Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review

Background  As an alternative to electric vacuum aspirations (EVA), there is an increasing interest in using manual vacuum aspiration (MVA).
Objective  To compare the safety, efficacy and acceptability of MVA with those of EVA for first-trimester abortion.
Search strategy  We searched MEDLINE, EMBASE, Cochrane Library and Chinese Biomedical Database in all language, together with reference lists of retrieved papers.
Selection criteria  Randomised controlled trials comparing MVA with EVA for first-trimester abortion were included. The outcomes are complete abortion rate, uterine perforation rate, blood loss, pain perception and acceptability.
Data collection and analysis  Two reviewers independently extracted the data. Results from the trials were combined to calculate relative risks (RRs) or risk differences for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes, together with 95% CIs.
Main results  Ten trials were included, involving 1660 women. Generally, the methodological quality was poor. There were no statistically significant differences, comparing MVA with EVA, in complete abortion rate (RR 1.00; 95% CI 0.99–1.02) and participants' satisfaction (RR 1.02; 95% CI 0.87–1.20). In participants with less than 50 days of gestational age, less blood loss (WMD −1.84; 95% CI −2.45 to −1.23) and less severe pain perception (RR 0.04; 95% CI 0.01–0.12) were reported during the MVA procedure, whereas the operation time was shorter (WMD 0.32; 95% CI 0.02–0.63) in the EVA procedure.
Author's conclusions  There is some evidence that MVA is as effective and acceptable as EVA and might be safer than EVA.     

Cervical priming with misoprostol before manual vacuum aspiration versus electric vacuum aspiration for first-trimester surgical abortion

Objective

To compare the efficacy of manual vacuum aspiration (MVA) with electric vacuum aspiration (EVA) and to evaluate whether cervical priming with misoprostol facilitates cervical dilation and reduces complications associated with first-trimester medical abortion performed up to 10 weeks of pregnancy.

Methods

A total of 600 women who requested termination of pregnancy were randomized into 4 groups (150 women in each group). Group I and II received a vaginal placebo 3 hours before MVA or EVA, respectively. Group III and IV received 400 μg of vaginal misoprostol 3 hours before MVA or EVA, respectively.

Results

Complete abortion rates after MVA and EVA were both 97.9%; after cervical priming with misoprostol complete abortion rates were 98.6% versus 97.3% after cervical priming with placebo (P > 0.05). Administration of misoprostol into the vagina before MVA resulted in 99.3% complete abortions (P = 0.40), and the least operative blood loss, operating time, and need for cervical dilation (P < 0.05). Overall complications and adverse effects were similar in all groups (P > 0.05).

Conclusion

For surgical evacuation, EVA and MVA did not differ in efficacy. Cervical priming 3 hours before MVA for termination of pregnancy significantly reduced the need for cervical dilation and the operative time, and improved the efficacy of the procedure. Pretreatment with vaginal misoprostol before MVA is a safe and effective method for terminating pregnancies of up to 10 weeks of gestation.Clinical Trials Registry: CTRI/2009/091/000008     

Gemeprost versus misoprostol for cervical priming before first-trimester abortion: a randomized controlled trial

OBJECTIVE: To compare the efficacy of 400 microg of misoprostol with that of 1 mg of gemeprost as cervical priming agents when administered vaginally 3 to 4 hours before first-trimester vacuum aspiration abortion. METHODS: In a prospective controlled trial 90 nulliparous women who requested termination of pregnancy before 12 weeks' gestation were randomized to receive vaginally either misoprostol or gemeprost for cervical priming. The force to dilate the cervix was measured by the use of a cervical tonometer connected to Hegar dilators from 3 to 10 mm. The main outcome measures were baseline cervical dilation; the peak force to dilate the cervix at 8, 9, and 10 mm; and the cumulative force to dilate the cervix to 10 mm. RESULTS: Baseline cervical dilation did not differ significantly between the women who received misoprostol and those who were treated with gemeprost. Neither the peak force required to dilate the cervix at 8, 9, and 10 mm nor the cumulative force to dilate the cervix to 10 mm showed any significant difference between the two groups. CONCLUSION: Vaginally administered misoprostol (400 microg) is as effective as gemeprost (1 mg) for cervical priming 3 to 4 hours before surgical termination of first-trimester pregnancies.     

Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss

Manual vacuum aspiration (MVA) is an alternative to the standard surgical curettage, performed under local anaesthetic in the setting of a treatment room. The aim of our study was to assess the efficacy of MVA in the management of first trimester early fetal demise and first- and mid-trimester incomplete miscarriage. This was a retrospective study of 246 patients who were scheduled to undergo MVA for first trimester early fetal demise and first- and mid-trimester incomplete miscarriage. One woman was excluded in the analysis because of the procedure being abandoned prior to MVA. Efficacy of the procedure was 94.7% (232/245). Incomplete uterine evacuation was seen in 5.3% (13/245) patients. Although not widely used in the UK, MVA could be considered routinely, thus avoiding general anaesthesia and the need for access to theatre.     

Manual vacuum aspiration and elecrical vacuum aspiration-A comparative study for first trimester MTP

Objectives

The present study compares MVA and EVA as the method for 1st trimester MTP in terms of effi7acy, blood loss, duration, acceptability and complications.

Method

The present study was conducted in the Department of Gynecology and Obstetrics, Eden Hospital, Medical College, Kolkata. Medical College, Kolkata is also a Government of India recognized center for MVA training programme. A total number of 200 patients were studied; out of which 100 patients underwent MVA and remaining 100 EVA. Cases were compared with respect to age, parity, blood loss, time taken and complications.

Results

In the present study MVAwas effective in 98% and EVAin 97% cases as 2% and 3% respectively of the 2 groups required reevacuation for incompleteness. Thus the two procedures did not show much difference as far as their effectiveness was concerned.

Conclusion

MVA has a safety and efficacy profile similar to that of EVA. Also, MVA is a simple, safe, effective procedure, portable and low cost technique. Hence, MVA is a promising method compared to EVA which can be practiced widely in rural areas where the access to medical facilities are limited, high tech equipments are not available, power supply erratic and maintenance of instruments not up to the mark. The judicious use of MVA comes with a promise to make early abortions safe and easily accessible to women of both rural and urban societies belonging to any socioeconomic strata.     

Expectant versus surgical management of first-trimester miscarriage: a randomised controlled study

Introduction

The aim of this study is to compare the efficacy and safety of expectant management with surgical management of first-trimester miscarriage.

Methods

This randomised prospective study was conducted in the Gynaecology Department at University of Saarland Hospital, Germany between February 2011 and April 2012. A total of 234 women were recruited following diagnosis of the first-trimester incomplete or missed miscarriage and randomised into two groups: 109 women were randomised to expectant management (group I), and 125 women to surgical management (groupII). All women were examined clinically and sonographically during the follow-up appointments at weekly intervals for up to 4 weeks as appropriate. The outcome measures were: efficacy, short-term complications and duration of vaginal bleeding and pain.

Results

Of 234 eligible women, 17 were lost to follow-up, and the remaining 217 women were analysed. The baseline characteristics were similar in both groups. The total success rate at 4 weeks was lower for expectant than for surgical management (81.4 vs 95.7 %; P = 0.0029). The type of miscarriage was a significant factor affecting the success rate. For missed miscarriage, the success rates for expectant versus surgical management were 75 and 93.8 %, respectively. For women with incomplete miscarriage, the rates were 90.5 and 98 %. No differences were found in the number of emergency curettages between the two study groups. The duration of bleeding was significantly more in the expectant than the surgical management (mean 11 vs 7 days; P < 0.0001). The duration of pain was also more in the expectant than the surgical group (mean 8.1 vs 5.5 days; P < 0.0001). The total complication rates were similar in both groups (expectant 5.9 % vs surgical group 6.1 %; P = 0.2479). However, the pelvic infection was significantly lower in the expectant than the surgical group (1.9 vs 3.5 %, respectively; P = 0.0146).

Conclusion

Expectant management of clinically stable women with first-trimester miscarriage is safe and effective and avoids the need for surgery and the subsequent risk of anaesthesia in about 81.4 % of cases, and has lower pelvic infection rate than surgical curettage. However, surgical management is more successful, and with a shorter duration of bleeding and pain. Therefore, the patient’s preference should be considered in the counselling process.     

Manual vacuum aspiration, a safe and effective alternative in early pregnancy termination

BACKGROUND: AND OBJECTIVE: Vacuum aspiration has become standard surgical procedure for safe early pregnancy termination. Most of these operations are performed in the operating theater using suction curettage and an electric vacuum pump. MVA (manual vacuum aspiration) is an alternative that is well suited for use as a clinical procedure, which could have advantages both for the patient and the health care system. In order to compare conventional VA and MVA in a Swedish setting, a randomized study was undertaken. METHODS: Two hundred women requesting abortion in early pregnancy, gestational age less than 56 days, and choosing surgical termination, were randomized to VA or MVA. Main study outcome was frequency of complete abortion but also other variables were recorded. RESULTS: There were no significant differences between the two groups regarding background characteristics. Altogether 91 MVA and 88 VA operations were performed. There was no significant difference in frequency of complete abortion; two patients in each group subsequently needed re-curettage because of incomplete evacuation. No case of ongoing pregnancy occurred. Two patients in each group received treatment for endometritis. No other complications were recorded. CONCLUSION: This study indicates that MVA is effective in emptying the uterine cavity, on par with the standard vacuum aspiration. The rate of complications with MVA was on the same low level as with conventional VA.     

Manual vacuum aspiration for second-trimester pregnancy termination.

OBJECTIVES: To compare manual and electric vacuum aspiration for surgical abortions between 14 and 18 weeks of pregnancy. METHODS: A consecutive case series of pregnant women presenting to Johns Hopkins Bayview Medical Center for abortion. There were 73 women in the manual vacuum aspiration group and 37 women in the electric vacuum aspiration group. Dilatation and evacuation was performed using manual or electric vacuum aspiration according to protocol. Procedure time was assessed with the t-test. RESULTS: In all cases, abortion was performed with initial vacuum. Group sizes were sufficient to detect a 20% difference in mean procedure time with 80% power (calculated with two separate S.D.s for procedure time). There was no significant difference in procedure time between the two groups. CONCLUSIONS: Manual vacuum aspiration can be safely and effectively used in second-trimester abortion procedures and should be more widely investigated for this purpose.     

A comparative study of cost of care and duration of management for first-trimester abortion with manual vacuum aspiration (MVA) and sharp curettage

Objective

This study compared the hospital charges, duration of in-hospital procedures, clinical course and complications between manual vacuum aspiration (MVA) and sharp curettage.

Materials and methods

A prospective observational study was conducted during the May 2007–April 2008 period in Songklanagarind Hospital, Thailand. Forty cases of pregnancy ≤9?weeks of gestation, with conditions of an incomplete abortion, a blighted ovum or missed abortion were treated with either MVA or sharp curettage. Both groups were compared in terms of demographic and obstetric data, hospitalization cost, clinical course and complications.

Results

The obstetric data of both groups showed that the median parity was two, with a median gestation age of 8?weeks. The median total hospital expenditure was 54.67 USD for patients using the MVA technique and 153.97 USD for the sharp curettage group (p?<?0.01). The median duration of in-hospital care in the MVA group was significantly less than that of the sharp curettage group, 4 versus 20?h, respectively (p?<?0.01). 90?% of patients in the MVA group had only one visit compared with 72.5?% in the sharp curettage group (p?=?0.04). No complications needing further curettage or treatment in either group were noted.

Conclusion

The use of MVA in the management of a first-trimester abortion is practical, safe, cheap and time-saving.     

Oral versus vaginal misoprostol for cervical priming in first-trimester abortion: a randomized trial

The objective of this study was to compare the oral and vaginal administration of misoprostol for cervical priming before surgical abortion up to 63 days' gestation. A total of 900 pregnant women, with ages ranging from 18 to 42 years, who asked for pregnancy termination, were included in this study. Women were randomly allocated to one of the following groups: oral administration of 400 μg misoprostol, 8 h before aspiration; and vaginal self-administration of 400 μg misoprostol, 4 h before aspiration. During admission, all subjects were checked on a 15-min basis. The preoperative cervical dilatation achieved was the main outcome assessed. The cervix was dilated (Hegar ≥ 8) in 348 (78%) subjects from the oral treatment group and in 391 (87%) women from the vaginal treatment group; this difference was statistically significant (p = 0.0004). The mean dilatation achieved in the oral treatment group was 8.1 mm (SD 1.6 mm) and it was 8.5 mm (SD 1.5 mm) in the vaginal treatment group; this difference was statistically significant (p = 0.0001). The frequencies of side-effects such as nausea, vomiting, diarrhea and chills reported by women from the vaginal misoprostol group were 10, 8, 18 and 4 times lower, respectively, than those reported by subjects from the oral misoprostol group. In conclusion, vaginal self-administration of misoprostol was the best administration route, as it obtained the same or greater priming effectiveness of the cervix in half the time with a much lower frequency of side-effects.     

Manual vacuum aspiration under local anaesthetic for early miscarriage: 2 years experience in a university teaching hospital in UK

Manual vacuum aspiration under local anaesthesia (MVA-LA) in an outpatient setting is an alternative to the standard surgical aspiration under general anaesthesia for miscarriage. We evaluate the feasibility, safety and clinical outcomes of MVA-LA in the management of miscarriage at less than 12 weeks of gestation in an outpatient setting. This prospective cohort study was conducted at the Birmingham Women’s Hospital. One hundred and thirty-one women with ultrasound scan confirmed incomplete or missed miscarriage underwent MVA-LA between November 2010 and January 2013. A computer database was used to record relevant information. The mean gestation age was 8.3 weeks (±1.8). Successful evacuation was achieved in 100 % of cases. One hundred and fourteen (87 %) patients underwent the procedure with direct intracervical LA block and the remaining cases did not have LA. There were no reported complications in 96 % of procedures. Cervical injury and vasovagal symptoms noted in 3.8 % of cases. In all cases, vaginal bleeding was minimal or mild. The post-operative pain was controlled successfully with a combination of paracetamol and diclofenac in 82 % of patients. The MVA method was associated with high levels (93 %) of patient satisfaction and acceptability. MVA-LA in an outpatient setting is a safe and acceptable therapeutic option for women diagnosed with early missed or incomplete miscarriage.     

Oral versus vaginal misoprostol for cervical priming in first-trimester abortion: a randomized trial.

The objective of this study was to compare the oral and vaginal administration of misoprostol for cervical priming before surgical abortion up to 63 days' gestation. A total of 900 pregnant women, with ages ranging from 18 to 42 years, who asked for pregnancy termination, were included in this study. Women were randomly allocated to one of the following groups: oral administration of 400 microg misoprostol, 8 h before aspiration; and vaginal self-administration of 400 microg misoprostol, 4 h before aspiration. During admission, all subjects were checked on a 15-min basis. The preoperative cervical dilatation achieved was the main outcome assessed. The cervix was dilated (Hegar > or = 8) in 348 (78%) subjects from the oral treatment group and in 391 (87%) women from the vaginal treatment group; this difference was statistically significant (p = 0.0004). The mean dilatation achieved in the oral treatment group was 8.1 mm (SD 1.6 mm) and it was 8.5 mm (SD 1.5 mm) in the vaginal treatment group; this difference was statistically significant (p = 0.0001). The frequencies of side-effects such as nausea, vomiting, diarrhea and chills reported by women from the vaginal misoprostol group were 10, 8, 18 and 4 times lower, respectively, than those reported by subjects from the oral misoprostol group. In conclusion, vaginal self-administration of misoprostol was the best administration route, as it obtained the same or greater priming effectiveness of the cervix in half the time with a much lower frequency of side-effects.     

Mifepristone versus vaginally administered misoprostol for cervical priming before first-trimester termination of pregnancy: a randomized, controlled study

OBJECTIVE: This study was undertaken to compare the effectiveness of mifepristone orally administered at 24 or 48 hours before first-trimester vacuum aspiration abortion with that of vaginally administered misoprostol as a cervical priming agent. STUDY DESIGN: In a randomized comparative trial 90 women who requested surgical termination of pregnancy were randomly assigned to receive 200 mg mifepristone orally 24 or 48 hours before the operation or 800 microg misoprostol vaginally 2 to 4 hours before the operation. The main outcome measures were baseline cervical dilatation, cumulative force required to dilate the cervix to 9 mm, and intraoperative blood loss. RESULTS: The baseline cervical dilatation was significantly greater among women who received mifepristone 48 hours before the operation (P =.02). This group also required the least mechanical force to dilate the cervix (P =.06). There were no significant differences among the 3 groups in the intraoperative blood loss, in the operating time, or in patient acceptability. Side effects such as hot flushes and headaches were significantly higher among women who received mifepristone 24 or 48 hours before the operation than among those who received misoprostol (P =.01 and P =. 002, respectively). CONCLUSION: Mifepristone is an effective cervical priming agent when orally administered 48 hours before vacuum aspiration for termination of first-trimester pregnancy. Because of its cost and availability in comparison with misoprostol, however, selective use may have to be considered.     

The effect of oral versus vaginal misoprostol on cervical dilatation in first-trimester abortion: a double-blind,randomized study

Objective: To determine the effect of oral versus vaginal misoprostol on cervical dilatation in first-trimester intrauterine evacuation or menstrual regulation (MR). Design and methods A total of 120 patients were randomly assigned to a double-blind prestudy. Four groups, each consisting of 30 cases, were administered one of four regimens: 200 μg misoprostol orally, 200 μg misoprostol intravaginally, placebo orally, or placebo intravaginally, 10 h before MR, respectively. Age, number of births and abortions, birth methods, date of last delivery and last abortion were recorded. The gestational age was determined by ultrasonography. Prior to MR, data regarding the time of the application of the drug, the presence of placenta in the cervical canal, the degree of cervical dilatation, the duration of MR and patients' complaints were recorded. The MRs were performed by the same physician. The statistical analyses were evaluated with the χ² test and Fisher's exact test in the Aegean University Science Faculty Department of Statistics. Results: In the oral misoprostol group, four patients had cervical bleeding and one had intracervical placenta. In the intravaginal misoprostol group, cervical bleeding was observed in seven patients and intracervical placenta was recorded in four cases. Cervical bleeding was observed in one case and intracervical placenta was also observed in one case in the oral placebo group. Cervical dilatation reached 8 mm in seven patients in the oral misoprostol group and in three patients in the intravaginal group, with none in the placebo group. Symptoms such as pelvic pain, headache and nausea were observed in 11 cases in the oral and 14 cases in the vaginal misoprostol groups. Conclusion: Different methods of misoprostol administration may not be equivalent in terms of efficacy and side-effects. Therefore, we decided to extend the study to include more patients so as to achieve statistically significant results.     

The effect of oral versus vaginal misoprostol on cervical dilatation in first-trimester abortion: a double-blind, randomized study.

OBJECTIVES: To determine the effect of oral versus vaginal misoprostol on cervical dilatation in first-trimester intrauterine evacuation or menstrual regulation (MR). DESIGN AND METHODS: A total of 120 patients were randomly assigned to a double-blind prestudy. Four groups, each consisting of 30 cases, were administered one of four regimens: 200 microg misoprostol orally, 200 microg misoprostol intravaginally, placebo orally, or placebo intravaginally, 10 h before MR, respectively. Age, number of births and abortions, birth methods, date of last delivery and last abortion were recorded. The gestational age was determined by ultrasonography. Prior to MR, data regarding the time of the application of the drug, the presence of placenta in the cervical canal, the degree of cervical dilatation, the duration of MR and patients' complaints were recorded. The MRs were performed by the same physician. The statistical analyses were evaluated with the chi(2) test and Fisher's exact test in the Aegean University Science Faculty Department of Statistics. RESULTS: In the oral misoprostol group, four patients had cervical bleeding and one had intracervical placenta. In the intravaginal misoprostol group, cervical bleeding was observed in seven patients and intracervical placenta was recorded in four cases. Cervical bleeding was observed in one case and intracervical placenta was also observed in one case in the oral placebo group. Cervical dilatation reached 8 mm in seven patients in the oral misoprostol group and in three patients in the intravaginal group, with none in the placebo group. Symptoms such as pelvic pain, headache and nausea were observed in 11 cases in the oral and 14 cases in the vaginal misoprostol groups. CONCLUSIONS: Different methods of misoprostol administration may not be equivalent in terms of efficacy and side-effects. Therefore, we decided to extend the study to include more patients so as to achieve statistically significant results.