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Approximately 1 million US women are diagnosed as having early pregnancy failure annually, contributing to roughly 500 000 emergency department (ED) visits for complaints of “pregnant and bleeding” each year [
]. To treat heavy vaginal bleeding in this population, prompt uterine evacuation is often achieved with prostaglandin medical management, suction or sharp curettage in the operating room, or manual vacuum aspiration (MVA) [
]. Manual vacuum aspiration has primarily been used to treat stable miscarriage in the outpatient setting and developing countries, but has not been the mainstay of treatment of miscarriages in most EDs in the United States [
Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomized controlled equivalence trial.
We recently initiated the use of MVA in the ED to treat first-trimester spontaneous miscarriages-in-process and retained products of conception (POC), requiring intervention. The goal of this study was to illustrate the feasibility of implementing this new clinical service in the ED, where previously all patients with first-trimester incomplete abortion and retained POC had been surgically managed in the operating room.
We performed a retrospective case series of all women presenting to the Hospital of the University of Pennsylvania ED with vaginal bleeding and treated with MVA in the ED. Cases from March 1, 2011, to February 29, 2012, the year after the implementation of EDMVA, were reviewed. Eligibility criteria for EDMVA included persistent bleeding from first-trimester nonviable pregnancy or retained POC. Exclusion criteria included live intrauterine pregnancy, gestational age beyond 12 weeks, and stable miscarriage referred for outpatient treatment. Obstetrics/gynecology consult teams performed all procedures.
We ascertained vital signs, gestational age, serum hemoglobin and human chorionic gonadotropin, and ultrasound findings. Descriptive statistics were calculated. Frequencies and proportions summarized categorical variables. Means and standard deviations or medians and interquartile ranges summarized continuous variables.
Nine women were treated with MVA during the study period (Table 1). Indications for treatment were incomplete abortion (n = 6; 67%) and retained POC (n = 3; 33%). Overall, the mean (SD) time from ED triage to completion of the EDMVA procedure was 6:12 (2:26) hours, and the average (SD) interval between EDMVA and ED exit was 1:39 (1:19) hours (Table 2). The overall mean (SD) time spent in the ED was 7:51 (2:56) hours compared with the 6:10-hour average ED visit duration at our institution for patients with symptomatic first-trimester pregnancy. There were no complications from the EDMVA procedure in any patient.
Table 1General patient characteristics (N = 9)
Variable
n (% or range)
MVA indication
Incomplete abortion
6 (67)
Retained POC
3 (33)
- Retained POC afte miscarriage
1 (11)
- Retained POC after induced abortion
1 (11)
- Retained POC after vaginal delivery
1 (11)
Age (y), mean (SD)
29 (7.2)
Black race
9 (100)
Gestational age by last menstrual period (d), mean (SD)
65 (11.3)
Vaginal bleeding present on admission
9 (100)
Duration of vaginal bleeding (d), mean (SD)
4.5 (4.1)
First serum hemoglobin, n (mean ± SD)
9 (11.3 ± 1.02)
Second serum hemoglobin, n (mean ± SD)
3 (8.7 ± 2.51)
Abdominal pain present on admission
7 (78)
Gravida, mean (SD)
6 (3.9)
Rh+
9 (100)
Serum β-hCG, mean (SD)
3898 (4149)
Patients receiving red blood cell transfusions
2 (22)
Temperature (°F), mean (SD)
98.4 (0.4)
Systolic BP (mm Hg), mean (SD)
127 (24.4)
Diastolic BP (mm Hg), mean (SD)
79 (8.4)
Heart rate (beats/min), mean (SD)
91 (16)
Pain score, mean (SD)
7.8 (3.7)
BP, blood pressure; hCG, human chorionic gonadotropin.
Five patients (56%) were discharged directly from the ED (Table 3). All were diagnosed as having incomplete abortion. For discharged patients, time from triage to EDMVA procedure end ranged from 2:56 to 9:50 hours (mean ± SD, 6:47 ±2:34 hours), and the average (SD) time from procedure end to discharge was 1:05 (0:42) hours. The average (SD) overall ED stay for discharged patients lasted 7:52 (2:35) hours.
Table 3Discharged home after MVA
ID
MVA indication
Complaints
Abnormal vital signs
Serum hgb (g/dL)
Ultrasound findings
Previous ED visit this pregnancy
1
Incomplete abortion
Vaginal bleeding (8 d)
10.4
Intrauterine gestational sac with embryo and no cardiac activity
Yes
Abdominal pain
Dizzy/lightheaded
2
Incomplete abortion
Vaginal bleeding (2 d)
12.3
Early embryonic demise, gestational sac in lower uterine segment, and endocervical canal indicative of abortion in progress
No
6
Incomplete abortion
Vaginal bleeding (3 d)
BP: 172/90 mm Hg
11.8
Thickened endometrium with heterogeneous hyper/hypoechoic material, open cervical os, abortion in progress
Yes
Abdominal pain
Nausea
7
Incomplete abortion
Vaginal bleeding (4 d)
10.4
Low-lying irregularly shaped intrauterine sac without fetal cardiac activity
Yes
Abdominal pain
Weakness
Shortness of breath
8
Incomplete abortion
Vaginal bleeding (14 d)
11.2
Low-lying irregular intrauterine gestational sac, no embryo, likely threatened abortion of anembryonic gestation
Four patients were admitted to the hospital (Table 4) after uncomplicated procedures. Two received blood transfusions for hemodynamic instability before EDMVA and were admitted for symptomatic anemia. The remaining patients were admitted for endometritis or pelvic pain.
This case series is, to our knowledge, one of the first reports on MVA offered exclusively in the ED setting. This study documents the clinical and cultural change of practice in the management of uterine evacuation for miscarriages-in-progress, where a procedure once requiring a surgical theater is now being performed in an expedited fashion without hospital admission.
The interval leading up to the EDMVA procedure comprised most of the time spent in the ED. This period is highly dependent on the time needed for obstetrics/gynecology consult team arrival, evaluation, and procedure completion. Manual vacuum aspiration performed in the outpatient setting is fast, lasting 19 minutes on average [
]. Training ED physicians to perform EDMVA could negate reliance on obstetrics/gynecology team delays and has the potential to greatly decrease ED wait times and congestion.
Sufficient pain control was universally achieved with local anesthetic via paracervical injections of 1% lidocaine, intravenous and oral opioids, and/or oral nonsteroidal anti-inflammatory drugs or acetaminophen. No conscious sedation or general anesthesia was used, suggesting that MVA can be tolerated and is appropriate for use in the ED setting without the need for anesthesia team assistance.
Our findings indicate that the implementation of MVA in the ED is feasible. Future studies should be designed with a larger patient population to confirm safety and efficacy of EDMVA and to determine whether emergency physicians may more efficiently perform this procedure.
References
Warburton D.
Fraser F.C.
Spontaneous abortion risks in man: data from reproductive histories collected in a medical genetics unit.
Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomized controlled equivalence trial.
☆☆Conflict of interest: The authors have no conflicts of interest.
★Author contributions: M.K., E.M.D., and C.A.S. conceived the study. E.M.D. and C.A.S. supervised the data collection. M.K., C.A.S., K.E.Q., and E.M.D. managed the data, including quality control. M.K. and K.E.Q. analyzed the data. M.K. and K.E.Q. drafted the manuscript, and all authors contributed substantially to its revision. M.K. takes responsibility for the manuscript as a whole.
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