Vacuum aspiration

Last updated
Vacuum aspiration
Background
Abortion type Surgical
First useChina 1958 and
UK 1967 [1]
Gestation 3-13+6 weeks
Usage
Figures are combined usage of MVA and EVA.
Sweden42.7% (2005)
UK: Eng. & Wales64% (2006)
United States59.9% (2016)
Infobox references
Single-use double-valve manual vacuum aspirator Manual vacuum aspirator.jpg
Single-use double-valve manual vacuum aspirator

Vacuum or suction aspiration is a procedure that uses a vacuum source to remove an embryo or fetus through the cervix. The procedure is performed to induce abortion, as a treatment for incomplete spontaneous abortion (otherwise commonly known as miscarriage) or retained fetal and placental tissue, or to obtain a sample of uterine lining (endometrial biopsy). [2] [3] It is generally safe, and serious complications rarely occur. [4]

Contents

Some sources may use the terms dilation and evacuation [5] or "suction" dilation and curettage [6] to refer to vacuum aspiration, although those terms are normally used to refer to distinctly different procedures.

History

Vacuuming as a means of removing the uterine contents, rather than the previous use of a hard metal curette, was pioneered in 1958 by Drs Wu Yuantai and Wu Xianzhen in China, [7] but their paper was only translated into English on the fiftieth anniversary of the study which would ultimately pave the way for this procedure becoming exceedingly common. It is now known to be one of the safest obstetric procedures, and has saved countless women’s lives. [1]

In Canada, the method was pioneered and improved on by Henry Morgentaler, achieving a complication rate of 0.48% and no deaths in over 5,000 cases. [8] He was the first doctor in North America to use the technique, which he then trained other doctors to use. [9]

Dorothea Kerslake introduced the method into the United Kingdom in 1967 and published a study in the United States that further spread the technique. [1] [10]

Harvey Karman in the United States refined the technique in the early 1970s with the development of the Karman cannula, a soft, flexible cannula that avoided the need for initial cervical dilatation and so reduced the risks of puncturing the uterus. [1]

Clinical uses

Vacuum aspiration may be used as a method of induced abortion as well as a therapeutic procedure after spontaneous abortion. The procedure can also aid in regulation of the menstrual cycle and to obtain a sample for endometrial biopsy. [11] A study found use of Karman vacuum aspiration to be a safer option for endometrial biopsy when compared to the alternatives such as conventional endometrial curettage. [3] It is also used to terminate molar pregnancy. [12]

When used as a spontaneous abortion management or as a therapeutic abortion method, vacuum aspiration may be used alone or with cervical dilation anytime in the first trimester (up to 12 weeks gestational age). For more advanced pregnancies, vacuum aspiration may be used as one step in a dilation and evacuation procedure. [13] Vacuum aspiration is the surgical procedure used for almost all first-trimester abortions in many countries, if medication abortion is not a viable option . [11]

Procedure

A diagram of a vacuum aspiration abortion procedure at eight weeks gestation. 1: Amniotic sac 2: Embryo 3: Uterine lining 4: Speculum 5: Vacurette 6: Attached to a suction pump Figure I is before aspiration of amniotic sac and embryo, and Figure II is after aspiration with the instrument still inside the uterus. Vacuum-aspiration.svg
A diagram of a vacuum aspiration abortion procedure at eight weeks gestation.
1: Amniotic sac
2: Embryo
3: Uterine lining
4: Speculum
5: Vacurette
6: Attached to a suction pump
Figure I is before aspiration of amniotic sac and embryo, and Figure II is after aspiration with the instrument still inside the uterus.

Vacuum aspiration is an outpatient procedure that generally involves a clinic visit of several hours. [14] The procedure itself typically takes less than 15 minutes. [15] [16] Depending on the state of residence and local laws, two appointments and various other proceedings may be required if the vacuum aspiration is being used for therapeutic abortion. [17] There are two options for the source of suction in the use of these procedures. Suction can be created with either an electric pump (electric vacuum aspiration or EVA) or a manual pump (manual vacuum aspiration or MVA). A hand-held 25cc or 50cc syringe can function as a manual pump. [18] Both of these methods can create the same level of suction, and therefore are considered equivalent in terms of efficacy of treatment and safety. [19] [20] The difference in use primarily comes down to provider preference.

The clinician places a speculum into the vagina in order to visualize the cervix. The cervix is cleansed, then a local anesthetic (usually lidocaine) is injected in the form of a para-cervical block or intra-cervical injection into the cervix. [21] The clinician may use instruments called "dilators" in incrementally larger sizes to gently open the cervix, or medically induce cervical dilation with drugs or osmotic dilators administered before the procedure. [22] [23] Finally, a sterile cannula is inserted into the uterus. The cannula may be attached via tubing to the pump if using an electric vacuum, or attached directly to a syringe if using a manual vacuum aspirator. The pump creates a vacuum and suction which empties uterine contents, which either enter a canister or the syringe. [15]

After a procedure for abortion or miscarriage treatment, the tissue removed from the uterus is examined for completeness to ensure that no products of conception are left behind. [15] Expected contents include the embryo or fetus, as well as the decidua, chorionic villi, amniotic fluid, amniotic membrane and other tissues. These are all tissues which are found in a normal pregnancy. In the case of a molar pregnancy, these components will not be found. [24]

Post-treatment care includes brief observation in a recovery area and a follow-up appointment approximately two weeks later. During these visits, it is possible that the provider may perform tests to check for infection, as retained tissue in the uterus can be a source of infection. [25]

Additional medications used in vacuum aspiration include NSAID analgesics [26] [21] that may be started the day before the procedure, as well as misoprostol the day before for cervical ripening which makes dilation of the cervix easier to perform. [27] Procedural sedation and analgesia may be offered to the patient in order to avoid discomfort.

Advantages over sharp dilation and curettage

Sharp dilation and curettage (D&C), also known as sharp curettage, was once the standard of care in situations requiring uterine evacuation. However, vacuum aspiration has a number of advantages over sharp D&C and has largely replaced D&C in many settings. [28] Manual vacuum aspiration has been found to have lower rates of incomplete evacuation and retained products of conception in the uterus. [29] Sharp curettage has also been associated with Asherman's Syndrome, whereas vacuum aspiration has not been found to have this longer term complication. [30] Overall, vacuum aspiration has been found to have lower rates of complications when compared to D&C. [19]

Vacuum aspiration may be used earlier in pregnancy when compared to sharp D&C. Manual vacuum aspiration is the only surgical abortion procedure available earlier than the sixth week of pregnancy. [15]

Vacuum aspiration, especially manual vacuum aspiration, is significantly cheaper than sharp D&C. The equipment needed for vacuum aspiration costs less than a set of surgical curettes. Additionally, sharp D&C is generally provided only by physicians, vacuum aspiration may be performed by advanced practice clinicians such as physician assistants and midwives, which greatly increases access to these services. [31]

Manual vacuum aspiration does not require electricity and so can be provided in locations that have unreliable electrical service or none at all. Manual vacuum aspiration also has the advantage of being quiet, without the louder noise of an electric vacuum pump, which can be stressful or bothersome to patients. [31]

Complications

When used for pregnancy evacuation, vacuum aspiration is 98% effective in removing all uterine contents. [19] One of the main complications is retained products of conception which will usually require a second aspiration procedure. This is more common when the procedure is performed very early in pregnancy, before 6 weeks gestational age. [15]

Another complication is infection, usually caused by retained products of conception or introduction of vaginal flora (otherwise known as bacteria) into the uterus. The rate of infection is 0.5%. [15]

Other complications occur at a rate of less than 1 per 100 procedures and include excessive blood loss, creating a hole through the cervix or uterus [19] (perforation) that may cause injury to other internal organs. Blood clots can possibly form within the uterus and block outflow of bleeding from the uterus which can cause the uterus to be enlarged and tender. [32]

Related Research Articles

Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of sections and/or layers of the lining of the uterus and or contents of the uterus such as an unwanted fetus, remains of a non-viable fetus, retained placenta after birth or abortion as well as any abnormal tissue which may be in the uterus causing abnormal cycles by scraping and scooping (curettage). It is a gynecologic procedure used for treatment and removal as well as diagnostic and therapeutic purposes, and is the most commonly used method for first trimester abortion or miscarriage.

Intact dilation and extraction is a surgical procedure that terminates and removes an intact fetus from the uterus. The procedure is used both after miscarriages and for abortions in the second and third trimesters of pregnancy. When used to perform an abortion, an intact D&E can occur after feticide or on a live fetus.

<span class="mw-page-title-main">Misoprostol</span> Medication to induce abortion and treat ulcers

Misoprostol is a synthetic prostaglandin medication used to prevent and treat stomach and duodenal ulcers, induce labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus. It is taken by mouth when used to prevent gastric ulcers in people taking nonsteroidal anti-inflammatory drugs (NSAID). For abortions it is used by itself or in conjunction with mifepristone or methotrexate. By itself, effectiveness for abortion is between 66% and 90%. For labor induction or abortion, it is taken by mouth, dissolved in the mouth, or placed in the vagina. For postpartum bleeding it may also be used rectally.

A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.

<span class="mw-page-title-main">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically or medically.

<span class="mw-page-title-main">Endometrial polyp</span> Mass on the interior lining of the uterus

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

Dilation and evacuation (D&E) or dilatation and evacuation is the dilation of the cervix and surgical evacuation of the uterus after the first trimester of pregnancy. It is a method of abortion as well as a common procedure used after miscarriage to remove all pregnancy tissue.

Cervical weakness, also called cervical incompetence or cervical insufficiency, is a medical condition of pregnancy in which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term. Definitions of cervical weakness vary, but one that is frequently used is the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester. Cervical weakness may cause miscarriage or preterm birth during the second and third trimesters. It has been estimated that cervical insufficiency complicates about 1% of pregnancies, and that it is a cause in about 8% of women with second trimester recurrent miscarriages.

<span class="mw-page-title-main">Endometrial ablation</span> Medical procedure

Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.

Instillation abortion is a rarely used method of late-term abortion, performed by injecting a solution into the uterus.

The Karman cannula is a soft, flexible cannula used in medical procedures that was popularized by Harvey Karman in the early 1970s. The flexibility of the Karman cannula was claimed to reduce the risk of perforating the uterus during vacuum aspiration. Both Karman's procedure, menstrual extraction, and his cannula were embraced by activists Carol Downer and Lorraine Rothman, who modified the technique in 1971 and promoted it. The "self-help" abortion movement envisioned by Downer and Rothman never entered the mainstream in the U.S. before or after Roe v. Wade. Physicians sometimes use a Karman cannula in early induced surgical abortion, in treatment of incomplete abortion, and in endometrial biopsy. In 2010, a Sri Lankan physician named Geeth Silva was the first physician to use the Karman cannula in the removal of impacted faeces from a patient; this was done in Columbo at the Sri Jayawardenepura General Hospital. Physicians and other health care providers sometimes use a Karman cannula in "menstrual regulation" vacuum aspiration procedures in developing countries where abortion is illegal.

Menstrual extraction (ME) is a type of manual vacuum aspiration technique developed by feminist activists Lorraine Rothman and Carol Downer to pass the entire menses at once. The non-medicalized technique has been used in small feminist self-help groups since 1971 and has a social role of allowing access to early abortion without needing medical assistance or legal approval. ME usage declined after 1973, when Roe v. Wade legalized abortion in the United States. There has been renewed interest in the technique, in the 1990s and more recently in the 2010s, due to increased restrictions on abortion. In some countries where abortion is illegal, such as Bangladesh, the terms "menstrual regulation" or "menstrual extraction" are used as euphemisms for early pregnancy terminations.

<span class="mw-page-title-main">Endometrial biopsy</span> Diagnostic medical procedure

The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. The tissue subsequently undergoes a histologic evaluation which aids the physician in forming a diagnosis.

<span class="mw-page-title-main">Hematometra</span> Medical condition

Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.

<span class="mw-page-title-main">Osmotic dilator</span> Medical device to dilate the uterine cervix

Osmotic dilators, also known as hygroscopic dilators, are medical implements used to dilate the uterine cervix by swelling as they absorb fluid from surrounding tissue. They may be composed of natural or synthetic materials. A laminaria stick or tent is a thin rod made of the stems of dried Laminaria, a genus of kelp. Laminaria sticks can be generated from Laminaria japonica and Laminaria digitata. Synthetic osmotic dilators are commonly referred to by their brand names, such as Dilapan. Dilapan-S are composed of polyacrylonitrile, a plastic polymer. The hygroscopic nature of the polymer causes the dilator to absorb fluid and expand.

<span class="mw-page-title-main">Cervical pregnancy</span> Medical condition

A cervical pregnancy is an ectopic pregnancy that has implanted in the uterine endocervix. Such a pregnancy typically aborts within the first trimester, however, if it is implanted closer to the uterine cavity – a so-called cervico-isthmic pregnancy – it may continue longer. Placental removal in a cervical pregnancy may result in major hemorrhage.

A paracervical block is an anesthetic procedure used in obstetrics and gynecology, in which a local anesthetic is injected into between two and six sites at a depth of 3–7 mm alongside the vaginal portion of the cervix in the vaginal fornices. In the United States, the paracervical block is underutilized during insertion of intrauterine devices (IUDs). There is speculation that this is related to the disproportionate under-researching of women's health.

<span class="mw-page-title-main">Prolonged labor</span> Medical condition

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. Failure to progress can take place during two different phases; the latent phase and active phase of labor. The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. The active phase of labor, on the other hand, if prolonged, can result in long term complications.

References

  1. 1 2 3 4 Coombes R (14 June 2008). "Obstetricians seek recognition for Chinese pioneers of safe abortion". BMJ. 336 (7657): 1332–3. doi:10.1136/bmj.39608.391030.DB. PMC   2427078 . PMID   18556303.
  2. ↑ Sharma M (July 2015). "Manual vacuum aspiration: an outpatient alternative for surgical management of miscarriage". The Obstetrician & Gynaecologist. 17 (3): 157–161. doi: 10.1111/tog.12198 . ISSN   1467-2561. S2CID   116858777.
  3. 1 2 Tansathit T, Chichareon S, Tocharoenvanich S, Dechsukhum C (October 2005). "Diagnostic evaluation of Karman endometrial aspiration in patients with abnormal uterine bleeding". The Journal of Obstetrics and Gynaecology Research. 31 (5): 480–485. doi:10.1111/j.1447-0756.2005.00324.x. ISSN   1341-8076. PMID   16176522. S2CID   20596711.
  4. ↑ Hemlin J, Möller B (2001-01-01). "Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination". Acta Obstetricia et Gynecologica Scandinavica. 80 (6): 563–567. doi:10.1080/j.1600-0412.2001.080006563.x. ISSN   0001-6349. PMID   11380295.
  5. ↑ Wood D (January 2007). "Miscarriage". EBSCO Publishing Health Library. Brigham and Women's Hospital. Archived from the original on 2007-09-27. Retrieved 2007-04-07.
  6. ↑ "What Every Pregnant Woman Needs to Know About Pregnancy Loss and Neonatal Death". The Unofficial Guide to Having a Baby. WebMD. 2004-10-07. Archived from the original on 2007-10-21. Retrieved 2007-04-29.
  7. ↑ Wu Y, Wu X (1958). "A report of 300 cases using vacuum aspiration for the termination of pregnancy". Chinese Journal of Obstetrics and Gynaecology.
  8. ↑ Morgentaler H (1973). "Report on 5641 outpatient abortions by vacuum suction curettage". CMAJ. 109 (12): 1202–5. PMC   1947080 . PMID   4758593. Archived from the original on 2015-10-18.
  9. ↑ Morgentaler H (May–Jun 1989). "Alan F. Guttmacher lecture". Am J Gynecol Health. 3 (3–S): 38–45. PMID   12284999.
  10. ↑ Kerslake D, Casey D (July 1967). "Abortion induced by means of the uterine aspirator". Obstet Gynecol. 30 (1): 35–45. PMID   5338708.
  11. 1 2 Baird TL, Flinn SK (2001). Manual Vacuum Aspiration: Expanding women's access to safe abortions services (PDF). Ipas. p. 3. Archived from the original (PDF) on 2008-02-27. Retrieved 2008-01-28., which cites:
    Greenslade F, Benson J, Winkler J, Henderson V, Leonard A (1993). "Summary of clinical and programmatic experience with manual vacuum aspiration". Advances in Abortion Care. 3 (2).
  12. ↑ "Managing complications in pregnancy and childbirth: A guide for doctors and midwives". World Health Organization. 2003. Archived from the original on 2006-09-09. Retrieved 2006-09-14.
  13. ↑ Baird (2001), pp. 4-5,14 (sidebars and information box).
  14. ↑ Baird (2001), p. 10 (table).
  15. 1 2 3 4 5 6 "Manual and vacuum aspiration for abortion". A-Z Health Guide from WebMD. October 2006. Archived from the original on October 28, 2008. Retrieved February 18, 2006.
  16. ↑ "What Happens During an In-Clinic Abortion?". www.plannedparenthood.org. Retrieved 2022-03-13.
  17. ↑ "Texas Abortion Laws". www.plannedparenthood.org. Retrieved 2022-03-13.
  18. ↑ "All About the Machine Vacuum Aspiration Procedure for Early Abortion". about.com. Archived from the original on 4 March 2016. Retrieved 3 May 2018.
  19. 1 2 3 4 Baird (2001), pp. 4-6.
  20. ↑ Goldberg AB, Dean G, Kang M, Youssof S, Darney PD (January 2004). "Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates". Obstetrics and Gynecology. 103 (1): 101–107. doi: 10.1097/01.AOG.0000109147.23082.25 . ISSN   0029-7844. PMID   14704252. S2CID   11374545.
  21. 1 2 Allen RH, Singh R (June 2018). "Society of Family Planning clinical guidelines pain control in surgical abortion part 1 — local anesthesia and minimal sedation". Contraception. 97 (6): 471–477. doi: 10.1016/j.contraception.2018.01.014 . PMID   29407363.
  22. ↑ Allen RH, Goldberg AB (2016-04-01). "Cervical dilation before first-trimester surgical abortion (<14 weeks' gestation)". Contraception. 93 (4): 277–291. doi: 10.1016/j.contraception.2015.12.001 . ISSN   0010-7824. PMID   26683499.
  23. ↑ Kapp N, Lohr PA, Ngo TD, Hayes JL (2010-02-17). "Cervical preparation for first trimester surgical abortion". Cochrane Database of Systematic Reviews (2): CD007207. doi:10.1002/14651858.cd007207.pub2. ISSN   1465-1858. PMID   20166091.
  24. ↑ "Molar pregnancy - Symptoms and causes". Mayo Clinic. Retrieved 2022-03-13.
  25. ↑ "FAQ: Post-Abortion Care and Recovery". ucsfhealth.org. Retrieved 2022-03-13.
  26. ↑ Cansino C, Edelman A, Burke A, Jamshidi R (December 2009). "Paracervical Block With Combined Ketorolac and Lidocaine in First-Trimester Surgical Abortion: A Randomized Controlled Trial". Obstetrics & Gynecology. 114 (6): 1220–1226. doi: 10.1097/AOG.0b013e3181c1a55b . ISSN   0029-7844. PMID   19935022. S2CID   22458136.
  27. ↑ Table 2 in: Allison JL, Sherwood RS, Schust DJ (2011). "Management of first trimester pregnancy loss can be safely moved into the office". Rev Obstet Gynecol. 4 (1): 5–14. PMC   3100102 . PMID   21629493.
  28. ↑ Baird (2001), p. 2.
  29. ↑ Mahomed K, Healy J, Tandon S (July 1994). "A comparison of manual vacuum aspiration (MVA) and sharp curettage in the management of incomplete abortion". International Journal of Gynaecology and Obstetrics. 46 (1): 27–32. doi:10.1016/0020-7292(94)90305-0. ISSN   0020-7292. PMID   7805979. S2CID   11606702.
  30. ↑ Barber AR, Rhone SA, Fluker MR (2014-11-01). "Curettage and Asherman's Syndrome—Lessons to (Re-) Learn?". Journal of Obstetrics and Gynaecology Canada. 36 (11): 997–1001. doi: 10.1016/S1701-2163(15)30413-8 . ISSN   1701-2163. PMID   25574677.
  31. 1 2 Baird (2001), pp. 5,8-13.
  32. ↑ "Vacuum Aspiration for Abortion | Michigan Medicine". www.uofmhealth.org. Retrieved 2022-03-13.
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