MANUAL VACUUM ASPIRATION

1	Provide emotional support and encouragement and give paracetamol 30 minutes before the procedure. Rarely, a paracervical block may be needed.
2	Prepare the MVA syringe (for molar pregnancy, when the uterine contents are likely to be copious, have three syringes ready for use): • Assemble the syringe • Close the pinch valve • Pull back on the plunger until the plunger arms lock.
3	Even if bleeding is slight, give oxytocin 10 units IM or ergometrine 0.2 mg IM before the procedure to make the myometrium firmer and reduce the risk of perforation.
4	Perform a bimanual pelvic examination to assess the size and position of the uterus and the condition of the fornices.
5	Apply antiseptic solution to the vagina and cervix (especially the os).
6	Check the cervix for tears or protruding products of conception. If products of conception are present in the vagina or cervix, remove them using ring (or sponge) forceps.
7	Gently grasp the anterior lip of the cervix with a vulsellum or single-toothed tenaculum: • With incomplete abortion, a ring or sponge forceps is preferable as it is less likely than the tenaculum to tear the cervix with traction and does not require the use of lidocaine for placement.
8	If using a tenaculum to grasp the cervix, first inject 1 ml of 0.5% lidocaine solution into the anterior or posterior lip of the cervix which has been exposed by the speculum (the 10 o’clock or 12 o’clock position is usually used).
9	Dilatation is needed only in cases of missed abortion or when products of conception have remained in the uterus for several days: • Gently introduce the widest gauge suction cannula • Use graduated dilators only if the cannula will not pass; begin with the smallest dilator and end with the largest dilator (usually 10–12 mm) that ensures adequate dilatation (Figure 12.5) • Take care not to tear the cervix or to create a false opening.
Figure 12.5
10	While gently applying traction to the cervix, insert the cannula through the cervix into the uterine cavity just past the internal os (Figure 12.6). Rotating the cannula while gently applying pressure often helps the tip of the cannula pass through the cervical canal.
Figure 12.6
11	Slowly push the cannula into the uterine cavity until it touches the fundus, but not more than 10 cm. Measure the depth of the uterus by dots visible on the cannula and then withdraw the cannula slightly.
12	Attach the prepared MVA syringe to the cannula by holding the vulsellum (or tenaculum) and the end of the cannula in one hand and the syringe in the other.
13	Release the pinch valve(s) on the syringe to transfer the vacuum through the cannula to the uterine cavity. Evacuate remaining contents by gently rotating the syringe from side to side (10 to 12 o’clock) and then moving the cannula gently and slowly back and forth within the uterine cavity (Figure 12.7).
Figure 12.7
14	Check for signs of completion: • Gently introduce the widest gauge suction cannula • A grating sensation is felt as the cannula passes over the surface of the evacuated uterus • The uterus contracts around (grips) the cannula.
15	Withdraw the cannula. Detach the syringe and place the cannula in decontamination solution. With the valve open, empty the contents of the MVA syringe into a strainer by pushing on the plunger.
16	Perform a bimanual examination to check the size and firmness of the uterus.
17	Quickly inspect the tissue removed from the uterus for quantity and presence of products of conception, to assure complete evacuation and to check for a molar pregnancy (rare). If no products of conception are seen: • All products of conception may have been passed before the MVA was performed (complete abortion) • The uterine cavity may appear to be empty but may not have been emptied completely: repeat the evacuation • The vaginal bleeding may not have been due to an incomplete abortion (e.g. breakthrough bleeding, as may be seen with hormonal contraceptives or uterine fibroids) • The uterus may be abnormal (e.g. cannula may have been inserted in the nonpregnant side of a double uterus).
18	Absence of products of conception in a woman with symptoms of pregnancy raises the strong possibility of ectopic pregnancy. Gently insert a speculum into the vagina and examine for bleeding. If the uterus is still soft and not smaller or if there is persistent, brisk bleeding, repeat the evacuation.