Manual Uterine Aspiration

Emergency Department Protocol for Early Pregnancy Loss (EPL)

Collaborative initiative by ED & OB at NSUH & LIJMC

• WHO

  • Patients with nonviable intrauterine pregnancy <10 weeks by size on ultrasound

• WHAT

  • Consult OB to offer Manual Uterine Aspiration or Medication Assisted Abortion

• WHY

  • Expectant management >> D&C can be more dangerous and/or less effective treatment with higher rates of failure.

  • Intrauterine damage or rupture (sources in the link in treatment section)

• HOW

  • See guidelines below

Help us improve by sending MRN of any EPL case to WHEM division

WHEM@northwell.edu

Guideline Title: MANUAL VACUUM ASPIRATOR FOR MANAGEMENT OF EARLY PREGNANCY LOSS IN THE EMERGENCY DEPARTMENT

Approval Date: 10/16/2024

Effective Date: 11/18/2024

PURPOSE: 

To provide expectant guidance to Emergency physicians regarding the preparation and performance of manual vacuum aspiration in the emergency department by obstetrics as a consult service

SCOPE: 

This policy applies to all members of the Long Island Jewish Medical Center and North Shore University Hospital work force but not limited to employees, business associates, medical staff, volunteers, students, physician office staff, and other persons performing work for or at these facilities.

BACKGROUND: 

Women who experience early pregnancy loss often will present to the Emergency Department with symptoms of cramping and vaginal bleeding.  Early pregnancy loss is defined as a nonviable, intrauterine pregnancy with either an empty gestation sac or a gestation sac containing an embryo without fetal cardiac activity within the first trimester¹. Management of early pregnancy loss include expectant, medical, and surgical management¹.  Patients who desire definitive surgical management of early pregnancy loss can opt to have a dilation and curettage with electric vacuum aspiration in the operating room with sedation or manual vacuum aspiration in the office or Emergency Department with a paracervical block, NSAIDS, and an anxiolytic, if needed. Manual vacuum aspiration is performed with a suction curette attached to a 60-mL syringe used to create negative pressure to aspirate products of conception from the uterine cavity.  The procedure is as safe and effective (>99%) as an electric vacuum aspiration for uterine evacuation with low rates of complications. It is highly acceptable to patients and providers^2-4.  Manual vacuum aspiration in the ED has also been shown to be more cost-effective than an OR procedure⁵.

Inclusion Criteria for Manual Vacuum Aspiration in Emergency Department:

1. Estimated Gestational age ≤ 10 weeks as determined by ultrasound, LMP and any previous ultrasound or HCG information.

2. A diagnosis of early pregnancy loss by criteria outlined by Society of Radiologists and ACOG 

3. Patient desire for manual vacuum aspiration as opposed to other treatment options

4. Active vaginal bleeding and/or pain present +/- demised fetus and/or retained products of conception.

Exclusion Criteria for Manual Vacuum Aspiration in Emergency Department:

1. Viable intrauterine pregnancy

2. Suspected ectopic or molar pregnancy

3. Patient desires sedation for procedure exceeding outlined parameters

4. Patient has clinical contraindication to procedure or alternate management indicated as deemed by ED and/or OB physician

Table 1.  Society of Radiologists in Ultrasound Guidelines for Transvaginal Ultrasonographic Diagnosis of Early Pregnancy Loss

If desired by the patient, a support person or non-provider may be present at the bedside during this encounter.

Procedure Steps:

1. Obtain informed consent for suction dilation and curettage with Manual Vacuum Aspiration (all procedural education and consent to be performed by obstetrical team)

2. Materials:

1. Manual vacuum aspirator kit: which includes Manual Vacuum Aspirator, Denniston dilators and curettes up to 10mm (supplied by OB)

2. Speculum (either metal or plastic) and light source

3. Ring forceps

4. Allis clamp or single-tooth tenaculum (supplied by OB)

5. Large swabs

6. Sterile 4x4 gauze

7. Betadine

8. Sterile field

9. Small basin

10. 1% Lidocaine

11. 10cc syringe and 22 G spinal needle

12. Specimen container for pathology

13. Ultrasound with abdominal probe and ultrasound gel

14. Sterile gloves

15. Silver nitrate sticks and/or Monsel’s solution (Monsel’s supplied by OB)

16. Methylergonovine (Methergine), Misoprostol (Cytotec), and Carboprost (Hemabate) prn bleeding complications

3. Medications (to be ordered by ED team):

   1. Doxycycline 200mg PO given either prior to or after procedure.

   2. If patient is Rh negative, a shared decision-making model should be used regarding the administration of RhoGAM which is to be between the Ob provider and the patient. 

   3. Uterotonics (Methylergonovine (Methergine), Misoprostol (Cytotec), and Carboprost (Hemabate) PRN bleeding complications

Table 2.  Pain and Anxiety Management options for manual vacuum aspiration in ED

1. Doxycycline 200mg PO can be administered either prior to or after the procedure. 

2. Administer pre-procedural pain control 

3. Place patient in dorsal lithotomy position and perform bimanual exam

4. Place speculum 

5. Clean cervix with betadine using swabs 

6. Perform paracervical block using Lidocaine 

7. Dilate cervix serially. If performed under ultrasound guidance, images must be stored in the medical record⁶.

8. Perform procedure with manual vacuum aspirator and place products of conception in small basin.  If performed under ultrasound guidance, images must be stored in the medical record⁶.

9. Ensure thin endometrial stripe at end of procedure by ultrasound⁶. Images will be documented in the medical record.

10. Examine products of conception to verify specimen is consistent with gestational age and then submit specimen to pathology in labeled specimen container. Appropriate documentation and paperwork surrounding specimen to be completed by obstetrical team. The specimen will be dropped off to pathology by the obstetrical team.

11. Nursing: ED nurse to be in attendance for the length of the procedure (estimated 10mins). Observe the patient for at least 30 minutes to monitor for bleeding.  Obtain one set of vitals 10 minutes after procedure to ensure stability. If patient is clinically stable, they can be discharged per ED protocol. 

12. Administer Rh immunoglobulin if Rh negative, as indicated.

13. Provide or refer for post-procedure contraception as appropriate, based on the patient's preferences and medical history.

Follow up:

1. Patient should follow up with an OB/GYN in 1-2 weeks

2. Discharge instructions should include return precautions including excessive bleeding, signs of infection, and severe abdominal pain.

References:

1. ACOG Practice Bulletin 150:  Early Pregnancy Loss.  May 2015

2. Management of first trimester pregnancy loss can be safely moved to the office.  Allison et al.  2011. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100102/

3. Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: a controlled study of complication rates. Obstet Gynecol 2004;103:101–7. 

4. Dalton VK, Harris L, Weisman CS, Guire K, Castleman L, Lebovic D. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol 2006;108:103–10. 

5. Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. Int J Gynaecol Obstet 1994;45:261–7. 

6. https://northwell.sharepoint.com/sites/NWHPolicies/Sys-RadiologyServiceLine/(23)%20RAD.8.001%20POCUS.pdf?web=1