Prof. Ashis Kumar MukhopadhyayProf. Ashis Kumar Mukhopadhyay

Professor, G & OProfessor, G & O

Medical Superintendent-cum-Vice PrincipalMedical Superintendent-cum-Vice Principal

CSS College of Obstetrics & Gynaecology, KolkataCSS College of Obstetrics & Gynaecology, Kolkata

National Chairperson, National Chairperson,

Medical Education Committee of FOGSIMedical Education Committee of FOGSI

WHAT IS MVA ?WHAT IS MVA ?

MVA meaning Manual Vacuum Aspiration – a MVA meaning Manual Vacuum Aspiration – a surgical method of TOP to enhance safe abortion surgical method of TOP to enhance safe abortion within the 1st trimester of pregnancy (WHO-2003).within the 1st trimester of pregnancy (WHO-2003).

MVA actually is the resurrcation of original MR MVA actually is the resurrcation of original MR method by MR syringe & Karman canulae. method by MR syringe & Karman canulae.

With the expectation that MM & Morbidity will be With the expectation that MM & Morbidity will be reduced, but on the contrary it is seen that the no. of reduced, but on the contrary it is seen that the no. of unsafe abortions have much more increased with a unsafe abortions have much more increased with a

disastrous result on MM & Morbidity.disastrous result on MM & Morbidity.

So new techniques started becoming introduced So new techniques started becoming introduced for safe abortion & for safe abortion & MVAMVA is one of them. is one of them.

This method is safe, simple, effective and This method is safe, simple, effective and economical too.economical too.

Parivar Seba Sangstha (PSS), a national level NGO for Parivar Seba Sangstha (PSS), a national level NGO for

quality abortion and family planning procedures – has quality abortion and family planning procedures – has experiences on MVA for more than 25 years. They also experiences on MVA for more than 25 years. They also have the same experience in their Kolkata branch.have the same experience in their Kolkata branch.

95% - MVA

5% - Med. Abortion

Manual Vacuum AspirationManual Vacuum Aspiration

Safe & updated technology for Safe & updated technology for termination of 1st Trimester Pregnancytermination of 1st Trimester Pregnancy

Recognized by FIGO, WHO, GOI, NAF, Recognized by FIGO, WHO, GOI, NAF, USAID for Post Abortion Care and World USAID for Post Abortion Care and World BankBank

Mechanism of ActionMechanism of Action MVA acts via vacuum extraction of the uterine MVA acts via vacuum extraction of the uterine

contents through a cannulacontents through a cannula

Cannula is attached to the vacuum syringe Cannula is attached to the vacuum syringe which has been previously charged and locked which has been previously charged and locked having created vacuum in the syringehaving created vacuum in the syringe

Vacuum extracts the entire contents of the Vacuum extracts the entire contents of the uterus with minimal damage to the lining of the uterus with minimal damage to the lining of the uterusuterus

OriginOrigin The Single Valve Syringe, the earlier version The Single Valve Syringe, the earlier version

originated in the USA in early 70'soriginated in the USA in early 70's

Karmen (Batelle Labs)Karmen (Batelle Labs)

Was studied intensively in India and around the worldWas studied intensively in India and around the world

Single valve syringe was originally designed to be a Single valve syringe was originally designed to be a technique of Menstrual Regulationtechnique of Menstrual Regulation

Double Valve MVA SyringeDouble Valve MVA Syringe

Designed to evacuate the uterus up to 12 Designed to evacuate the uterus up to 12 weeksweeks

Proven safe and effective for termination Proven safe and effective for termination of incomplete abortion, endometrial of incomplete abortion, endometrial biopsy and backup for medical abortionbiopsy and backup for medical abortion

MVA - FeaturesMVA - Features

Flexible Plastic Flexible Plastic CannulaeCannulae

Manual Vacuum Syringe Manual Vacuum Syringe with double valve with double valve adapteradapter

Portable Non-ElectricPortable Non-Electric Practical use in Medical Practical use in Medical

Office, Clinic or HospitalOffice, Clinic or Hospital

Summary of StudiesSummary of StudiesEffectiveness of EVA - MVAEffectiveness of EVA - MVA

Studies Patients Efficacy

Induced

Abortions

EVA : 37

MVA : 9

EVA : 385,000

MVA : 15,000 98%

Incomplete

Abortions

EVA : 15

MVA : 4

EVA : 3,600

MVA : 1,400 98%

* Effectiveness defined as complete evacuation* Effectiveness defined as complete evacuation

- Adapted from Greenslade et al., 1993- Adapted from Greenslade et al., 1993

Recent Clinical ExperienceRecent Clinical Experience Edward 1997Edward 1997

2399 MVA procedures of less than 6 weeks, found to be 2399 MVA procedures of less than 6 weeks, found to be effective in 99.2% of caseseffective in 99.2% of cases

Westfall et al 1998Westfall et al 1998

1677 MVA procedures, of less than 10 weeks, found to be 1677 MVA procedures, of less than 10 weeks, found to be effective in 99.5% of caseseffective in 99.5% of cases

FOGSI Multicentric study 2001FOGSI Multicentric study 2001

926 Cases between 6-12 weeks, found to be effective in 926 Cases between 6-12 weeks, found to be effective in 98.6% of cases98.6% of cases

Manual Vacuum Aspiration(MVA)

Comparison between Comparison between Two Contemporary MethodsTwo Contemporary Methods

- Takes 1-1.5 minutes to - Takes 1-1.5 minutes to create 26” Hg Vacuumcreate 26” Hg Vacuum

- 180- 180O O Rotation possible on Rotation possible on either side because of either side because of kinking of tubingkinking of tubing

- Vacuum is created gradually - Vacuum is created gradually in the uterine cavity, hence in the uterine cavity, hence less effectiveless effective

Electrical Vacuum Aspiration (EVA)

- Takes 1 Second to create - Takes 1 Second to create 26” (660mm) Hg Vacuum26” (660mm) Hg Vacuum

- 360- 360O O Rotation possible Rotation possible because of easy because of easy maneuverabilitymaneuverability

- Pre-created vacuum gets - Pre-created vacuum gets transferred to the uterine transferred to the uterine cavity which is highly cavity which is highly effectiveeffective

Manual Vacuum AspirationManual Vacuum Aspiration(MVA)(MVA)

- Since vacuum takes time to - Since vacuum takes time to reach 26” of Hg, not possible reach 26” of Hg, not possible to create cleavage easily to create cleavage easily and therefore, material and therefore, material comes in pieces causing comes in pieces causing more bleedingmore bleeding

Electrical Vacuum Electrical Vacuum Aspiration (EVA)Aspiration (EVA)

- - Pre created transfer of Pre created transfer of vacuum helps to find vacuum helps to find cleavage between the sac cleavage between the sac and the endometrial lining. and the endometrial lining. This allows sac to get sucked This allows sac to get sucked into the aperture of the into the aperture of the cannula en mass causing cannula en mass causing minimum bleedingminimum bleeding

Comparison between Comparison between Two Contemporary MethodsTwo Contemporary Methods

Manual Vacuum AspirationManual Vacuum Aspiration(MVA)(MVA)

-- In case of perforation, the In case of perforation, the vacuum creation continues vacuum creation continues endangering pulling out endangering pulling out mesentery or intestines if mesentery or intestines if plugged into the aperture of plugged into the aperture of cannulacannula

Electrical Vacuum Electrical Vacuum Aspiration (EVA)Aspiration (EVA)

-- In case of uterine In case of uterine perforation, the vacuum perforation, the vacuum drops to less than 10mm of drops to less than 10mm of Hg and therefore, prevents Hg and therefore, prevents sucking of mesentery or sucking of mesentery or intestinesintestines

Comparison between Comparison between Two Contemporary MethodsTwo Contemporary Methods

Removed with electric suction machine (left) Removed with electric suction machine (left)

and MVA syringe (right)and MVA syringe (right)From: Creinin and Edwards, Curr Problems in Obs Gyn Fert, 20 (1) 1997From: Creinin and Edwards, Curr Problems in Obs Gyn Fert, 20 (1) 1997

EVA Vs MVA EVA Vs MVA Comparison of 5 week’s gestation

MVA Plus Aspirator MVA Plus Aspirator (recent)(recent)

Can be autoclave at 121Can be autoclave at 1210 0 c with a pressure of (15 lbs/inc with a pressure of (15 lbs/in22))

Colour coated & graduated canulae – they can also be autoclavedColour coated & graduated canulae – they can also be autoclaved

Loading the Syringe Loading the Syringe

Close the pinch valve of an assembled syringeClose the pinch valve of an assembled syringe

Creation of VacuumCreation of Vacuum

Withdraw plunger till catcher arms lockedWithdraw plunger till catcher arms locked

Insertion of CannulaeInsertion of Cannulae

Serial insertion with gentle rotatory movementsSerial insertion with gentle rotatory movements

MVA ProcedureMVA Procedure

Pinch valve released to create intrauterine vacuumPinch valve released to create intrauterine vacuum

Evacuation of UterusEvacuation of Uterus

Back & forth & rotatory movements of cannulaBack & forth & rotatory movements of cannula

Care of InstrumentsCare of Instruments

Care of instruments comprises of Care of instruments comprises of following steps :following steps :

DecontaminationDecontamination

CleaningCleaning

High Level Disinfection (HLD) or High Level Disinfection (HLD) or SterilizationSterilization

Storage / ReassemblyStorage / Reassembly

Processing of the InstrumentsProcessing of the Instruments

Syringe & cannulae decontaminated in a Syringe & cannulae decontaminated in a bleach solution for 10 minutes (optional)bleach solution for 10 minutes (optional)

Wash well with detergent and waterWash well with detergent and water

Soak in 2% Glutaraldehyde (Cidex) or 0.5% Soak in 2% Glutaraldehyde (Cidex) or 0.5% chlorine solution for 20 minuteschlorine solution for 20 minutes

Do not boil the Syringe or use Do not boil the Syringe or use

any heat technique or autoclaveany heat technique or autoclave

Cervical Ripening :Cervical Ripening : For pregnancies up to eight weeks, no priming is For pregnancies up to eight weeks, no priming is

required. For pregnancies of 9-12 weeks in required. For pregnancies of 9-12 weeks in nulliparous women and <18 years old. nulliparous women and <18 years old.

ProstaglandinProstaglandin in cervical ripening in cervical ripening

ProstodinProstodin – 250mcg by intramuscular injection 45 – 250mcg by intramuscular injection 45 minutes before the procedure.minutes before the procedure.

MisoprostolMisoprostol – 400mcg tablet administered either – 400mcg tablet administered either vaginally or sublingually/orally 3-4 hours before the vaginally or sublingually/orally 3-4 hours before the procedure.procedure.

The instruments are reusable (disposable in The instruments are reusable (disposable in

developed countries), provided those are very developed countries), provided those are very

well maintained. The aspirators described, could well maintained. The aspirators described, could

be reused from 50-200 times and the new be reused from 50-200 times and the new

canulae can be reused for 10 – 20 times.canulae can be reused for 10 – 20 times.

Post Operative Contraception :Post Operative Contraception :

For pain control, Para cervical block – For pain control, Para cervical block – all that is necessary for complete all that is necessary for complete evacuationevacuation

A sedative or anxiolytic may be A sedative or anxiolytic may be necessary if the patient is apprehensivenecessary if the patient is apprehensive

MAJOR COMPLICATIONS OF MVAMAJOR COMPLICATIONS OF MVA(12,888) 24,00024,000

(2003-06)(2003-06)D & CD & C

0.15 – 28 0.15 – 28 Excess bleeding 0.4 0.06%

Pelvic infection0.01

0.01 0.7 – 8

Cervical injury0.02

0.025% 0.3 – 6.4

Uterine perforation0.02 0.04%

0 – 3.3

Laufe, 1977 PSS (Kolkata)

Greenslade et al 1993Greenslade et al 1993

EFFICACY :EFFICACY :Several authors have shown that the efficacy of MVA in general - 98% Several authors have shown that the efficacy of MVA in general - 98%

AuthorAuthor GestationGestation NumberNumber EffectivenessEffectiveness

Hemin et al 2001, SweedenHemin et al 2001, Sweeden <8 wks<8 wks N = 91N = 91 > 97%> 97%

Fogsi Multicentric Study 2001, IndiaFogsi Multicentric Study 2001, India <6-12 wks<6-12 wks N = 926N = 926 98.6%98.6%

Edward & Creinin 1997, USAEdward & Creinin 1997, USA < 6 wks< 6 wks N = 2,399N = 2,399 > 99%> 99%

Westfall et al. 1998, USAWestfall et al. 1998, USA < 12 wks< 12 wks N = 1,677N = 1,677 99%99%

Greenslade, 1993Greenslade, 1993 Within 12 wksWithin 12 wks N = 15,000N = 15,000 97%97%

PSS, Kolkata, India (2003-2006)PSS, Kolkata, India (2003-2006) 8-12 wks8-12 wks N = 24,000N = 24,000 98.5%98.5%

MVA – in Low tech rural & High tech urban :MVA – in Low tech rural & High tech urban :

Low tech ruralLow tech rural

Limited access to medical Limited access to medical facilitiesfacilities

Non availability of reliable Non availability of reliable equipmentequipment

MVA is – portable instrument, MVA is – portable instrument, can be used as an OPD can be used as an OPD procedure.procedure.

Erratic electricity supplyErratic electricity supply

High tech urbanHigh tech urban

Accidental perforation – no Accidental perforation – no damage to the abdominal damage to the abdominal organs because of dropping organs because of dropping vacuum.vacuum.

Client friendly procedure – Client friendly procedure – surgeon can continue to speak surgeon can continue to speak to the patient.to the patient.

Appreciation of minimally Appreciation of minimally invasive concept.invasive concept.

MVA Pilot Project – GOI, FOGSI & WHOMVA Pilot Project – GOI, FOGSI & WHO

OTHER USES OF MVAOTHER USES OF MVA There are other uses of MVA and they are:-There are other uses of MVA and they are:-

Endometrial Biopsy / sampling (using 4mm Endometrial Biopsy / sampling (using 4mm cannulae)cannulae)

Blighted ovumBlighted ovum

Hydatidiform moleHydatidiform mole

Incomplete abortionIncomplete abortion

To conclude, MVA technology can be used as the first To conclude, MVA technology can be used as the first

line surgical method for uterine evacuation within 1st line surgical method for uterine evacuation within 1st trimester of pregnancy. MVA is safe, simple and trimester of pregnancy. MVA is safe, simple and effective & a low cost procedure, reusable for many effective & a low cost procedure, reusable for many many times. The method is highly recommended by many times. The method is highly recommended by FIGO, FOGSI, WHO & GOI. MVA today is considered as FIGO, FOGSI, WHO & GOI. MVA today is considered as the the NEW GOLD STANDARD NEW GOLD STANDARD for early abortion and there for early abortion and there is no place for other traditional method like D & C. is no place for other traditional method like D & C.

(ICPD, WHO, (ICPD, WHO, FIGO, 1997)FIGO, 1997)