Unit II:- Bleedings in early

pregnancy
 Bleedings in early pregnancy
Reflective activity;
Why do you think the reason for a certain
women to bleed in early pregnancy?
 Bleedings in early pregnancy

Cause:
1. Abortion
2. Ectopic pregnancy
3. Gestational trophoblastic diseases
4. Other pregnancy unrelated causes:
-accidental trauma
-genital infections & cancers
 Abortion

• is the termination of pregnancy or expulsion of the

fetus either spontaneously or by induction before it
reaches viability
• before 20 weeks of gestation in developed country and
28 weeks of gestation in developing country.
• Between 10 and 15% of all pregnancies terminate as
spontaneous abortions,
• 10-60% are terminated by an induced abortion.
• The majority of spontaneous abortions occur between
the 8th and 12th weeks of pregnancy
 Abortion

• It can be induced or spontaneous in type.

• Spontaneous abortion is pregnancy loss at
less than 20/28 weeks' gestation in the
absence of elective medical or surgical
measures to terminate the pregnancy.
• The term “miscarriage” is can be synonymous
 Causes of spontaneous abortion

• 3 categories -- fetal, maternal and paternal

Fetal causes
• Chromosomal abnormality or disease of the
fertilized ovum may account for 60% of
spontaneous -- 1st TM abortions.
• Malformation of the trophoblast and poor
implantation of the blastocyst may result in
placental separation with consequent hypoxia
and impaired embryonic development.
 Causes…

Maternal causes
• Disease acquired during pregnancy such as rubella or
influenza, + fever + sepsis
• interfere with transplacental oxygenation and may
precipitate abortion.
• Chronic disorders-- renal disease accompanied by HTN,
• Drugs - large doses of any drug are poisonous
• ABO incompatibility between mother and embryo may
result in abortion.
• Psychological factors
 Causes…

Local disorders of the genital tract

• retroverted uterus which is unable to rise out of the
pelvis may occasionally predispose to abortion.
• Developmental defects such as a bicornuate uterus and
myomas
• Cervical incompetence
Paternal causes
• Since the paternal spermatozoon gives to the ovum half
of its chromosomes, any defects may result in abortions.
Other -- trauma -- accidental or intentional
 Mechanism of abortion
• In the first 8 wks: separation of the decidua basalis
and the ovum is expelled with the decidua
• Between 8-12 weeks: rupture decidua capsularis and
the embryo expelled through the decidua.
 Mechanism…
• After 12 weeks: the abortion is a miniature
labour.
• Uterine contractions result in cervical
dilatation,
• followed by fetal and placental expulsion
 Types of spontaneous abortion

1. Threatened abortion
2. Inevitable Abortion
3. Complete
4. Incomplete
5. Missed
6. Habitual abortion
7. Septic abortion
 1. Threatened abortion

 It is presumed that a pregnancy is threatening to abort

 refers to mild vaginal bleeding prior to 20 weeks
gestation without any cervical dilatation or effacement.
 70-80% of all mothers diagnosed as having threatened
abortion in the first trimester will continue with their
pregnancies to term.
Diagnosis:
• Vaginal bleeding is minimal in amount.
• Suprapubic pain is mild and pelvic heaviness may be
present.
 Threatened…
• On bimanual examination: the uterine size
corresponds to GA, and the cervix is closed.
• Quantitative hCG assay matches well with the
duration of pregnancy.
• Ultrasonography shows:
– An intact pregnancy, correlating with the date of
the LMP.
– After the 7th week, fetal pulsations are evident.
 Threatened…

Sign and symptoms

• Light bleeding (takes longer than 5 minutes for a
clean pad or cloth to be soaked )
• Closed cervix
• Uterus corresponds to dates
• Cramping/lower abdominal pain
• Uterus softer than normal
 Threatened…
Management
• Medical treatment is usually not necessary.
• Advise the woman to avoid strenuous activity and sexual
intercourse.
• If bleeding stops, follow up ANC. Reassess if bleeding recurs.
• If bleeding persists, assess for fetal viability (pregnancy
test/ultrasound) or ectopic pregnancy (ultrasound).
• Persistent bleeding, particularly in the presence of a uterus
larger than expected, may indicate twins or molar
pregnancy.
 2. Inevitable Abortion

• When it is impossible for the pregnancy to continue it is

termed as inevitable abortion.
• excessive uterine bleeding prior to 20 weeks gestation,
accompanied by uterine contractions and cervical
dilatation, without expulsion of fetal or placental tissue
through the cervical os
• Profuse vaginal bleeding which suggests that a large
section of the placenta has separated from the uterine
wall.
• The abdominal pain becomes more acute and rhythmic in
character
 Inevitable…

Diagnosis:
• Bleeding is usually excessive with passage of blood clots.
• Suprapubic pain is always present. It may be severe, radiating to
the back (like labour pains)
• Hypovolaemic shock: may occur whenever blood loss is rapid and
severe, especially in anaemic patients.
• General examination: hypotension, tachycardia, tachypnia and
oliguria.
• Bimanual Examination:
– The uterus corresponds to GA or slightly smaller.
– The cervix is dilated and products of conception may be felt through
cervical os.
 Inevitable…
Ultrasonography shows:
• The foetus is usually dead.
• The placenta is partially or completely separated.
• The internal os is dilated.
Sign and symptoms
• Heavy bleeding (takes less than 5 minutes for a clean pad or cloth
to be soaked )
• Dilated cervix
• Uterus corresponds to dates Cramping/lower abdominal pain
• Tender uterus
• No expulsion of products of conception
 Inevitable…
Management
• If pregnancy is < 12 wks, plan for evacuation of
uterine contents – MVA
• If evacuation is not immediately possible:
• Give ergometrine 0.2 mg IM (repeated after 15
minutes if necessary) OR misoprostol 400 mcg PO
(repeated once after 4 hours if necessary);
• Arrange for evacuation of uterus as soon as possible.
 Inevitable…
Mgt…
• If pregnancy is greater than 12 weeks:
• Await spontaneous expulsion of products of conception
• then evacuate the uterus to remove any remaining
products of conception;
• If necessary, infuse oxytocin 40 units in 1 L IV fluids
(normal saline or Ringer’s lactate) at 40 drops per
minute to help achieve expulsion of products of
conception.
• Ensure follow-up of the woman after treatment.
 3. Complete abortion

• A complete abortion is more likely to occur prior to the

8th week of pregnancy and constitutes the expulsion of
All products of conception (the embryo, placenta and
intact membranes.)
• There is relief from pain and the bleeding usually stops 
Clinical diagnosis: The bleeding diminishes significantly,
pains disappear gradually, the uterus diminishes in size,
and the cervix becomes closed on vaginal examination.
Ultrasound diagnosis: Empty uterus with no fetal or
placental contents detected
 Complete …

Sign and symptoms

• Light bleeding, Closed cervix, Uterus smaller than dates
• Uterus softer than normal
• Light cramping/lower abdominal pain
• History of expulsion of products of conception
Management
• Evacuation of the uterus is usually not necessary.
• Observe for heavy bleeding.
• Reassurance and Ensure follow-up of the woman after treatment
 4. Incomplete Abortion

• When the products of conception are only partially

evacuated during abortion, the abortion is incomplete.
This usually occurs in the second trimester.
• Bleeding is profuse but the abdominal pain and back
ache may cease.
• The cervix will be soft and purplish in color and will be
partly closed.
• Prolonged retention of the tissues predisposes the
woman to infection and immediate medical
intervention is needed.
 Incomplete…
Management
• If bleeding is light to moderate and pregnancy is less
than 12 weeks, use fingers or ring (or sponge)
forceps to remove products of conception protruding
through the cervix.
• If bleeding is heavy and pregnancy is less than 12
weeks, evacuate the uterus:
• MVA is the preferred method of evacuation.
 Incomplete…
• Evacuation by sharp curettage should only be done if
MVA is not available;
• If evacuation is not immediately possible, give
ergometrine 0.2 mg IM (repeated after 15 minutes if
necessary) OR misoprostol 400 mcg orally (repeated
once after 4 hours if necessary).
 Incomplete…
• If pregnancy is greater than 12 weeks:
• Infuse oxytocin 40 units in 1 L IV fluids (normal saline
or Ringer’s lactate) at 40 drops per minute until
expulsion of products of conception occurs;
• If necessary, give misoprostol 200 mcg vaginally
every 4 hours until expulsion, but do not administer
more than 800 mcg;
• Evacuate any remaining products of conception from
the uterus.
• Ensure follow-up of the woman after treatment
 5. Missed abortion

• It is death of the foetus < 20 weeks, with prolonged

retention of foetal and placental tissue in utero for
several weeks
• Pain and bleeding may cease but the mother may
experience a residual brown vaginal discharge as
having an odour of decaying matter and it can be
offensive and distressing.
• - All other physiological signs of pregnancy will regress,
• uterine enlargement will cease and a pregnancy test
will prove negative
 Missed…
• Symptoms and signs: Recurrent attacks of mild
vaginal bleeding, which is usually dark brown in
colour, with minimal or no pain. The uterus is normal
size, or smaller for gestational age, and the cervix is
formed and closed.  
• Ultrasonography may reveal either:
– Anembryonic sac: small for date gestational sac, with no embryonic
echoes (blighted ovum).
– A dead embryo (< 9.0 weeks) with no evidence of pulsations.

• A dead foetus (> 9.0 weeks), with no movements or

cardiac pulsations
 Missed…
Conservative treatment:  if left alone
spontaneous expulsion will occur
Surgical evacuation of the uterus; by D & C:
Indicated in 1st TM missed abortion
Medical termination of pregnancy: by
Misoprostopl
Subsequent surgical evacuation is needed in
cases of RPOC
The main side effects of cytotec are nausea,
vomiting and fever. 
 6. Recurrent abortion (habitual)

• This term is applied when a mother has had at least

two consecutive spontaneous abortions before.
• The risk of further abortion increases with each
successive aborted pregnancy.
• The majority of mothers who encounter this problem
will loss their babies in the early weeks of pregnancy.
• If a pregnancy continues following a mid trimester
threatened abortion there is a greater risk of
preterm labour.
 7. Septic abortion

• refers to abortion is complicated by Infection

• This may be due to criminal interference
• It may be associated with incomplete abortion but is
more commonly found after an induced abortion.
• severe vaginal bleeding with passage of product of
conception, with or without history of evacuation
• Features of pelvic infection
 Septic…
• The infection may be limited to the decidual
lining of the uterus but virulent organisms may
cause the infection to spread and involve the
myometrium, fallopian tubes and pelvic organs.
Types :
 Mild  the infection is confined to decidua : 80%
 Moderate the infection extended to myometrium15%
 Severe the infection extended to pelvis + Endotoxic
shock + DIC 5%
 Septic…
Sign and symptoms
• Lower abdominal pain
• Rebound tenderness
• Tender uterus
• Prolonged bleeding
• Malaise
• Fever
• Foul-smelling vaginal discharge
• Purulent cervical discharge
• Cervical motion tenderness
 Septic…
Management
• Begin antibiotics as soon as possible before
attempting manual vacuum aspiration
• Give ampicillin 2 g IV every 6 hours + gentamicin
5 mg/kg body weight IV every 24 hours PLUS
metronidazole 500 mg IV every 8 hours until the
woman is fever-free for 48 hours.
• Dilatation and curettage will be performed
preferably after the acute infection subsides
Induced

Abortion
abortion
 Induced abortion
INTRODUCTION

Induced abortion is a controversial topic that creates a complex

and emotional debate.

Unintended pregnancy is a problem that may never be fully resolved, and women who do not
wish to continue a pregnancy will often seek out termination by any means, regardless of safety.

All patients choosing abortion are entitled to quality care by practitioners who are qualified to
perform procedures and to identify and manage complications.

Clinical guidelines were prepared with the best available evidence and professional consensus on
induced abortions.

abortion
 Debate
Is performing induced abortion legal or not?

abortion
 Induced abortion

I. Therapeutic abortion/ safe abortion

• Legal termination of pregnancy is a therapeutic procedure that is
offered to clients as permitted by the law.
• It is important to provide adequate counseling and support prior
and following procedure
• Many mothers do not make the decision to have a pregnancy
terminated with out some inner conflict.
• There are religious, psychological, social and cultural factors, which
affect the woman's decision.
• Important considerations are her economic and marital status, the
health and well being of existing children in the family and the
presence of an abnormal fetus.
II. Criminal abortion/ unsafe
• A criminal abortion is one performed in contravention of
legal abortion.
• Such procedures are illegal and are punishable by
imprisonment.
• The abortion is attempted by an unqualified person. Injuries
to the birth canal and pelvic organs can occur if implements
are inserted.
• It is usually the subsequent bleeding which causes a mother
to seek professional help and care should be given as for
threatened abortion until medical assistance arrives.
Who is at risk of unsafe abortion?
• Poor women
• Adolescents, especially unmarried
• Rural women
• Refugees or internally displaced

40
40
 Abortion is allowed by law in the following
conditions:
CONSTITUTION OF FDRE Article 551
Implementation guide for article 551
1. Pregnancy is a result of rape/ incest – 1 –A
2. Px endanger the life of mother/ child – s 1B
3. When the fetus has incurable deformity – s 1C
4. When she has physical/ mental deficiency/ minor
1D
5. In case of grave and imminent danger – s 2
Elements of woman centered CAC

42
42
Key reproductive rights related to abortion

• The right to life

– No woman’s life should be put at risk by reason’s of
pregnancy
• The right to privacy
• The right to information and education
• The right to decide whether or when to have
children
• The right to benefit from scientific progress

43
43
 Timing & place for terminating pregnancy
• In a public/ private facility that fulfills the pre-set
criteria
• At the level of a health center and above if < 12 weeks
of gestation
• In a secondary or tertiary level of care if 13-28 weeks
of gestation

Women who are eligible for termination should have the necessary
information to seek abortion care as early in pregnancy as possible

44
44
 Methods of Induced…
1. Medication abortion
2. Manual vacuum aspiration
Medication-Abortion Pills
Mechanism of induced abortion
 Mifepristone
• First developed and approved for clinical use in 1988 in
France (RU-486).
• Blocks progesterone activity in the uterus, leading to
detachment of the pregnancy.
Misoprostol
• Prostaglandin analogue that stimulates uterine
contractions and facilitate cx diltation
• stable at room temperature & available in the market.
• Easily absorbed orally/ vaginally.
• Commonly used for rx of gastric ulcers.
 Effectiveness
• Combination of two drugs more effective than
either used alone.
• Combined regimen is 92 to 98 percent
effective in pregnancies ≤ nine weeks since
last menstrual period (LMP)
 Diagnose and Date Pregnancy
• Confirm that the pregnancy is 63 days/nine
weeks or less since the LMP.
• Date pregnancy through medical history,
pregnancy test and bimanual exam.
• Ultrasound used to date pregnancy can be
helpful but is not required.
 Contraindication of MA

• Ectopic pregnancy (confirmed or suspected) or undiagnosed

adnexal mass
• Allergy to mifepristone, misoprostol or other prostaglandin
• Current use of long-term systemic corticosteroid
• Chronic adrenal failure
• Hemorrhagic disorder
• Current anticoagulant therapy
• Inherited porphyria
• IUD in place (remove before giving mifepristone)
 Administration of Mifepristone

• Administer 200mg mifepristone orally.

• Most women will feel no change after taking the pill.
• Some women will begin bleeding before taking the
next pill (misoprostol).
• A few women will abort after the mifepristone alone.
 Dosage and route
Less than 7 weeks
• Mifepristone 200mg PO followed 24-48h later by
 Misoprostol 800 mcg vaginally or sublingual or bucal
 Misoprostol 400 mcg oral less than 7weeks

(WHO Clinical practice hand book 2014 , MOH training

manual)
 Dosage and route
Less than 9 weeks
• Mifepristone 200mg per os followed 24-48h later by
• Misoprostol 800 mcg vaginally, sublingual or bucal
or 400mcg misoprostol oral

Source …June TPGL 2014 page 13

 Administration of Misoprostol

• There is a range of options in route, dosage and

timing.
• Institutional or national policy determines instructions
to be followed.
• Client safety and convenience should be considered.
• After seven weeks LMP, vaginal doses are more
effective than oral doses.
• Up to 90% of women will expel tissue within six hours
of vaginal dose (WHO, 2003).
Protocol for Misoprostol Administration
Day 1 is defined as the day mifepristone is taken.

Vaginal use:
56 days/8 weeks On Day 2, 3 or 4, insert four 200mcg tablets
(800mcg total) of misoprostol.
56–63 days/ On Day 2 or 3, insert four 200mcg tablets
8–9 weeks (800mcg total) of misoprostol.
Oral use:
49 days/7 weeks On Day 2 or 3, take two 200mcg (400mcg
total) tablets of misoprostol.
49–63 days/ Not recommended due to lower efficacy—
7–9 weeks use vaginal misoprostol.

(Schaff et al., 2000; Schaff et al., 1997; Ashok et al., 1998; and Creinin et al., 1999.)
 Instructions for Vaginal Insertion

• Empty the bladder.

• Wash hands.
• Insert misoprostol tablets, one after the other.
• Push tablets far up into the vagina.
• Tablets may not fully dissolve.
 Misoprostol Alone
• Effectiveness: 85 to 90% ≤ 63 days/ nine
weeks LMP
• Current recommended regimen:
– 800mcg misoprostol vaginally, taken twice
at 24-hour intervals (1600mcg total)
(Gynuity Health Projects and Reproductive Health Technologies
Project, 2003)
 Counseling Should Include
• Eligibility, regimen, effectiveness, protocols
• Side effects and complications
• Ensuring access to emergency care
• Contraceptive needs
• Informed consent
Pain During Medication Abortion
• Pain usually begins one to three hours
after taking the misoprostol.
• Cramping occurs during uterine
contractions and POC expulsion.
• Pain levels vary greatly among women.
• Pain diminishes after abortion is
complete.
 Managing the Pain
• Verbal support:
– Counseling about what to expect
– Reassurance during the abortion
• Low heat to the abdomen or lower back
– Hot-water bottle
– Warm cloths
• Hot bath or shower
 Pain Medications
• Should be taken before cramping begins
• Non-narcotic and narcotic analgesics can
be used:
– Paracetamol (acetaminophen), with or
without codeine
– Ibuprofen
– Codeine
• NSAIDs do not interfere with misoprostol
 Medication-Abortion Complications

• Medication abortion is associated with few

serious complications.
• Occasional complications include:
– Failed abortion
– Hemorrhage
– Infection
What Women Need to Know Before Leaving
the Clinic
• When to return for a routine but important
follow-up visit.
• How to recognize warning signs; when and
where to seek medical help.
• That they can become pregnant again as
early as 10 days after the abortion.
• That most women can begin contraception
before the follow-up visit.
Warning Signs During or After Abortion

• Excessive bleeding (for example, soaking more

than two or three thick pads per hour for two
consecutive hours)
• Persistent fever of 38C/100.4F or higher or
fever beginning more than eight hours after
taking misoprostol
• No bleeding within 24 hours of taking
misoprostol
 Follow-Up Visit
• Inquire about the woman’s experience
with the abortion.
• Assess the completeness of the abortion.
• Review any laboratory test results with
the woman.
• Discuss contraception and provide a
contraceptive method, if she desires one.
Assess Completeness of Abortion
• Return visit -- Ask the woman if she thinks the
abortion was complete.
• Take a history: Amount and duration of
bleeding, cramping, passage of clots.
• Conduct a physical examination.
• If it is unclear whether the abortion is
complete, perform ultrasound or check -hCG
levels (if done prior to the abortion as well).
 Continuing Pregnancy

• If the pregnancy continues, terminate

the pregnancy through other means,
preferably vacuum aspiration.
 Failed Abortion
• If there is a persistent gestational sac,
treatment options include:
– Expectant management, giving more time for
expulsion of the POC
– A repeat dose of vaginal misoprostol
– Vacuum aspiration (preferable to sharp curettage)
 Inform the Woman About Failure
• Small risk that medication abortion will not
work.
• Slight risk that medications could cause birth
defects if the pregnancy continues.
• If medication abortion does not work, she
should undergo vacuum aspiration.
 2. Manual vacuum aspiration
• a simple procedure done early in pregnancy,
which uses the suction of a syringe to remove
the pregnancy tissue from the uterus.
• A local anaesthetic is used to numb the cervix
and medicines to reduce pain and anxiety may
also be offered.
 MVA has three parts
1. MVA Cylinder
2. Valve
3. Cannulae

NB: 1 & 2 in combination are called MVA

aspirator
MVA Parts Disassembled
Parts Assembled
 Selection of Cannulae
• Depends on uterine size and amount of
dilation:
– Uterine size 4–6 weeks LMP:
suggest 4–7mm
– Uterine size 7–9 weeks LMP:
suggest 5–10mm
– Uterine size 9–12 weeks LMP:
suggest 8–12mm
 Disassembling the Aspirator
• Remove cannula by twisting its base and
pulling it out of valve.
• Pull cylinder and remove from valve.
• Press cap-release tabs to remove cap.
• Open hinged valve by pulling open clasp.
Disassembling the Aspirator (cont.)
• Remove valve liner.
• Disengage collar stop by sliding under
retaining clip, or remove completely.
• Pull plunger completely out of cylinder.
• Displace O-ring by squeezing its sides
and roll down into groove below.
Remove the O-Ring
 Assembling the Ipas MVA Plus ®

• Place valve liner in valve by aligning ridges.

• Close valve; ensure it snaps into place.
• Snap cap onto end of valve.
• Push cylinder straight into base of valve.
• Place O-ring into groove near tip of plunger.
Assembling the Ipas MVA Plus ®
(cont.)

• Spread one drop of lubricant around O-ring

with finger.
• Squeeze plunger arms, push fully into cylinder.
• Move plunger in and out to lubricate.
• Insert collar stop tabs into holes in cylinder.
When Assembling the Aspirator
• Introduce plunger straight into cylinder.
• Do not introduce plunger at an angle.
Steps to Lubrication
Create a Vacuum
 Creating a Vacuum
• Begin with valve buttons open, plunger
all the way in and collar stop locked in
place.
• Close valve by pushing buttons down
and forward until they lock.
• Pull plunger back until plunger arms
catch on wide sides of cylinder.
 Creating a Vacuum (cont.)
• Ensure that both arms are extended
and secured over edge of cylinder.
– Incorrect positioning of plunger arms can
allow plunger to slip back into cylinder
 Check Aspirator for Vacuum
• Charge aspirator.
• Leave charged for several moments.
• Push buttons to release vacuum.
• A rush of air indicates vacuum was retained.
Checking Why Vacuum Fails
• Check that instrument is properly
assembled.
• Inspect O-ring for proper positioning and
lubrication.
• If damaged, replace O-ring.
• Ensure no foreign bodies are present.
• Check cylinder is firmly seated on valve.
 Checking Why Vacuum Fails (cont.)
• Charge and test again.
• If vacuum is still not retained, use another
aspirator.
 Post abortion family planning
• All women receiving post abortion care need
counseling and information to ensure that they
understand:
• They can become pregnant again before the next
menses
• There are safe methods to prevent or delay
pregnancy
• Where and how they can obtain family planning
service
Components of Post abortion care (PAC)
• Emergency treatment of incomplete abortion
and potentially life threatening complications
• Post-abortion family planning counseling and
services
• Links between post-abortion emergency services
and the reproductive health care system.
• Community service provider partnership
• Counseling
Clinical assessment during abortion

• Check vital signs.

• Note lethargy, malnourishment.
• Check her abdomen for masses,
tenderness.
 Pelvic Exam
• Ensure her privacy is protected.
• Ask the woman to empty her bladder.
• Help her move into lithotomy position.
• Attend to any special physical needs.
• Conduct both a speculum and a bimanual exam.

NB: It is recommended to do pelvic exam in the presence of female

assistants
Lithotomy Position
 Speculum Exam
• Gently insert appropriately sized speculum.
• Check for bleeding, discharge, pus, lesions,
mass, cervical opening, conceptus tissue,
etc.

NB: Care should be taken during speculum insertion and removal to

avoid inflicting pain and trauma
 Bimanual Uterine Examination
• Assess uterine size, consistency and
position.
• Compare the size of the uterus with her
history of amenorrhea.
• Assess cervical condition (consistency,
tenderness, etc.)
• Check for adnexa (mass and tenderness)
 Reminder:
Uterine Size estimation
A. History
• Last normal menstrual period
C. Physical exam
• Bimanual pelvic exam
Uncertain About Uterine Size?

• Ask another provider to check/ consult.

• Use ultrasound (if available).
 Lab Tests
• No routine labs test is required.
(History and exam usually sufficient)

• If there is doubt, use pregnancy test or

ultrasound.
• Hemoglobin, hematocrit optional.
• Rh iso-immunization
UTERINE EVACUATION USING MVA AND PAIN
MANAGEMENT
 Purpose
The module explains the steps for
performing a manual vacuum
aspiration (MVA) procedure using the
Ipas MVA Plus® aspirator and Ipas
EasyGrip® cannulae within a woman-
centered care context.
 Objectives
1. Describe steps for performing uterine
evacuation with MVA
2. Describe precautionary measures and
instrument technical problems
3. Apply the concepts and goals of pain
management as an essential component
of MVA
Steps of the MVA Procedure
1. Prepare instruments.
2. Prepare the woman.
3. Perform cervical antiseptic prep.
4. Dilate cervix.
5. Insert cannula.
6. Suction uterine contents.
7. Inspect tissue.
8. Perform any concurrent procedures.
9. Process instruments.
Step 1: Prepare Instruments
• Prepare all necessary equipments and
instruments for doing UE using MVA
• Check that the aspirator retains a
vacuum.
• Have more than one aspirator
available.
Create a Vacuum
Step 2: Prepare the Woman
• Ask for consent (when appropriate)
• Ensure pain medication is given at the
appropriate time.
• Ask the woman to empty her bladder.
• Help her onto the table.
• Wash hands and put on barriers.
• Perform a bimanual exam.
Wear Barriers for MVA Procedures
Perform Bimanual Exam
Step 3: Perform Cervical Antiseptic Prep

• Follow No-Touch Technique.

• Use antiseptic sponges to clean cervical os,
cervix and, if desired, vaginal walls.
• Do not retrace areas previously cleaned.
Antiseptic Cervical Prep

NB: Clean circularly from inside to outside

 Step 4: Dilate Cervix
• Dilatation required in most but not all
cases.
• Use small size (#4) cannulae for cervical
dilatation
• Cannula should fit well in cervical os to hold
vacuum.
• Use gentle operative technique.
• Use progressively larger cannulae.
 Step 5: Insert Cannula
• Gently apply traction to the cervix using
tenaculum.
• Rotate the cannula while gently applying
pressure.
• Insert cannula slowly until it touches the
uterine fundus, then pull it back slightly.
Insert Cannula Into Uterus
Don’t apply PRESSURE!
Attach Aspirator
Step 6: Suction Uterine Contents
• Attach charged aspirator to cannula.
• Release buttons to start suction.
• Gently rotate cannula 180 degrees in
each direction.
• Use a gentle “in and out” motion.
• Do not withdraw cannula opening beyond
external os.
Release Buttons
Evacuate Uterine Contents
 Reasons for Decrease in MVA Vacuum

• Aspirator is full.
• Cannula is withdrawn past os.
• Cannula is clogged.
• Aspirator is incorrectly assembled.
 When Aspirator Is Full
• Close the valve buttons.
• Detach the cannula and leave in os.
• Open the valve; squeeze plunger arms.
• Push plunger and empty the aspirator.
• Establish new vacuum.
• Reattach aspirator to the cannula and
continue.
 When Cannula Is Withdrawn Past Os

• Remove cannula and aspirator; don’t touch

vaginal walls.
• Detach and empty aspirator.
• Reestablish vacuum.
• Reconnect aspirator to cannula.
• Continue evacuation.
 When Cannula Is Clogged
• Ease cannula back toward, but not through,
the external os OR
• Depress buttons and withdraw aspirator and
cannula out of uterus.
• Remove tissue clogging cannula using
forceps.
• Reinsert cannula and continue aspiration.
• Never push tissue through cannula while still
in uterus.
 If Aspirator Does Not Hold Vacuum

• Check O-ring for damage.

• Reassemble and test aspirator.
 Signs of complete evacuation
• Red or pink foam without tissue passing
through cannula
• Gritty sensation over surface of uterus
• Uterus contracting around cannula
• Increased uterine cramping
 When the Procedure Is Finished
• Push buttons down and forward to close valve.
• Disconnect cannula from aspirator OR
Remove cannula from uterus without
disconnecting.
• INSPECT for bleeding following procedure.
 Use Care to Disconnect Cannula
• Ipas EasyGrip® cannulae fit firmly into the
valve of the aspirator.
• Use care when disconnecting cannula from
the aspirator.
Detach Cannula From Aspirator
 Step 7: Inspect Tissue
• Empty contents of aspirator into container.
• Look for POC; villi and decidua should be
visible.
Inspect Tissue
 Inspect Tissue
• Evaluate amount of POC based on estimated
length of pregnancy.
• Determine that all POC have been evacuated.
• Strain POC, float in water or vinegar, view with
light underneath.
Detailed Tissue Inspection
 Possible Reasons That No POC Visible

• Uterus emptied before procedure

• Uterine cavity still contains POC
• Ectopic pregnancy
• Misdiagnosed pregnancy
• Uterine anatomical variation prevented
evacuation
Possible Reasons for Less Than Expected POC

• Incomplete procedure; reevacuation

necessary
• Incorrect estimation of length of pregnancy
Step 8: Perform Any Concurrent Procedures

If POC inspection results satisfactory:

– Wipe the cervix with swab to assess additional
bleeding.
– Perform bimanual exam to check uterine size and
firmness, if advised.
 Step 9: Process Instruments
• Process or discard instruments immediately.
 Post-Procedure
• Reassure the woman that the procedure is
finished.
• Help her into a comfortable position.
• Ensure she is escorted to the recovery area.
 summary
• Cause of early pregnancy bleeding?
• Abortion?
• Types of abortion?
• Spontaneous abortion?
• Methods of induced abortion?
• Drug regimen for medication abortion?
THANKS!!!