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  7. Manual Vacuum Aspiration (MVA) for treatment of miscarriage and retained pregnancy tissue (1078)
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Manual Vacuum Aspiration (MVA) for treatment of miscarriage and retained pregnancy tissue (1078)

Objectives

To provide guidance to clinical teams undertaking MVA in the management of early pregnancy loss.

Audience

All healthcare workers in GGC involved in the care of women experiencing early pregnancy loss including doctors, nurses, midwives, EPAS staff, A&E staff

Please report any inaccuracies or issues with this guideline using our online form

Manual Vacuum Aspiration (MVA) is an option for women for the management of early pregnancy loss or retained tissue.

NICE suggest surgical or medical management can be offered when expectant treatment is not acceptable to the woman or has failed.  The Miscarriage Association and the Association of Early Pregnancy Units support discussing with women all options that are clinically appropriate and locally available.

MVA has been shown to be a safe and effective procedure and compared with Electric Vacuum aspiration management under general anaesthetic.  Advantages include quicker recovery, shorter hospital stay, lower cost, reduced waiting time and avoids the risks associated with general anaesthesia.

Complication rates (infection, retained tissue, bleeding, perforation and intrauterine adhesions) are similar to those of electric vacuum aspiration. 

MVA can also be used in an emergency situation as it can be performed quickly in a clinical room, providing there is access to an ultrasound machine, MVA supplies, resuscitation equipment and a trained nurse is present.  

Ultrasound features (see NICE guidance for diagnostic criteria of miscarriage, below indicates suitability for MVA procedure)

  •  Ultrasound diagnosis of early embryonic miscarriage where Crown Rump Length (CRL) does not exceed 25mm on TVUSS
  • Ultrasound diagnosis of anembryonic pregnancy ≤ 10 weeks gestation where there is no CRL and Mean Gestation Sac (MGS) does not exceed 40mm on TVUSS
  • Ultrasound diagnosis of an incomplete miscarriage with RPOC measuring less than 5cm mean diameter on TVUSS
  • Ultrasound diagnosis as above with failed medical management of miscarriage

Patient characteristics

  • Motivated and well counselled woman who can tolerate a speculum examination, bearing in mind that the procedure will be performed under local anaesthetic with the patient still awake.
  • No clinical signs of infection - fever/offensive discharge/ generalized lower abdominal pain.
  • An emergency procedure can be carried out in the event of heavy vaginal bleeding where an ultrasound scan has previously confirmed a non-continuing pregnancy of less than 10 weeks gestation.

  • pregnancy >10 week period of gestation by Ultrasound measurements
  • Bleeding disorders/ Current Anti-coagulant treatment
  • Signs of active Infection
  • Allergy to local anaesthetic
  • Mobility issues affecting positioning on couch with footrests
  • Hb <10
  • Women with Uterine anomalies or suspected molar pregnancy should be discussed with consultant prior to procedure

Note - Previous caesarean section is not a contra-indication to MVA, providing ultrasound excludes scar implantation

MVA is safe but like all procedures there is a small risk of complications. The risk of complications with an MVA are similar to surgical uterine evacuation under general anaesthesia but without the complications caused by general anaesthetic.

Complications related to the procedure are uncommon or rare—they include:

  • Heavy bleeding (haemorrhage) (3%)
  • Infection (3%)
  • The need for a repeat operation if not all the pregnancy tissue is removed (3%)
  • Perforation (tear) of the womb that may need repair (less than 1 in 1000)
  • Adhesions or scar tissue within the womb.

  • Elective MVA procedures are currently performed on sites in the North and South or the City and within Clyde. The procedure will be organised by contacting EPAS or via the gynaecology emergency team at each of the units.
  • Provide Patient information leaflet outlining Elective MVA with contact numbers for EPAS, local gynaecology ward, and ward or clinic area for planned procedure.  Include details of admission procedure (day, date, time)
  • Discuss and complete Procedure Consent form
  • Discuss and complete Form 2 (Sensitive Disposal of pregnancy tissue) with original to be sent to pathology on day of procedure, with a copy for patient notes and an additional copy for the patient.
  • Obtain FBC and Group and Save (valid for 72 hours)
  • Prescribe Misoprostol 400 mcg Sublingual to be taken 2 – 3 hours prior to procedure
  • Prescribe analgesia to be taken 1 hour before procedure, suggested regime is  Paracetamol 1g oral or Cocodamol 8/500 x 2 tablets oral and Ibuprofen 800mg oral
  • Advise patient to have breakfast or light lunch as normal the day of the procedure

  • Review with nursing and medical staff involved with procedure
  • Confirm paperwork complete and medication has been taken as directed
  • Confirm blood results and request Anti-D if required
  • Baseline observations to be recorded in notes (Temperature, Pulse and Blood Pressure)

  • Women should be observed in a recovery area after the procedure for at least 1 hour
  • Observations should be obtained and recorded (Temperature, Pulse and Blood Pressure)
  • Vaginal blood loss to be monitored
  • Patients can eat and drink and should be offered refreshments
  • Check Rhesus status and administer Anti-D if required

  • Patient may be discharged home an hour after procedure if well and vaginal loss is not excessive
  • Discuss performing a home pregnancy test in 4 weeks and where to contact if it remains positive
  • Discuss return of periods and future fertility
  • Discuss and provide contraception if required
  • Ensure patient has phone numbers for EPAS and local gynaecology ward
  • Offer support and give contacts from The Miscarriage Association if needed
  • Ensure discharge letter for GP is complete

Editorial Information

Last reviewed: 23/03/2023

Next review date: 31/03/2028

Author(s): Sarah Woldman.

Version: 1

Approved By: Gynaecology Clinical Governance Group

Document Id: 1078

References

BPAS – Mannual Vaccum Aspiration Clinical Guideline – March 2008 Manual Vacuum Aspiration (durbinglobal.com)

Manual Vacuum Aspiration: an outpatient alternative for surgical management of miscarriage.  The Obstetrican and Gynaecologist (TOG) 2015;17:157–61

Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group A.M. Kolte1,*, L.A. Bernardi2, O.B. Christiansen1,3, S. Quenby4,

R.G. Farquharson5, M. Goddijn6, and M.D. Stephenson7 on behalf of the ESHRE Special Interest Group, Early Pregnancy, Human Reproduction, Vol.30, No.3 pp. 495–498, 2015

110   Ectopic pregnancy and miscarriage: diagnosis and initial management.  NICE guideline [NG126] Published 17 April 2019, updated 24 November 2021

Mean sac diameter | Radiology Reference Article | Radiopaedia.org

Abortion care, Cervical priming before surgical abortion NICE guideline NG140 Evidence reviews September 2019 Abortion care review M: Cervical priming before surgical abortion (nice.org.uk)