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

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