meta-analysis : surgical more effective than medical than expectant (3x, 1.5x)
Graziosi 2004 meta-analysis : missed 81% vs expect 21%; incomplete 99% vs 94%
Dose and scheduling ranges
800 mcg vaginal d1,3 71% completed d1, 84% completed d3 Zhang 2005
400 mcg vaginal q 4hrs max 3 days 91% effective Sifakis 2005
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38. Case 2 Key Concepts Anembryonic Pregnancy
Consider the emotional aspects of miscarriage
Element of choice in patient satisfaction
Effectiveness of medication methods as well as surgical methods

39. Case 3
26 yo G2P2002 LMP uncertain because of irregular periods well known to you presents to your office with spotting x 4 days. She denies any pain. Her urine pregnancy test is positive, her cervical os closed. Her uterus is retroverted. She has a remote history of Chlamydia infection about 10 years ago.
What is your differential diagnosis?
What tests would you order now?
Early pregnancy vs ectopic
Ultrasound Bhcg
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40. Case 3
You perform an ultrasound and you see small echolucent area, which could be a small gestational sac or a pseudosac.
What should you do now?
What is your diagnosis? What are you options for treatment?
Differentiating early pregnancy from ectopic
mife+miso not harmful to ectopics but can mask ectopic rupture and confuse situation
MTX option for early ectopics
MVA can allow you to review POCs and determine whether or not pregnancy intrauterine
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41. Case 3 Key Concepts Ectopic Pregnancy
Ectopic vs early pregnancy may be hard to differentiate
Methotrexate an option for early & stable patients
MVA can help evaluate POC in clinic, guiding diagnosis & referral decisions

42. MVA for Miscarriage Management in the Out-Patient Setting
ARHP Workshop
September 6, 2006
Emily Godfrey, MD MPH
Michelle Forcier, MD MPH
Rivka
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43. Updates in Miscarriage Management
To discuss issues in evaluation & management of early miscarriage
To discuss the evidence behind the options for miscarriage management
To review manual vacuum aspiration (MVA) for miscarriage management
Summarize the safety and efficacy of MVA
Discuss pain management in out-patient settings
Discuss moving miscarriage management out of OR
To demonstrate technique or update your skills in MVA for uterine evacuation
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44. What is MVA? Manual vacuum aspirator Semi-flexible plastic cannula
Portable & reusable
Efficacy = electric vacuum (98-99%)
CORE SLIDE
Compare to EVA machine: Many more parts, electricity required, and will not fit in your back pack for sure where I have been known to stash an aspirator for an MVA on a few occasions. Easy to care for and store parts when you are sharing a space. Using a 60-ml receptacle, the aspirator provides identical suction pressure (26 inches of mercury) as an electric pump until approximately 80% capacity. The aspirator can be quickly emptied and reused if more capacity is needed. It is portable and small. These qualities make it very practical for a variety of settings, including an office, emergency room, and hospital-based location.
Sources:
Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv Feb;56(2):
Hemlin J, Moller B. Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination. Acta Obstet Gynecol Scand 2001;80:
Goldberg AB, Dean G, Kang MS, Youssof S, Darney P. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol 2004;103:
Goldberg 2004; Creinin 2001; Hemlin 2001
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45. Indications for MVA Uterine evacuation first trimester
Induced abortion
Spontaneous abortion or early pregnancy failure (EPF)
Complications management
Incomplete medical abortion
Post-abortal hematometra
Uterine sampling
Endometrial biopsy
product labeling, clinical indications for uterine aspiration with MVA are:
Treatment of incomplete abortion for uterine sizes up to 12 weeks LMP
First trimester abortion
Endometrial biopsy
Endometrial biopsy should not be performed in cased of suspected pregnancy
There are no known contraindications for other clinical indications.
MVA is also being used to treat:
Spontaneous abortions including missed, inevitable, and incomplete
Induced abortions
As a back up to medical abortions
Postabortal hematometra
Uterine sampling with MVA is especially useful in the clinic setting when a woman presents with a significant amount of bleeding. In such cases, the pipelles that are usually used for endometrial biopsies are too small. Instead, MVA can fully evacuate the clot and sample underlying tissue.
If using MVA beyond 12 weeks, a provider should do so with caution as it is not an FDA-approved use.
Sources:
Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv Feb;56(2):
Dalton VK, Castleman L. MVA for treatment of early pregnancy loss.” Postgraduate Obstetrics & Gynecology 2002;22(19).
Edwards J, Creinin MD. Surgical Abortion for Gestation of Less than 6 Weeks. Current Problems in Obstetrics, Gynecology, and Fertility 1997; 20 (1):11-19.
MVA Label, U.S., English. Ipas
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46. MVA Safety & Efficacy
Hale 1979 (MVA in 1st trimester, gynecology office, Hawaii)
Edwards 1997 (MVA at < 6 weeks gestation, women’s clinic, Texas)
Westfall 1998 (MVA in 1st trimester, family practice office, Colorado)
Hemlin 2001 (EVA vs. MVA at < 8 weeks gestation, hospital operating room, Sweden)
Paul 2002 (EVA and MVA at < 6 weeks, Planned Parenthood, Massachusetts)
Goldberg 2004 (EVA vs. MVA up to 10 weeks, University of California, San Francisco)
There have been many studies conducted over the past 30 years that document the safety and efficacy of MVA. In the following several slides we will review the significant studies including:
Hale 1979 (MVA in 1st trimester, gynecology office, Hawaii)
Edwards 1997 (MVA at < 6 weeks gestation, women’s clinic, Texas)
Westfall 1998 (MVA in 1st trimester, family practice office, Colorado)
Hemlin 2001 (EVA vs. MVA at < 8 weeks gestation, hospital operating room, Sweden)
Paul 2002 (EVA and MVA at < 6 weeks, Planned Parenthood, Massachusetts)
Goldberg 2004 (EVA vs. MVA up to 10 weeks, University of California, San Francisco)
Sources:
Edwards J, Creinin MD. Surgical abortion for gestations of less than 6 weeks. Curr Probl Obstet Gynecol Fertil 1997;Jan/Feb:11-19.
Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol 2004;103:
Hale RW, Kobara TY, Sharma SD, Tsuei JJ, Gramlich EP, Nakayama RT. Office termination of pregnancy by “menstrual aspiration.” Am J Obstet Gynecol 1979;134:
Hemlin J, Moller B. Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination. Acta Obstet Gynecol Scand 2001;80:
Paul ME, Mitchell CM, Rogers AJ, et al. Early surgical abortion: Efficacy and safety. Am J Obstet Gynecol 2002;187:
Westfall JM, Sophocles A, Burggraf H, Ellis S. Manual vacuum aspiration for first-trimester abortion. Arch Fam Med 1998;7:
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47. Early Abortion with MVA
Author
Date N
Gestational Age
Efficacy
Paul et al.
2002
1,132 (MVA+EVA)
<6
98%
Edwards & Carson
1997
1,530 MVA
99%
Edwards & Creinin
2,399 MVA
Hemlin & Moller
2001
91 MVA
<8
Laufe
1977
12,888
“About 6”
Baird TL, Flinn SK. Manual Vacuum Aspiration: A Safe and Accessible Method for First-Trimester Induced Abortion. Chapel Hill, NC: Ipas, 2001.
Edwards J, Carson SA. New technologies permit safe abortion at less than six weeks’ gestation and provide timely detection of ectopic gestation. Am J Obstet Gynecol 1997;176:1101–1106.
Edwards J, Creinin MD. Surgical abortion for gestations of less than 6 weeks. Curr Probl Obstet Gynecol Fertil 1997;Jan/Feb:11–19.
Hemlin J, Moller B. Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination. Acta Obstet Gynecol Scand 2001;80:563–567.
Paul ME, Mitchell CM, Rogers AJ, Fox MC, Lackie EG. Early surgical abortion: efficacy and safety. Am J Obstet Gynecol 2002;187:407–411.
Adapted from Baird and Flinn 2001
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48. MVA vs EVA Manual aspirator Electric pump Inexpensive
Quiet
Portable
Capacity: 60 cc
Suction decreases as aspirator fills
POCs likely intact
EVA
Electric pump
Costly but longer life
Variable noise level
Not easily portable
Capacity: 350-1,200 cc
Constant suction
Fragmentation of POCs
CORE SLIDE
Implications of being quiet:
Perceived as a benefit by some patients (see Dean study summarized below)
Improves patient-provider rapport
Improves provider’s ability to “hear” the procedure (the grittiness sometimes has a sound)
Reduces patient noise-imprinting
A study done at University of California, San Francisco investigated the acceptability of MVA vs. EVA and tried to quantify the impact of noise upon women undergoing vacuum aspiration. (Dean 2003) The study included 84 women undergoing abortion at less than 10 weeks gestation.
There was no significant difference in patient satisfaction, though significantly more women in the electric group were bothered by noise (19% vs. 2%, p = 0.03). There were significantly more times in the electric group that physicians would have preferred manual aspiration (43% vs. 17%, p = 0.02); this usually applied to early pregnancies.
Also, MVA “may cause less disruption of evacuated uterine contents and facilitate identification of products of conception,” (Dean 2003) which is especially important for abortions performed at an early gestational age. (you can easily see the little sac-not shredded or adherent to the trap.
Dean G. et al. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception 2003;67:
Physicians for Reproductive Choice and Health and Association of Reproductive Health Professionals. Manual Vacuum Aspiration: A slide presentation
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49. Complications with MVA
Rare
Same as for EVA
Incomplete evacuation
Uterine or cervical injury
Infection
Hemorrhage
Vaso-vagal reaction
These are the same as may result from electric vacuum aspiration.
FDA warnings on Ipas MVA label are:
Vagal reaction
Incomplete evacuation
Uterine or cervical injury/perforation
Pelvic infection
Acute hematometra
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50. MVA for Miscarriages Aspiration recommended if Advantages
Prolonged or excessive bleeding
Signs of infection
Patient preference
Advantages
Portable & low cost device
Suitable for outpatient services
Applications to variety of settings (primary care, ob/gyn office, ER)

51. Patient Satisfaction Both EVA and MVA groups highly satisfied
No difference reported in
Pain
Anxiety
Bleeding
Acceptability & satisfaction
More EVA patients bothered by noise (p=0.03)
Bird et al.:
Multicenter US trial of women seeking first-trimester abortion
Patients were prospectively randomized to either MVA (n = 64) or EVA (n = 63)
Results showed no difference in patients’ reports of pain, anxiety, or bleeding, or in the acceptability of each method
Both groups were highly satisfied, would choose their abortion method in the future, and would recommend it to a friend
Dean et al.:
University of California, San Francisco
N = 84 women requesting abortion at <10 weeks of gestation, randomized to either MVA or EVA
No difference found in pain levels or satisfaction. Women in both groups were treated with similar amounts of intravenous fentanyl and midazolam.
More EVA patients (19 oercent) than MVA patients (2 percent) were bothered by noise (P = 0.03).
Edelman et al.:
Planned Parenthood, Portland
N = 114 <11 weeks of gestation
Women were randomized to either MVA or EVA
Patients assessed pain level with visual analog scales
Patients’ reports of pain did not differ by procedure
Sources:
Bird ST, Harvey SM, Beckman LJ, Nichols MD, Rogers K, Blumenthal PD. Similarities in women’s perceptions and acceptability of manual vacuum aspiration and electric vacuum aspiration for first trimester abortion. Contraception 2003;67:207–212.
Dean G, Cardenas L, Darney P, Goldberg A. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception 2003;67:201–206.
Edelman A, Nichols MD, Jensen J. Comparison of pain and time of procedures with two first-trimester abortion techniques performed by residents and faculty. Am J Obstet Gynecol 2001;184(7):1564–1567.
Bird et al. 2003, Dean et al. 2003, Edelman et al. 2001
MVA Education Partnership

52. MVA Instruments MVA Education Partnership
This slide shows supplies needed to perform MVA procedures.
[Shama: this slide shows only the Ipas syringe and cannula. One reviewer suggested showing some variety.]
MVA Education Partnership

53. MVA: Key Benefits Safety & efficacy equivalent to EVA Portable
Low tech
Low-cost
Small and quiet
 Significant implications for incorporating services into the office setting
The set-up is very simple, as shown by this tray.
Dalton and Castleman 2002; Goldberg et al. 2004
MVA Education Partnership

54. MVA: Essentials for Providers
Pain management for awake patient
Counseling & rapport
Ultrasound
Identifying products of conception
Instrument processing
Although the procedure is easily incorporated into an office-type setting, there are definitely training issues involved. Before providing the procedure, the clinician should receive training in such topics as:
Pain management with an awake patient
Patient-provider rapport
Ultrasound as needed (lack of ultrasound in the immediate office setting should not become a barrier to service provision)
Identification of products of conception
Instrument processing, if the devices are to be reused
MVA Education Partnership

55. Video of MVA Procedure

56. MVA Video- Important Points?

57. Video – Important Points
Actual patient from local outpatient clinic
Ibuprofen and paracervical block only
In procedure room time ~10-15 minutes
Actual time for uterine evacuation ~1-2 minutes
Recovery time ~30 minutes
10 minute video of mva procedure
MVA Education Partnership

58. Pain Management
In the
Out Patient Setting

59. Pain Management in Outpatient Settings
Staff often express concern that uterine evacuation requires general or conscious sedation
Many uterine evacuations done under paracervical (local) block
Definite ways you can improve pain management in your outpatient setting

60. Pain Management Techniques
With Addition Of:
Focused breathing: 76%
Visualization: 31%
Localized massage: 14%
This slide shows pain control techniques used by National Abortion Federation clinics. This is a particularly helpful slide in locations where the group feels that “their patients will only tolerate general anesthesia.”
In general, NAF clinics provide high quality abortion care and strive to make sure their customer is satisfied. Pain management matters a lot to women. The fact that the majority of NAF clinics offer local anesthesia as a primary method of pain control strongly implies that many women like this option.
Also, this slide can be used to make the point that ancillary methods of pain management, such as focused breathing, visualization, and massage, are important.
Source:
Lichtenberg ES, Paul M, Jones H. First trimester surgical abortion practices: a survey of National Abortion Federation members. Contraception 2001;64:
Lichtenberg 2001
MVA Education Partnership

61. Importance of Pain Management
Most common concern expressed by patient
Highly linked to patient satisfaction
Whose perspective?
Patients
Clinician
Counselor/bedside assistant
What are we trying to do?
Minimize risk / maximize benefit
Take away all pain/all feeling
Get through it

62. Effective pain management
What worsens pain?
Pre-procedure fearfulness
Anxiety
Depression
What reduces pain?
Respectful, informed and supportive staff
Warm and friendly environment
Gentle operative technique
Women’s involvement & sense of control
Effective pain medications
Belanger 1989; Smith 1979
How does this model of pain apply to MVA? We know that psychological factors have a strong impact on how much pain women seem to experience during uterine evacuation.
Belanger E, Melzack R, Lauzon P. Pain of first-trimester abortion: a study of psychosocial and medical predictors. Pain 1989;36:
Smith GM, Stubblefield PG, Chirchirillo L, McCarthy MJ. Pain of first trimester abortion: its quantification and relations with other variables. Am J Obstet Gynecol 1979;133(5):
MVA Education Partnership

63. Other Influences on Pain
Provider
The clinician has a profound effect on pain score, independent of anesthetic (Rawling 1998 and 2001)
Patient’s sense of control
“The idea that I could manage the miscarriage myself with guidance available whenever I needed it…I felt calmer, more confident, less medicated and out of control.”(Wiebe 1999)
Wiebe and Janssen in Canada interviewed 59 women who had recently undergone expectant management of miscarriage. These women were asked numerous questions about their experience. One of the themes that came out is that women really liked having options for treatment. One patient said, “The idea that I could manage the miscarriage myself with guidance available whenever I needed it…I felt calmer, more confident, less medicated and out of control.”
Sources:
Rawling MJ, Wiebe ER. A randomized trial of fentanyl for abortion pain. Am J Obstet Gynecol 2001;185(1):103-7.
Rawling MJ, Wiebe ER. Pain control in abortion clinics. International Journal of Gynecology & Obstetrics 1998;60:
Wiebe E, Janssen P. Conservative management of spontaneous abortions. Canadian Family Physician 1999;45:
MVA Education Partnership

64. Role Play- Patient Centered Care
23 yro G1P0 miscarrying at EGA 8 weeks
Very desired pregnancy
Bleeding and cramping x 24 hrs
No fetal heart activity & CRL only measuring 5 weeks

65. Paracervical Block Maltzer 1999; Castleman 2002
The paracervical block is commonly used for vacuum aspiration abortions in North America. However, clinicians use many different techniques for administering a paracervical block. “There is a little science and a lot of art in this area.” (Maltzer page 77)
Studies have shown that deep injections using the Glick technique can be more effective than superficial injections and injecting slowly has been found to be less painful than injecting quickly.
Castleman L, Mann C. Manual vacuum aspiration (MVA) for uterine evacuation: Pain management. Chapel Hill: Ipas, 2002.
Maltzer DS, Maltzer MC, Wiebe ER, Halvorson-Boyd G, Boyd C. “Pain Management” in NAF’s A Clinician’s Guide to Medical and Surgical Abortion. Philadelphia: Churchill Livingstone, 1999.
Maltzer 1999; Castleman 2002
MVA Education Partnership

66. Options for Anesthesia
Local
Conscious sedation
Other
Psychological
Information, preparation & support
Music as analgesia
85% abortion patients wearing headphones rated pain as “0” compared to 52% controls
Distraction
Residency programs in the U.S. often do not emphasize ancillary techniques of pain management for procedures on awake patients. Dentists have known for a long time that if patients hear music through headphones and are otherwise treated nicely while they have their teeth drilled, the patients feel less pain.
In an interesting study out of University of Miami from 1974, 144 women undergoing first trimester abortion with suction curettage, oral valium, and paracervical block were randomized to 1) standard technique, 2) headphones with music, or 3) self-administered methoxyflurane. The group using the headphones had less than half the incidence of pain than the other two groups. 85% of the group with headphones said they had no pain, compared to 52% of the other two groups.
Pre-procedure fearfulness appears to play a major role in the amount of pain women perceive. Stubblefield noted that women who know what to expect through better education and psychological preparation tend to be less afraid, which may be associated with reduced pain.
Sources:
Shapiro AG, Cohen H. Auxiliary pain relief during suction curettage. Contraception 1975;11(1):25-30.
Stubblefield PG. Control of pain for women undergoing abortion. Suppl Int J Gynecol Obstet 1989;3:
Stubblefield 1989
Shapiro 1974
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67. Curettage and Pain
Using the curette often requires increased dilatation
Curetting hurts! Makes reducing anesthesia more difficult
Sharp curettage generally not indicated & not routinely recommended following MVA
Studies on incomplete abortion reveal that suction causes less pain than sharp curettage.
Forna, F. and A.M. Gulmezoglu. Surgical procedures to evacuate incomplete abortion (Cochrane Review). In: The Cochrane Library 2002; Issue 1. Oxford: Update Software.
Forna 2002
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68. In Conclusion . . . No pain panacea
Affirm the patient’s existing viewpoint wherever possible
Avoid glib reassurances
Advise the patient that her fears are widely shared
Help the patient to differentiate between emotional and physical pain
Women want to be involved in developing their pain management plan
Curette check hurts - usually not needed
Pre-procedure preparation & psychological support reduce anxiety & improve overall experience
MVA Education Partnership

69. Other Clinical Benefits of MVA
POCS are easier to visualize & inspect
Often more intact
Easier detection of early EGA
Fewer re-aspirations in MVA vs EVA group (Goldberg 2004)
Can still send to pathology for genetics
study out of UCSF detailed earlier which compared complication rates of MVA vs. EVA.
Of total 1726 pts, 37 patients were less than 6 weeks. In 35 out of 37, provider chose to use MVA
No reaspirations in patients under 6 weeks.
Both MVA and EVA were readily available in the procedure rooms; the clinician could choose to use either one.
There were no reaspirations among these 37 early cases, though the study was not specifically designed to look at this early group.
In the entire group (up to 10 weeks gestation), there were significantly more reaspirations in the electric group for inability to accurately identify the pregnancy. The study’s authors commented that this trend may be especially important for women whose pregnancies were under 6 weeks, though they did not have enough patients in this category to adequately address this question.
Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol 2004;103:
Goldberg 2004; MacIsaac 2000; Edwards 1997
MVA Education Partnership

70. MVA POC Check: Benefits for EPL
There it is!
What is that?
As the photo conveys, for early gestational ages POC may be easier to identify using MVA rather than EVA. This is important in order to confirm completion of procedures.
study out of UCSF detailed earlier which compared complication rates of MVA vs. EVA.
Of total 1726 pts, 37 patients were less than 6 weeks. In 35 out of 37, provider chose to use MVA
No reaspirations in patients under 6 weeks.
Both MVA and EVA were readily available in the procedure rooms; the clinician could choose to use either one.
There were no reaspirations among these 37 early cases, though the study was not specifically designed to look at this early group.
In the entire group (up to 10 weeks gestation), there were significantly more reaspirations in the electric group for inability to accurately identify the pregnancy. The study’s authors commented that this trend may be especially important for women whose pregnancies were under 6 weeks, though they did not have enough patients in this category to adequately address this question.
Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol 2004;103:
Electric Suction Machine
MVA Aspirator
Creinin and Edwards 1997
MVA Education Partnership

71. MOVING OUT OF THE OPERATING ROOM
Some of the following evidence comes from abortion-related work, and some from miscarriage management. Since the procedures have much in common, the results may be applicable to both clinical settings.
MVA Education Partnership

72. Uterine evacuation- Why the OR?
OR was necessary when emptying the uterus was an emergency
Abortion was illegal
Antibiotics were not available
Access to blood transfusion limited
“Puerperal (childbed) fever was the scourge of nineteenth century obstetrics and abortion.” Joffe 1999
Today, out patient care safe, convenient, cost effective option for stable patients
This slide covers a historical perspective regarding why we treat women undergoing miscarriages with D&C in the OR.
Our current practices developed during a time when…
Abortion was illegal. Women self-induced, and presented with septic, incomplete abortions. They were often very sick and clinically unstable.
Uterine evacuation was an emergency.
Antibiotics were not available.
Access to blood transfusion was limited
Source (including italicized quote):
Joffe C, Abortion in Historical Perspective, in NAF’s A Clinician’s Guide to Medical and Surgical Abortion. Edited by Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG. Philadelphia: Churchill Livingstone, 1999
MVA Education Partnership

73. OR to Out Patient Clinic – Benefits
Simplify scheduling
Reduce waiting and repeat exams
Avoid cumbersome OR protocols
Prolonged NPO requirements & discharge criteria
Save resources
Outpatient saves materials required, costs/charges, personnel
Avoidance of repeated exams:
When women present to the emergency room with signs and symptoms of a miscarriage, they may be put through many pelvic exams (first the ER resident, then the ER attending, often followed by the gyn resident and then gyn attending—none of whom are usually the woman’s own physician). In a clinic setting, the woman usually undergoes one exam--by her own doctor, midwife, or nurse practitioner.
2. Long waits in the hospital:
Women undergoing miscarriages are usually not acutely ill. Both in the emergency room as well as in the operating room, they usually receive care only after sicker patients have already been treated. Patients who received care in the hospital reported dissatisfaction with the fact that “miscarriage was not perceived by medical staff as important or an emergency.”(Lee 1996) Women do not like these long waits.
3. Impersonal, mechanized, extensive protocols in operating room:
The operating room environment is extremely high-tech and mechanized. Patients undergoing procedures in the OR must adhere to strict protocols; this can be frustrating and intimidating for patients.
4. Saves resources
In an interactive setting:
How long is the average waiting time for a woman who is treated with a D&C for miscarriage?
How many of you have had to interrupt your office schedule or get out of your bed at home in order to go into the hospital to perform a D&C on a very stable, non-urgent miscarriage patient? (Most ob-gyns will answer yes to this question and will have a lot of real self-interest in offering office-based miscarriage management).
Does anyone offer miscarriage management in the office? If so and if time allows, anyone answering yes to this question can be asked to talk about these services.
Lee C, Slade P. Miscarriage as a traumatic event: a review of the literature and new implications for intervention.” J. Psychosom Res 1996;40(3):
Demetroulis 2001
MVA Education Partnership

74. Out Patient - Benefits to your Patients
Why some patients want MVA
Control/autonomy while awake during procedure
Convenience & time
Single appointment
Rapid recovery time
Personalized care by single provider
Improved patient education, attitudes, accommodations in out patient setting (Lee 1996)
Women treated in the clinic-setting are usually in a more familiar and private setting than that of the operating room.
Many women undergoing early pregnancy failure value education about what they are currently experiencing and what is likely to happen. Opportunities to answer related questions may be better in the clinic. Miscarriage patients treated in the hospital reported dissatisfaction with the limited amount of education received regarding medical aspects such as what to expect regarding vaginal bleeding, when to resume sexual intercourse, and when contraception could be initiated.(Lee 1996) In this paper summarizing women’s experiences in hospital-based miscarriage management, women complained about the following aspects of hospital care:
Staff attitudes-- “insensitive and unsympathetic”
Accommodations—miscarriage patients are sometimes put right next to women in labor or undergoing an induced abortion. This can be upsetting.
Resident involvement—some women preferred to avoid resident involvement in their care, though residents are often an integral part of service delivery in hospitals.
Lee C, Slade P. Miscarriage as a traumatic event: a review of the literature and new implications for intervention.” J. Psychosom Res 1996;40(3):
MVA Education Partnership

75. Moving Miscarriage Management to Outpatient Setting – Johns Hopkins Study
Results
Decreased anesthesia requirements
Decreased overall hospital stay from 19 to 6 hours
Decreased patient waiting time by 52%
Decreased procedure time from 33 to19 minutes
Decreased costs per case
$1404 in OR
$827 in L&D
$200 or less in ER
The MVA-based procedures resulted in significant savings in:
Patient waiting time
Cost. There were only 3 patients who received care in the ER, so that cost number may not be as reliable as the others.
Anesthesia requirements. Most women undergoing management in the operating room received higher doses of intravenous sedation given by an anesthesiologist. Women undergoing MVA received local anesthesia with lighter intravenous sedation.
Procedure time was thought to be reduced because the products of conception were immediately available to look at when using MVA, as opposed to having to take the tubing apart to inspect the POC when using EVA.
There were no procedural complications in either group (although study not designed as a safety/efficacy study).
Blumenthal 1994
MVA Education Partnership

76. Moving Abortion to an Outpatient Clinic - Bellevue Hospital
Methods
Compared costs, staff, complications: OR vs. Outpatient
N = 967; Patients undergoing first trimester pregnancy termination in outpatient procedure room ( )
Results
Outpatient MVA
Operating
Room
Cost per Procedure
$167
$1,435
Staff 2 5
$1268 savings
survey is from Bellevue Hospital in New York.
summary of results from the first two years of moving first trimester abortion procedures out of the OR, where all patients received general anesthesia, into a procedure room using vacuum aspiration (MVA or EVA) with paracervical block and moderate intravenous sedation.
Bellevue Hospital Center Quality Management; Summary of Performance Improvements (unpublished); 15 North Procedure Room, 2002
No reported complications with outpatient MVA
Bellevue Hospital Improvement Reports, Masch 2002
MVA Education Partnership

77. Moving Abortion to an Outpatient Clinic- University of Michigan
Results: 60 women chose clinic, 29 women chose OR
MVA: 91% would choose again
“get home soon,” “avoid GA”
69% less patient time
50% shorter procedure time
As of Jan 2003: 45 people; only 2 said not again but one of those would recommend it to friend.
Big issue: dollars saved per case: over $3000
50:50 choosing local vs. general
Some minor institutional crises prompted the change;
ongoing increases in patient volume - inability to acomodate patients in an OR on L and D or main OR in a timely way
We introduced office D and C
- grand rounds not unlike this
- several faculty and resident inservices
- now routine to offer all patients choice of OR with GA or awake MVA with local.
There are some patient selection criteria for office procedures - our list of contraindications includes: bleeding disorders, anticoagulation, fibroids >20 weeks, severe anemia, uncontrolled hypertension, uncontrolled seizures, severe anxiety disorder, ability to tolerate speculum exam,
We have pre-made instrument trays like the ones I’ve shown.
We’ve extended this to the ER as well - allowed us to quickly do a D and C with minimal resources.
Cost savings of moving out of the OR of $3,000 per case
Dalton 2003
MVA Education Partnership

78. Medications/Supplies Needed
Analgesia
Anesthetic
Silver nitrate or ferric subsulfate
Uterotonic agent
Rhogam
Urine pregnancy tests
Emergency cart
Pharmacologic agents for cervical ripening (optional)
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79. Equipment Needed PROCEDURE TISSUE EXAMINATION Aspirators Basin for POC
Cannulae
Speculae
Sharp-toothed and/or atraumatic tenaculae
Antiseptic solution
Mechanical dilators
20-cc syringe for local anesthesia
TISSUE EXAMINATION
Basin for POC
Fine-mesh kitchen strainer
Back light
Tools to grasp tissue and POC
Specimen containers
Source:
McInerney T, Baird TL, Hyman AG, Huber AB. A guide to providing abortion care. Technical Resources for Abortion Care. Chapel Hill, NC: Ipas, 2001.
MVA Education Partnership

80. Finances Behind Out Patient Tx
Diagnosis code: (Spontaneous Abortion, without mention of complication)
CPT Billing codes for in office management vs in patient management
59812 – Treatment of incomplete abortion, any trimester, completed surgically
59820 – Treatment of missed abortion, completed surgically, first trimester
Reimbursement issues

81. Conclusions Evidence demonstrates
Uterine evacuation can be managed safely in an out-patient clinic setting
Moving out of the operating room
Saves both time, money, resources
Offers significant both choice & advantages to both women & clinicians
CORE SLIDE
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82. “Never, ever, think outside the box.”
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83. Discussions about MVA For Outpatient Management of Miscarriage
CASES
Discussions about MVA
For Outpatient Management of Miscarriage

84. Case 1 continued
The same 18 yro G2P1001, experiencing mild-moderate cramping with mild-moderate bleeding in your clinic, and an ultrasound evidence of an incomplete abortion elects an MVA procedure as she wants to take care of this as soon as possible.
You are performing the MVA-all seems to be going well. However, the aspirator is only about one-quarter full and you remember from this course that at this gestational age, you would expect more tissue than this. You are not sure whether or not you are done.

85. Case 1 continued
How can you tell if you are done? List 4 signs suggesting completion.
What do you do?
For “bonus” credit---at what pregnancy age does the volume of POC become more than 60 cc (equivalent to the volume of the aspirator)?
No pocs back, rough gritty feel, expected amount of tissue, ________________
Take cannula out and reposition
MVA Education Partnership

86. MVA Key Concepts
MVA safe & effective for early pregnancy loss in first trimester
Allows for care that day, in the office, with their primary provider
Any uterine evacuation’s efficacy is improved by systematically checking for completion

87. Case 2 continued
41 yo G2P1001 with an LMP suggesting a 10 week pregnancy but ultrasound findings revealing anembryonic pregnancy. The patient decided to opt for medical treatment.
She took both mifepristone and misoprostol and is now seeing you for her routine follow-up visit, scheduled 2 weeks after she took mifepristone. She has been having persistent spotting, and says that she is really “sick of it.” Vaginal ultrasound reveals a non-viable, persistent gestational sac. Specifically, there is no evidence of growth but the sac is still present.

88. Case 2 continued
You counsel her about options, including observation, repeating misoprostol, and surgical completion. The woman has significant childcare problems and wants to minimize the number of visits she must make to your clinic. Therefore, she requests surgical completion.

89. Case 2 continued
You perform MVA and are partway through the aspiration when you note that the cannula seems to be sliding back and forth over the uterine lining too easily; it feels like nothing is happening.
What could be going on?
What do you do to test your answer to question #1?
How might MVA on this patient be different from that performed on surgical abortion patients who have not received mifepristone or misoprostol?
Lack of suction in syringe, blocking at opening of cannula
Are you in cervix, uterus, elsewhere?
Take out, check suction
Dilate and sound uterus, with or without u/s guidance
re-prime, and re-insert your cannula
Procedure may be more painful, _____________________
(if they mean, not receive miso, then can discuss dilation)
MVA Education Partnership

90. MVA Key Concepts
Helpful to trouble shoot & know how to solve common MVA problems
Lack of suction can caused by
Device not assembled or working properly
Clogged cannula
Can never go wrong by stopping & reassessing

91. Case 3 continued
26 yo G2P2002 LMP uncertain because of irregular periods is at your office for pregnancy termination with either early intrauterine versus ectopic pregnancy in the differential. She would like to deal with it today and with you if possible. You want to make sure it is not an ectopic pregnancy….

92. Case 3 continued
Initially, dilitation of the cervix seems slightly more difficult than usual. However, after the first two dilator passes, it then progresses uneventfully. A 6 mm cannula is placed in the os, the aspirator is connected, and only scant blood is obtained. Dilitation for correct placement is attempted again. Again, only scant blood is obtained.
What do you think is happening?
What do you do now?
Is it small amount of tissue consistent with early pregnancy?
Float pocs
Is it blood, no villi, no yolk, so sac consistent with ectopic
MVA Education Partnership

93. MVA Key Concepts
Checking device & placement helpful when not getting scant or no products back
Ultrasound helps assess placement of cannula
MVA can be help diagnose ectopic pregnancy
Floating products of conception very helpful in assessing uterine contents (and is easy to do)