DOI: 10.1111/tog.

12198 2015;17:157–61
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Manual vacuum aspiration: an outpatient alternative for

surgical management of miscarriage
Mona Sharma MBBS MD MRCOG*

Locum Consultant Obstetrics and Gynaecology, St Helier Hospital, Wrythe Lane, Carlshalton, Surrey SM5 1AA, UK
*Correspondence: Mona Sharma. Email: [email protected]

Accepted on 3 March 2015

Key content  To review the data on effectiveness and complications

 Manual vacuum aspiration (MVA) is a safe and effective of MVA.
alternative method for surgical management of miscarriage.  To review the feasibility of implementing the service in National
 MVA can be performed in the outpatient setting under Health Service hospitals while delivering a quality service which is
local anaesthesia. safe, cost-effective and acceptable.
 MVA reduces patient waiting time for surgery, cost of hospital stay
Ethical issues
and avoids general anaesthesia-related complications and increases  How safe is it to perform MVA in an outpatient setting?
patient choice. 
 Complication rates are similar to those of electric vacuum aspiration
Is it ethical to perform MVA under local anaesthesia, in
emotionally vulnerable miscarrying women?
carried out under general anaesthesia in the operating theatre.  Is the outpatient department an ideal setting in which to train
 The necessary skills are easy to acquire and require minimal
doctors to perform MVA?
additional training and resources.
Keywords: manual vacuum aspiration / miscarriage / suction
Learning objectives

evacuation / surgical management of miscarriage / termination
To understand the indications, procedure and advantages
of pregnancy
of MVA.

Please cite this paper as: Sharma M. Manual vacuum aspiration: an outpatient alternative for surgical management of miscarriage. The Obstetrician &
Gynaecologist 2015;17:157–61.

anaesthesia as an alternative method for surgical

Introduction
management of miscarriage. MVA is also recommended as
Approximately 10–20% of pregnancies end in miscarriage an effective and acceptable surgical method of termination of
and early pregnancy loss accounts for over 50 000 admissions pregnancy in the Royal College of Obstetricians and
in the UK each year.1 Treatment options for miscarriage Gynaecologists (RCOG) evidence-based guideline The Care
include expectant management, surgical and medical of Women Requesting Induced Abortion.2
management. Each has its own advantages and Harvey Karman, in 1972, designed the vacuum syringe and
disadvantages and is selected according to clinical described the principles of MVA for surgical uterine
indication and the woman’s preferences. Clinical evacuation.3 The principle of MVA is exactly the same as
indications for offering surgical evacuation include routine surgical management of miscarriage except that it
persistent excessive bleeding, haemodynamic instability, involves the use of a handheld syringe as a source of suction
evidence of infected retained tissue and suspected instead of an electric suction machine. It has been used for first-
gestational trophoblastic disease. In the National Health trimester termination of pregnancy, incomplete miscarriage,
Service (NHS) setting, standard surgical management of missed miscarriage, endometrial biopsy and following failed
miscarriage involves suction evacuation under general medical termination of pregnancy. In particular, in areas with
anaesthesia using electric vacuum aspiration (EVA). limited resources it has gained wide popularity as a reliable,
However, over the last few decades, manual vacuum safe, cost-effective and ambulatory method for managing
aspiration (MVA) has emerged as an effective and safe miscarriage. Slowly but steadily, this method is also gaining
alternative for surgical management of miscarriage. MVA can acceptance in the NHS setting as an option for the surgical
be carried out in the outpatient setting under local management of miscarriage.

ª 2015 Royal College of Obstetricians and Gynaecologists 157

 MVA in miscarriage

half to two-and-half cartridges of the local anaesthesia can

Description
be given.
The MVA syringe is made of latex-free plastic and it can be The anterior lip of the cervix is held with an Allis
single-valved or doubled-valved. The double-valved syringe is forceps, tenaculum or vulsellum. An appropriately sized
the newer version that is used more frequently. It has a cannula is introduced into the uterus and, if required, the
volume of 60 ml and can create a vacuum of cervical os is gently dilated with the rounded tip of
610–660 mmHg; similar to that generated by an electric the cannula. Alternatively, Hegar dilators can be used. The
vacuum machine. Cannulae are 24 cm long and are colour- charged syringe is then attached to the cannula. Once
coded according to their diameter, which ranges from 4 mm the syringe is fixed, the proximal valves on either side of
to 12 mm. The size of the cannula is chosen according to the the syringe are released and the operator moves the syringe
period of gestation and the estimated size of the uterus. It has in a rotating motion. The intrauterine contents will start
graduations with six marking dots starting at 6 cm from the being aspirated via the cannula into the syringe. After the
tip and spaced 1 cm apart. The tube is flexible and the tips syringe is about 80% full with products of conception, it is
are rounded to help minimise the risk of uterine perforation. detached from the cannula. The contents of the syringe are
emptied into a bowl. The syringe is charged again and
reattached to the cannula and the process repeated until
Principles of the procedure
the uterine cavity is empty. At the end of the procedure the
The MVA procedure can be performed in an outpatient products in the bowl can be inspected for confirmation of
setting, for example, in a treatment room in an early products of conception and sent for histology. The woman
pregnancy assessment unit. Written consent should be can then recover in an easy chair and should be allowed
obtained from the woman. Cervical preparation with to go home within 1 or 2 hours after completion of
synthetic prostaglandin E1 (misoprostol) 2–3 hours prior to the procedure.
the procedure is mostly used for termination of pregnancy or The procedure room in the outpatient department should
missed miscarriage, especially in women with a tightly closed be equipped with emergency resuscitation equipment
cervix. Some operators prefer to dilate the cervix by starting including intravenous cannulae, intravenous fluids,
with a smaller cannula and increasing the diameter until it is adrenaline (epinephrine), oxygen, atropine, oxytocin,
possible to insert the required size cannula. misoprostol and a defibrillator, to handle common medical
Misoprostol (400 micrograms) can be taken by the woman emergencies. Careful selection of low-risk women is
sublingually, orally or vaginally 2–3 hours prior to the important to reduce the chance of unexpected emergencies.
procedure. This makes the cervix softer and easier to dilate
with the plastic Karman cannula, thereby avoiding the use of
Selection criteria
a metal dilator, which may make the procedure less painful.
For pre-emptive pain relief, 500 mg naproxen or 400– There is no consensus in the literature regarding the selection
800 mg ibuprofen can be given orally 1 hour before the criteria and suitability of the women for MVA in the
procedure. In women with contraindications to nonsteroidal outpatient department, but the following criteria are used
anti-inflammatory drugs, paracetamol and/or codeine can by some:4
be used.  haemodynamically stable
Baseline observations of pulse, temperature and blood  parous women
pressure are taken on admission. The patient is asked to  well-motivated nulliparous women who can tolerate
empty her bladder just before the procedure. Vaginal speculum examination
examination is performed after cleaning and draping, with  ultrasound diagnosis of early fetal demise with crown–
the woman in the lithotomy position. The size and position rump length <25 mm
of the uterus and cervix are assessed.  ultrasound diagnosis of an incomplete miscarriage with
The MVA syringe is ‘charged’, that is, a vacuum is created retained products of conception measuring less than 5 cm
by pressing distal valves of the syringe until they click into the (mean diameter).
locking position. The plunger is then pulled backwards to  no clinical signs of infection (fever, offensive discharge or
generate a vacuum, until it locks. A Cusco’s speculum is generalised lower abdominal pain).
inserted to visualise and infiltrate the cervix with a local
Women who are not suitable for outpatient MVA include
anaesthesic. Lidocaine hydrochloride 2% anaesthetic gel may
those with:
be applied topically to the cervix, followed by paracervical
injection of local anaesthetic, (30 mg/ml prilocaine and  >10 week period of gestation
0.03 IU/ml felypressin) into the four quadrants using a  panic attacks
dental needle (0.40 x 35 mm, 27 G). About 1–5 ml, that is,  cervical stenosis

158 ª 2015 Royal College of Obstetricians and Gynaecologists

 Sharma

 fibroid uterus >12 weeks in size review commented on the economic aspect of
 uterine malformation either procedure.12
 haemorrhagic disorder and treatment with anticoagulants
 allergy or contraindication to the use of misoprostol or to
How do the complication rates compare?
local anaesthetic agents
 postnatal retained products Complications during MVA could include uterine and
 uterine infection cervical injury, pelvic infection, incomplete evacuation,
 inability to tolerate pelvic examination perforation, pain and vasovagal collapse. In 2004 Goldberg
 retained products more than 5 cm. et al.13 conducted a controlled study of complications of
MVA versus EVA in early first-trimester miscarriage. A total
of 1726 procedures were included, of which 1002 were MVAs
Role of ultrasound scan during manual
and 724 were EVAs. There was no difference in the rates of
vacuum aspiration (MVA) in outpatient
reaspiration and complications between the
setting
two procedures.13
There are no studies comparing the benefits of carrying out A more recent study carried out in 2013 by Kerure
MVA under ultrasound guidance with a routine procedure et al.14 showed that MVA in women with less than
without ultrasound guidance. Theoretically, using ultrasound 10 weeks of gestation was associated with less blood loss
may decrease the rate of perforation, ensure complete than EVA. In a series of 200 women, 1% of those in the
evacuation, avoid excessive curettage and thus prevent MVA group had incomplete evacuation compared with 4%
adhesions, but it depends on the operator’s expertise in of those in the EVA group. There were no cervical
scanning and may increase the overall duration of the lacerations in the MVA group compared with 3% in the
procedure. More studies are required to establish its benefits. EVA group.14
Theoretically, the risk of uterine perforation should be
lower in conscious women than in women under anaesthesia
Evidence
as they would be able to give an indication of severe pain
Several studies have shown MVA to be a safe, effective and before the uterus is perforated.
acceptable alternative to electric vacuum aspiration with
very high success rates.5–12 In 1997 Creinen and Edwards7
Cost-effectiveness
reported their experience of early surgical termination of
pregnancy using MVA under local anaesthesia in 2399 The MVA syringe and cannula itself costs about £12. As MVA
women, with complete uterine evacuation reported in can be performed in the outpatient setting it also reduces the
99.2%. A pilot study in the UK involving 56 women cost and use of theatre facilities. It has the advantage of early
investigated the feasibility and acceptability of MVA and recovery and reduced hospital stay compared with EVA. A
showed that 98% of women had a successful procedure study at Michigan University compared 115 women
without the need for any further surgical or medical undergoing MVA in an office setting with 50 women
intervention. Also, 98% of women were satisfied with the undergoing EVA in theatre.15 Operation room management
procedure and 86% said they would recommend it to a of early pregnancy failure incurred greater costs and required
friend. Eighty percent said they would undergo the same more resources based on all surrogate measures. The
procedure again, if required in the future.11 Another study procedure itself took 80% longer and estimated costs were
in the UK involving 246 women undergoing MVA under more than two-fold higher in the operating room than in the
local anaesthesia for first-trimester, early fetal demise and office setting. For both groups, complication rates were
mid-trimester incomplete miscarriage reported complete consistent with published rates. Performing MVA in an office
uterine evacuation in 95%, with the remaining 5% setting resulted in almost $1,000 savings per case. In the same
requiring additional treatment.5 A systematic review of study, a cost-effectiveness model examining different care
ten randomised trials involving a total of 1660 women strategies estimated that using MVA could save $779 million
compared MVA versus EVA in first-trimester miscarriage. per year over traditional methods. Blumenthal and
No difference was found in the number of complete Remsburg6 performed a cost-analysis of MVA compared
evacuations and patient satisfaction. With a gestation with EVA conducted in the operating theatre. MVA
period of less than 50 days, MVA was associated with procedures resulted in significant savings in terms of both
less blood loss and pain. However, operation time was waiting times and costs. Waiting time was reduced by 52%
shorter in women in the EVA group and physicians and procedure time was reduced from a mean of 33 to
considered it easier to perform. No trials in this systematic 19 minutes (P < 0.01). Total hospital costs were reduced by
41% (P < 0.01).6

ª 2015 Royal College of Obstetricians and Gynaecologists 159

 MVA in miscarriage

A 2006 UK multicentre randomised trial reported that sufficient time to decide. Detailed counselling about what
the overall cost of surgical evacuation for miscarriage to expect during the MVA procedure, aftercare and a specific
under general anaesthesia in theatre is estimated to be telephone contact number to call if they need further
£1,585.16 A study in Sweden estimated that performing discussion or support will help women to cope with the
MVA in the outpatient setting rather than in an operating procedure better.
room would result in cost savings of 24% from the
operating theatre and surveillance time. The authors
Training
estimated that, if one-tenth of Sweden’s procedures were
conducted with MVA, the national savings would be about The RCOG training courses on MVA are helpful for doctors
$1,140,000 annually.17 In addition, there is an extrapolated new to the technique. These half-day training courses are
cost saving from the management of fewer post-MVA organised annually by the RCOG. Trainees should ideally
complications compared with EVA.17 perform their first few MVAs under general anaesthesia in the
operating theatre under the supervision of experienced staff
using an MVA kit. This would help them familiarise with the
Pain management
equipment and procedure prior to performing MVAs on
One of the most important factors for the success of conscious women in the outpatient setting.
outpatient MVA is the appropriate management of pain
during and after the procedure. Women’s experience with
Conclusion
pain during MVA varies widely, with some women feeling
no pain while others describe considerable pain. The source In recent years, MVA has gained increasing popularity in
of the pain could be anxiety, cervical dilatation and/or the USA and mainland Europe. It is also gradually gaining
uterine manipulation and evacuation. Adequate pain relief acceptance as an alternative procedure for the surgical
should be offered through pre-procedure and post- management of miscarriage in many NHS trusts across the
procedure analgesia, and adequate use of local UK. The slower acceptance of MVA in the context of NHS
anaesthesia. Nitrous oxide is useful for women who have hospitals could be a result of a lack of familiarity with the
severe pain during the procedure. A woman’s anxiety level procedure among women and doctors. Studies have shown
strongly influences her perception of pain. Her level of no statistical difference in women’s acceptability of MVA
comfort can be improved by different factors such as a compared to EVA.7,20 National Institute for Health and
procedure room that is quiet, comfortable and relaxing, Care Excellence guidance on the management of
and a clear explanation of what to expect before, during miscarriage recommends that when clinically indicated,
and after the procedure. Healthcare professionals who are women should be offered the choice of MVA in the
calm, friendly, empathetic, unhurried and efficient can also outpatient setting.1 The acceptability of MVA among
make a considerable difference. women could be considerably enhanced by effective
The uterine fundus is innervated by T10 to L1 spinal nerves. counselling. Motivated, well informed and experienced
These nerves follow along the ovarian plexus and uterosacral clinicians, with careful selection of cases, proper training,
and utero-ovarian ligament. They are not fully accessible by regular audits and patient feedback would help to establish
the paracervical block since they accompany the ovarian MVA as a safe and effective choice for women requiring
vessels and are higher in the pelvis than the local infiltration surgical management of miscarriage.
will reach.18 Ibuprofen 400–800 mg or naproxen 500 mg
given 30–60 minutes prior to the procedure are recommended Contribution of authorship
to decrease the pain caused by uterine cramping.19 MS solely contributed to conception and design of the article,
literature review and writing of article.
Ethical issues
Disclosure of interests
Miscarriage is an event in a woman’s life that is beyond her The author reports no conflict of interest.
control. During this vulnerable period some women may not
be able to tolerate the procedure under local anaesthesia. The
References
woman’s preference should be the primary consideration at
the time of this early pregnancy loss. Informed choice should 1 National Institute for Health and Care Excellence. Ectopic Pregnancy and
be the underlying aim when offering options for management Miscarriage: Diagnosis and Initial Management in Early Pregnancy of Ectopic
Pregnancy and Miscarriage. NICE Clinical Guideline 154. London: NICE; 2012.
of miscarriage. 2 Royal College of Obstetricians and Gynaecologists. The Care of Women
Women should be fully counselled on what to expect with Requesting Induced Abortion: Evidence-based Green-top Guideline No. 7.
each method and be given an information leaflet and London: RCOG; 2011.

160 ª 2015 Royal College of Obstetricians and Gynaecologists

 Sharma

3 Karman H, Potts M. Very early abortion using syringe as vacuum source. 13 Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus
Lancet 1972;1:1051–2. electric vacuum aspiration for early first-trimester abortion: a controlled
4 Jurkovic D, Farquharson R, editors. Acute Gynaecology and Early study of complication rates. Obstet Gynecol 2004;103:101–7.
Pregnancy: Advanced Skills Series. London: RCOG Press; 2011. 14 Kerure SB, Kerure RD, Sagarad SS, Biradar V. A comparative study of manual
5 Milingos DS, Mathur M, Smith NC, Ashok PW. Manual vacuum aspiration: a vacuum aspiration (MVA) & electric vacuum aspiration (EVA) for pregnancy
safe alternative for the surgical management of early pregnancy loss. BJOG termination of up to 10 weeks gestation. Int J Reprod Contracept Obstet
2009;116:1268–71. Gynecol 2013;2:199–203.
6 Blumenthal PD, Remsburg RE. A time and cost analysis of the management 15 Dalton VK, Harris L, Weisman CS, Guire K, Castleman L, Lebovic D. Patient
of incomplete abortion with manual vacuum aspiration. Int J Gynaecol preferences, satisfaction, and resource use in office evacuation of early
Obstet 1994;45:261–7. pregnancy failure. Obstet Gynecol 2006;108:103–10.
7 Creinin MD, Edwards J. Early abortion: surgical and medical options. 16 Petrou S, Trinder J, Brocklehurst P, Smith L. Economic evaluation of
Current Problems in Obstetrics Gynecology and Fertility 1997;20:6–32. alternative management methods of first-trimester miscarriage based on
8 Macisaac L, Darney P. Early surgical abortion: an alternative to and backup results from the MIST trial. BJOG 2006;113:879–89.
for medical abortion. Am J Obstet Gynecol 2000;183(2 Suppl):S76–83. 17 Hemlin J, M€ oller B. Manual vacuum aspiration, a safe and effective
9 Mahomed K, Healy J, Tandon S. A comparison of manual vacuum alternative in early pregnancy termination. Acta Obstet Gynecol Scand
aspiration (MVA) and sharp curettage in the management of incomplete 2001;80:563–7.
abortion. Int J Gynaecol Obstet 1994;46:27–32. 18 Maltzer DS, Maltzer MC, Wiebe ER, Halvor-Boyd G, Boyd C. Pain
10 Westfall JM, Sophocles A, Burggraf H, Ellis S. Manual vacuum aspiration for management. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA,
first-trimester abortion. Arch Fam Med 1998;7:559–62. Stubblefield PG, editors. A Clinician’s Guide to Medical and Surgical
11 Hamoda H, Flett GM, Ashok PW, Templeton A. Surgical abortion using Abortion. New York NY: Churchill Livingstone; 1999.
manual vacuum aspiration under local anaesthesia: a pilot study of 19 Wiebe ER, Rawling M. Pain control in abortion. Int J Gynaecol Obstet
feasibility and women’s acceptability. J Fam Plann Reprod Health Care 1995;50:41–6.
2005;31:185–8. 20 Bird ST, Harvey SM, Nichols MD, Edelman A. Comparing the acceptability of
12 Wen J, Cai QY, Deng F, Li YP. Manual versus electric vacuum aspiration for manual vacuum aspiration and electric vacuum aspiration as methods of
first-trimester abortion: a systematic review. BJOG 2008;115:5–13. early abortion. J Am Med Womens Assoc 2001;56:124–6.

ª 2015 Royal College of Obstetricians and Gynaecologists 161