Uterine Aspiration for Biopsy or Miscarriage Management

Manual vacuum aspiration (MVA) can be used in the office setting for easy sampling of the uterine endometrium with a 4-mm or 5-mm cannula when a small endometrial biopsy catheter is insufficient (Fig. 28-19). The MVA can also be used in the office for removal of retained products of conception after an incomplete or missed miscarriage up to 12 weeks without the added cost of an emergency room visit, surgical suite, and general anesthesia. The MVA device is a handheld plastic aspirator syringe attached to a plastic cannula of varying sizes. The cannula can be flexible or rigid to allow for provider preference. Vacuum aspiration is safe, quick to perform and less painful than sharp curettage and should be recommended for use in the management of incomplete abortion (Forna and Gulmezoglu, 2001).

Confirmation of a non-viable pregnancy or incomplete abortion is verified with a falling serum p-hCG level, an appropriately timed ultrasound, or by clinical findings of uterine bleeding in pregnancy with significant cervical dilation in the first trimester. A blood type is obtained to determine if Rho-GAM is necessary. A hematocrit may be obtained if bleeding has been significant. Once informed consent outlining the risks of bleeding, pelvic infection, uterine perforation, Asherman's adhesions, and possible need for reaspiration is obtained, the patient may receive a sedative, analgesia, or anesthesia. Most women do well with an oral NSAID for analgesia and a paracervical block for local anesthesia. For comfort, the patient should void before the procedure.

The patient is placed in the dorsal lithotomy position, and uterine size, location, and shape are assessed. A transvaginal or transabdominal ultrasound can be performed at this time to confirm findings but is not required. A speculum is placed intravaginally, vagina and cervix are cleansed, and a paracer-vical block is placed before the procedure. A single-toothed tenaculum is placed on the anterior cervix.

The uterus is sounded to the fundus to determine intra-cavitary size and position. If not already dilated, the cervical os is successively dilated to a size in millimeters corresponding to the gestational age, using Denniston, Pratt, or Hegar dilators. The MVA curette is generally chosen in millimeters to correspond to the gestational age in weeks as well. Thumb buttons are used to occlude the opening to the MVA barrel, and the plunger is retracted and allowed to snap into place

Figure 28-19 The Ipas manual vacuum aspirator (MVA) is displayed with 4-mm and 5-mm cannulas used for miscarriage management in outpatient setting. Note thumb buttons that close the barrel entrance to hold negative pressure in the canister when the plunger is retracted. The buttons are then released to transfer the suction pressure to the cannula once in place.

to develop the negative pressure for suction. The cannula is attached to the MVA and placed through the cervix to the uterine fundus. The thumb buttons on each side are released, and the negative suction from the syringe is transferred to the endometrial cavity. The MVA barrel can be rotated and then brought in and out in a piston motion to dislodge the remaining products of conception. These can be observed passing through the cannula and can be evaluated fully by visual or pathologic examination after the procedure. The syringe may need to be emptied and the negative pressure reapplied based on the volume of the uterine contents. A sensation of grittiness is present in the fundus and all four uterine quadrants when the products of conception are completely removed and the cannula makes contact with the myometrium.

On completion, the MVA cannula is removed from the uterus, tenaculum from the cervix, and speculum from the vagina. The patient is observed for 15 to 30 minutes to assess for excessive bleeding, hemodynamic stability, and unusual pain. Intrarectal or intravaginal misoprostol, intracervical or intramuscular methylergonovine, and intramuscular carbo-prost may be used for excessive bleeding. The patient may be discharged and instructed to refrain from intercourse for 2 weeks or until the bleeding resolves. She should return for excessive bleeding, significant pelvic or abdominal pain, and fever. A form of contraception is provided if the patient desires.

Pregnancy Guide

Pregnancy Guide

A Beginner's Guide to Healthy Pregnancy. If you suspect, or know, that you are pregnant, we ho pe you have already visited your doctor. Presuming that you have confirmed your suspicions and that this is your first child, or that you wish to take better care of yourself d uring pregnancy than you did during your other pregnancies; you have come to the right place.

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