Surgical management of miscarriage under local anaesthetic using manual vacuum aspiration

What is MVA (manual vacuum aspiration)?

Surgical management of miscarriage is a minor procedure that is performed after an ultrasound scan shows that you have remaining pregnancy tissue inside the womb following a miscarriage or childbirth. 

This was previously done primarily under a general anaesthetic but this can also be done while you are awake. A MVA is the way of removing the pregnancy or tissue from the uterus (womb) while you are awake. 

MVA uses a narrow tube to enter and empty the uterus using aspiration (gentle suction). Local anaesthesia (pain relief) is injected into the cervix (neck of the womb) with the aim of reducing some of the sensation of pain.

Why have a MVA?

MVA does not involve general anaesthesia (anaesthesia which induces a state of deep unconsciousness). You attend a scheduled appointment time and will be able to go home from an hour after the procedure. Women therefore avoid the need for admission to hospital and the side effects of general anaesthesia.

MVA is offered to women in the following situations:

• Delayed miscarriage (where a pregnancy has failed to develop normally but the pregnancy sac is still present within uterus [womb])
• Incomplete miscarriage (where some of the pregnancy tissue remains inside the uterus [womb] even if the main pregnancy sac has passed naturally)
• Retained products of conception (where some placental tissue remains in the uterus following childbirth)

Is MVA a new procedure? 

No. MVA has now been performed for more than 30 years. Several studies of MVA have been reported from the United States, Europe and the United Kingdom. It has been shown to be a safe procedure, with high success rates and good patient acceptability where women overall are very satisfied with the procedure.

It offers an additional choice to women with miscarriage who want surgical management but also want to avoid a general anaesthetic.

What does an MVA involve?

Preparation

• You will be asked to attend the department 1 hour before the procedure beings to prepare you for the procedure.
• The procedure will be explained to you, and if you would like to proceed we complete a form in which you provide your written consent.
• You will have blood tests done to check your blood
• You may take ibuprofen 1 – 2 hours before the procedure. You will be given additional pain killers 1 hour before the procedure (co-dydramol, which contains a combination of paracetamol and codeine).
• You may also be given tablets (misoprostol) to keep under your tongue for 15 minutes one hour prior to the procedure to help soften the cervix (neck of the womb).
• Alternatively, these tablets can also be given to insert into the vagina.

During the procedure

• Some women find the additional pain relief of Entonox or Penthrox helpful during the procedure. It is a mixture of oxygen and nitrous oxide gas which you breathe in through a mouthpiece. It works in 20 seconds and the effect wears off just as quickly. Entonox is available at our Chelsea site and Penthrox is available at our West Mid site.
• You will have a speculum examination. This will allow the doctor/nurse specialist to assess the cervix (neck of the womb) and a local anaesthetic will be injected to help numb the
• When you feel comfortable, the cervix will be dilated (stretched) gradually and the womb will be emptied by a narrow suction tube.
• Sometimes, ultrasound scan may be required during the procedure. This is done by placing the ultrasound probe on your tummy while the procedure is being carried out.   You will not see the scan
• During the procedure you may hear suction noises. If you would like to have some calming music to be played during the procedure then please let the doctor/nurse specialist know.  
• The doctor/nurse specialist may do an ultrasound scan at the end of the procedure to check that your womb is empty.
• You will be offered an antibiotic to be taken by mouth after the procedure as well, as 3 days of antibiotics to take home with you, to help reduce the risk of infection. 

What if I have bleeding before my procedure?

A small number of women will have a natural miscarriage prior to their planned procedure.  If you have significant bleeding before the procedure, please contact the unit.  If the bleeding becomes very heavy, you should attend as an emergency via the A&E department.

How long will MVA take? What will I feel? 

The whole procedure (including gently dilating the cervix) will take approximately 15-20 minutes. You may feel discomfort during the procedure (similar to a period pain). Should you feel severe pain or you feel you are not coping during the procedure please immediately inform the nurse or doctor looking after you.

What do I need to do before the MVA? 

This is already covered under preparation. No additional preparation is needed.

What happens after the MVA? 

We will monitor you for up to one or two hours after the procedure in a quiet rest area. This includes checking your blood pressure, pulse and monitoring any pain you may have. You can leave the department once you feel well enough to go home. We recommend someone escorts you home after the procedure.

You can expect some vaginal bleeding after the MVA. This usually settles within seven to fourteen days.

We advise you to perform a urine pregnancy test 3 weeks after the procedure to ensure it is negative.   If the pregnancy test is still positive, or you have bleeding that has lasted longer than 3 weeks, please contact the Early Pregnancy Unit.

You will need to contact your local Early Pregnancy Unit or nearest Accident and Emergency Department if you experience:

• Excessive Bleeding (for example soaking one or more sanitary towels in one hour)
• Fever (temperature greater than 38 degrees Centigrade) or an offensive smelling discharge from the vagina
• Fainting, persistent vomiting or severe abdominal pain

We recommend you use sanitary towels instead of tampons and do not have sexual intercourse until the bleeding has fully settled.  This reduces the risk of infection. You may return to work after 48 hours, or when you feel able. If your blood group is Rhesus negative you will need an injection of Anti-D. Please ask for further information on Anti-D, if required.

What are the options if I do not want MVA?

Other treatment options will be discussed with you by our team.

These include:

• Conservative management (waiting for the pregnancy to pass naturally).
• Tablets to induce a natural miscarriage
• Surgical removal of the pregnancy under general anaesthetic.

How does an MVA compare to surgery under general anaesthetic? 

Many studies have compared MVA to surgical evacuation under general anaesthetic. They show MVA to be equally effective. More than 97 out of 100 women having MVA will not require any further surgical treatment.

What are the possible complications of MVA?

MVA is safe but like all procedures there is a small risk of complications. The risk of complications with an MVA are similar to surgical uterine evacuation under general anaesthesia but without the complications caused by general anaesthetic.

Complications related to the procedure are uncommon or rare; they include:

• Heavy bleeding (haemorrhage) (0.3%)
• Infection (4%)
• Retained placental or fetal tissue (4%)
• The need for a repeat operation if not all the pregnancy tissue is removed (0.3-1.8%)
• Perforation (tear) of the womb that may need repair (0.1%)
• Adhesions or scar tissue within the womb (16.3 – 18.5%)

The overall risk of adhesions following any method of miscarriage management is 19%.  These are normally mild and no significant differences were shown in long term fertility outcomes with medical, surgical or expectant management as per the MIST trial.   

If a perforation is suspected, we may need to look to see if there is any internal bleeding or internal damage to the bowel or bladder. This is done by a small cut on your tummy (abdomen) under general anaesthetic and inserting a telescope (laparoscopy).

During the MVA you may feel dizzy or light-headed. Please let the team looking after you know if this happens and the procedure will be paused until you feel better.

The risk of infection is the same with surgical (MVA or surgery under general anaesthesia), medical or conservative treatment options.

When can I get pregnant again?

Most women will have their next period within 4-6 weeks of the MVA procedure. We generally recommend that you wait for this before you start trying again.

Patient Advice & Liaison Service (PALS)

If you have concerns or wish to give feedback about services, your care or treatment, you can contact the PALS office in the main atrium or you can complete a feedback form on our website www.chelwest.nhs.uk/pals. We value your opinion and invite you to provide us with feedback.

WMUH: 020 8321 6261; chelwest.wmpals@nhs.net 

C&W: 020 3315 6727; chelwest.cwpals@nhs.net 

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