Comparative study to evaluate the
success rate of manual vaccum aspiration and Medical abortion in
termination the first trimester pregnancy
Bhardwaj M1, Bhargava S2
1Dr Malini Bhardwaj, Associate Professor, Department of Obstetrics
& Gynecology, RKDF Medical College, Bhopal, MP, India, 2Dr Sumit
Bhargava, Associate Professor, Department of Anesthesiology, L.N.
Medical College Bhopal, MP, India
Address for
correspondence: Dr Malini Bhardwaj, Email:
dr.malinibharadwaj@gmail.com
Abstract
Objectives:
This study was undertaken to evaluate the success rate of manual
vaccume aspiration in termination the first trimester pregnancy, study
the merits and demerits of the method and compare it with other method
i.e. medical abortion by misoprostol and mifepristone in first
trimester MTP. Methodology: In a prospective randomized controlled
study, participants were divided in two groups: Study group of 30
patients of 6-12 weeks gestational age subjected to MTP by manual
vacuum aspiration. Another group consisted of 30 patients of 6-8- weeks
gestational age who were subjected to MTP by medical method using
mifepristone and misoprostol. Result: Present study consist of 30 cases
of medical termination of pregnancy in Ist trimester carried out by
(manual vaccum aspiration) MVA. A comparison of observation and results
was made with another group of 30 patients who had undergone pregnancy
termination in Ist trimester using mifepristone and misoprostol. In 6-8
weeks pregnancies incidence of complete abortion was 100% In 10 weeks
complete termination was done in 8 patient’s only 1 patient
had incomplete termination. In medical abortion also results show that
in up to 6 week pregnancy 3(12%) patient had incomplete expulsion, in
up to 8 week 11(20%) patient had incomplete expulsion In present study
over all success rate with MVA was 93.33% whereas with medical abortion
success rate is found to be 86.67%. Conclusion: It is concluded from
present study that Manual Vaccum Aspiration is safe, simple and easy
procedure with minimal need of anesthesia and analgesia. It is very
good option in low resource settings.
Keywords: Manual Vaccum Aspiration, Medical Termination of
Pregnancy, Medical Abortion
Manuscript received:
4th Aug 2015, Reviewed:
10th Aug 2015
Author Corrected:
17th Aug 2015, Accepted
for Publication: 30th Aug 2015
Introduction
Fertility control through induced abortion though an ancient practice,
continues to be popular in present day obstetrics as well.
Contraception is definitely a far superior way of family and population
limitation than termination of pregnancy. Yet it cannot be ignored that
the lack of fore sight often leaves an individual with burden of an
unwanted or illegal pregnancy. Number of such pregnancies is
significantly enough to render pregnancy termination an important
method of fertility control.
Before the era of legalized abortion, such pregnancy termination was
considered illegal by law, therefore it was domain of untrained quacks
who performed them most unhygienically which made significant
contribution to maternal morbidity & mortality rates.
Intense realization about the grave consequences of population
explosion all over the world led to formation of abortion laws in
various counties. The pressing need of time made the policymakers to
revise the law of abortion thereby leading to liberalization of
indications for abortion.
In India, the bill on medical termination of pregnancy was passed
through parliament in 1971 and brought into execution on April 1972[1].
This revolutionized the sphere of obstetrics, which deals with
pregnancy termination and also made tremendous impact on religious and
cultural values of present day social setup. Abortion has been legal in
India since 1971, The law is quite liberal, as it aims to reduce
illegal abortion and maternal mortality. An abortion can be performed
in India until the 20th week of pregnancy. The opinion of a second
doctor is required if the pregnancy is past its 12th week. The Medical
Termination of Pregnancy Act was amended in 2002 and 2003 to allow
doctors to provide mifepristone and misoprostol (also known as the
“medical abortionl”) on prescription up to the
seventh week of pregnancy. With legalization of abortion, demand for
better, more reliable and safer method of pregnancy termination in
first trimester has become more pressing. Safety of pregnancy
termination is inversely related to the gestational period. First
trimester abortions are relatively easy to perform and are attended by
fewer complications and unpleasant sequels, whereas mid trimester
abortion mortality rates are likely to be 3 to 4 times greater than
those associated with first trimester pregnancy terminations. There are
various method of first trimester pregnancy termination like
mifepristone (RU-486) misoprostal ePGE2 (Gameprost) in medical methods
and menstrual regulation, manual vacuum aspiration and suction
evacuation in surgical methods. But the search for safer solution led
to discovery of MVA. This study was conducted to evaluate the safety
and effectiveness of Manual Vacuum Aspiration in first trimester MTP.
Methodology
Design:
Prospective comparative study,
Setting:
Department of Obstetrics and Gynecology in GRMC Gwalior and Associated,
Hospital over a period of 18 months.
Selection of cases:
participants for study were selected in two groups:
Sample size:
Study group of 30 patients of 6-12 weeks gestational age subjected to
MTP by manual vacuum aspiration. Another group consisted of 30 patients
of 6-8- weeks gestational age who were subjected to MTP by medical
method using mifepristone and misoprostol.
Inclusion criteria:
Patients of early pregnancy (6-12 weeks in MVA group and 6-8 weeks in
medical abortion) willing for termination of pregnancy were included in
the study.
Exclusion criteria
1- Suspicion of ectopic pregnancy
2- Pregnancy with fibroid uterus.
3- History of caesarean section or uterine surgery
4- Severe cervical stenosis
5- Pelvic inflammatory disease.
6- Medical disorders anaemia, renal diseases, heart diseases,
bleeding disorder.
Material
MVA syringe is a 60cc syringe (Usually made with polyethylene) with a
capacity to hold vacuum of 25-26 inches of Hg which is equivalent to
the vacuum created in an electric suction pump, sterile gloves,
sim’s or Cusco’s speculum ,anterior vaginal wall
retractor, allis forceps (long)/volsellum (small toothed),sponge
holding forceps.
For medical method tablet Mifepristone and tablet Misoprostol are
required. Mifepristone is a substituted 19 non steroid compound
clinically designated as 11β [p-dimethylamine pheny1] 17
hydroxy 17- (1-propyny1) octra4,9 dien 3 one. It acts by binding to
human progesterone receptors. Misoprostol is a prostaglandin
Procedure
MVA technique/procedure
1. Preparation of vacuum syringe and canulae
i- Close the pinch valve by pushing the buttons down
forward towards the syringe tip (can feel the valve locks)
ii- Pull back on the plunger until the arms of the
plunger snap outward at the end of the syringe barrel holding the
plunger in place.
iii- Check the stable positioning the plunger arms (the
plunger arms must be fully extended to the sides and secured over the
edge of the barrel). With the arms in this position, the plunger will
not move forward and vacuum is maintained.
2. The procedure: Patients is put in lithotomy position after emptying
the bladder. After part preparation and P/v examination hold the
anterior lip of the cervix using volsellum.
i- Insert the canulae through the cervix into the uterine
cavity just past the internal os by rotating the canulae while gently
applying pressure. Start with canula of size 4 and gradually increase
to the size that corresponds with the period of gestation.
ii- Push the chosen canula slowly into the uterine cavity just
beyond the os until it touches the fundus. Note the uterine depth by
the dots visible on the canula (the dot nearest to the tip of the
canula is 6 cm from the tip and each dots are at 1 cm interval.)
iii- After measuring the uterine depth, withdraw the canula
slightly.
iv- Attach the prepared syringe to the canula holding the
Allis forceps and the end of the canula is one hand and the syringe in
the other ensuring that the canula does not move forward.
v- Release the pinch valve on the syringe to release the
vacuum into the uterine cavity. Tissue and bubbles should
begin to flow through the canula into the syringe.
Complications like excessive bleeding, incomplete evacuation were
noted.
In patients care after
the procedure
i- Check the vital signs while Patients is still on operation
table.
ii- Check for bleeding per vagina and vital signs.
iii- Discharge the patients when she is stable (usually after
two hours).
iv- Oral methyl ergometrine, analgesic and antibiotic are
given after discharge.
v- Patients were asked to contact the doctor
immediately if any of the following happens:
• Bleeding more than menstrual flow
• Severe or increased pain
• Prolonged bleeding (more than two weeks)
• Foul smelling discharge per vagina
Medical Abortion:
Tablet mifepristone 200 mg. is given on day one, followed by two tablet
misoprostol (400 mcg) orally after 48 hrs and again two tablets
misoprostol 400 mcg after 12 hrs. Observations were made about pattern
of bleeding, abdominal cramps, any other side effects and see whether
the expulsion is complete or not.
Statistical Analysis:
Statistical analysis was done with Stata 11 software. Demographic
characteristics, marital status, parity, age, educational status and
complications were compared between two groups and data was analyzed
statistically. for continuous variables descriptive statistics(mean and
standard deviations) were computed. Comparison of means in MVA group
and medical abortion group was done using unpaired t –test.
For categorical data chi-square test was applied. P<0.05 was
considered significant.
Results
Present study consists of 30 cases of medical termination of pregnancy
in Ist trimester carried out by MVA in department of Obst. &
Gynae. GRMC, Gwalior. A comparison of observation and results was made
with another group of 30 patients who had undergone pregnancy
termination in Ist trimester using mifepristone and misoprostol during
January 2002 to July 2003.
Table No 1: Shows
comparable age incidence (cumulative) of patient in MVA and medical
abortion series
|
Age in yrs
|
MVA
|
Medical abortion
|
|
|
No. of cases
|
%
|
No. of cases
|
%
|
|
Up to 20
|
0
|
0%
|
0
|
0%
|
|
21-25
|
6
|
20%
|
14
|
46.67%
|
|
26-30
|
18
|
60%
|
12
|
40.00%
|
|
31-35
|
2
|
6.67%
|
4
|
13.33%
|
|
36-40
|
3
|
10%
|
0
|
0%
|
|
>40
|
1
|
3.33%
|
0
|
0%
|
Mean age in MVA group – 29.3 years
Mean age in medical abortion group – 26.66 years.
Table No 2: Shows time
taken for the procedure at different gestational age
|
Period of
gestation
|
No. of patients
|
Mean Time taken
|
|
6 weeks
|
8
|
10 min
|
|
8 weeks
|
12
|
15 min
|
|
10 weeks
|
9
|
18.8 min
|
|
12 weeks
|
1
|
25 min
|
Mean time taken in 30 patients – 14.47 min. The mean time
taken for the procedure increase with gestational age.
Table No 3: Shows
relation of complete and incomplete termination with gestational age in
MVA series
|
Weeks in
gestation
|
No. of cases
|
Complete
|
Incomplete
|
|
6 weeks
|
8
|
8
|
-
|
|
8 weeks
|
12
|
12
|
-
|
|
10 weeks
|
9
|
8
|
1
|
|
12 weeks
|
1
|
0
|
1
|
As is evident from above table the success rate decreases with
increasing gestational age after 10 week this method is infective in
our study.
Table No 4: Shows
associated side effect in MVA series
|
Side effect
|
No. of patients
|
|
Excessive bleeding
|
1
|
|
Perforation
|
-
|
|
Incomplete evacuation
|
2
|
|
Pain
during procedure
|
7
|
Complications may occur in MVA as seen in above table.
Table No 5: Comparative
study in MVA and medical abortion in 6-8 week gestation
|
Side effect
|
MVA
|
Medical abortion
|
|
6 week
|
8 week
|
6 week
|
8 week
|
|
No. of cases
|
8
|
12
|
25
|
5
|
|
Complete termination
|
8
|
12
|
22
|
4
|
|
Incomplete
|
0
|
0
|
2
|
1
|
|
Failed
|
0
|
0
|
1
|
0
|
It is obvious from above table that success rate in MVA group is 100%
in upto 8 weeks gestation while it is 88% in 6 weeks and 80% in 8 weeks
gestation. Failure rate or rate of incomplete abortion is 0% in MVA
group while in medical abortion group rate of incomplete expulsion is
8% in 6 weeks and 20% in 8weeks. Failure rate was 4% in 6 weeks in
medical abortion group.
P value of complete termination in 6 and 8 weeks gestation is 0.003 and
0.027 respectively and P value of incomplete termination of incomplete
termination in 6 & 8 weeks is 0.015 & 0.027
respectively. Thus it is concluded that this difference is significant.
Table No 6: Comparative
study in MVA and medical abortion group up to 8 week gestation
|
Side effect
|
MVA
|
Medical abortion
|
|
No. of cases
|
20
|
30
|
|
Complete
|
20
|
26
|
|
Incomplete termination
|
0
|
3
|
|
Failed
|
0
|
1
|
|
Excessive bleeding
|
0
|
4
|
|
Pain
|
6
|
6
|
Discussion
In India, the bill on medical termination of pregnancy was passed
through parliament in 1971 and brought into execution on April 1972[1].
This revolutionized the sphere of obstetrics, which deals with
pregnancy termination and also made tremendous impact on religious and
cultural values of present day social setup. Abortion has been legal in
India since 1971, when the Medical Termination of Pregnancy Act was
passed. The law is quite liberal, as it aims to reduce illegal abortion
and maternal mortality. An abortion can be performed in India until the
20th week of pregnancy. The opinion of a second doctor is required if
the pregnancy is past its 12th week. Late pregnancy termination caries
more risk then early pregnancy termination and this has led to
discovery of a variety of methods which will render the early pregnancy
termination more safe and effective with minimum side. Manual vacuum
aspiration is one of them.
Surgical methods especially vacuum aspiration in early pregnancy is
safe, reliable and quick and yet there is a definite place for medical
method for termination of pregnancy. There are many women who prefer to
avoid surgery and want secrecy.
In the present study an attempt was made to evaluate the usefulness of
MVA as a method of trimester pregnancy termination. A relative
evaluation of MVA and medical abortion was done by comparing the
observation and results of patients in MVA series with those of similar
group of patients in whom pregnancies were terminated by medical method
at almost the same gestational age as that of MVA. This comparison was
made considering age, parity, gestation age of pregnancy and efficacy,
side effects and complication etc.
There is fear of surgery specially when adolescent girls have unwanted
pregnancy and need help. The effectiveness of medical abortion has been
well demonstrated in a series of trial by Krishna and Coyaji undertaken
in variety of settings in India [2]. Success rate is very good (98%) up
to 50 days of LMP but this decline to some extent when the period of
amenorrhea extends. Side effects are nausea, occasional vomiting and
abdominal cramps. Occasionally there may be mild diarrhea.
I M Spitz et al reported an incidence of 11.6 per abortion 1000 live
birth before legalization of abortion in year 1967. [3] After which the
incidence has increased 8 times the previous one.
Age: In the
present study patients who sought MTP were from 22 to 42 yrs. of age.
Incidence was maximum in 26-30 yrs of age group (60%) Incidence
declined sharply after 35 yrs. In 35-40 yrs age group it was minimum as
fertility also to fall after the age of 35 yrs. In medical abortion
groups was not very much different i.e. 29.3 yrs. in MVA and 26.66 in
medical groups.
Gestational Age :
In the present study 8(26.67%) of all patients who were aborted with
MVA had 6 weeks size uterus 12(40%) had 8 weeks uterus and 9(30%) of
patient had 10 weeks uterus 1(3.33%) had 12 wk size uterus. FOGSI Ipas
(2007) conducted multicentric study in settings of medical college
hospitals to private hospitals and clinics of India [4]. In which 926
patients were taken, out of them 39.8% performed prior to 6th week
33.8%. In medical abortion series 25(83.33%) patient had up to 6 weeks
at 5(16.6%) of patients had up to 8 weeks.
Complication
Incomplete Abortions: In MVA series percentage of patients of complete
abortion decreased with increased gestational age. Only 2 patients had
on incomplete evacuation. They needed electric suction and curettage.
In 6-8 weeks pregnancies incidence of complete abortion was 100%. In 10
weeks complete termination was done in 8 patient’s only 1
(11.11%) patients had incomplete termination. In 12 weeks group all
patient had incomplete abortion. The above results show that definite
improvement in quality of abortion with decreased gestational age. In
MVA series termination is quick, success rate is higher and evacuation
more complete with decreased gestational age as compared to increased
week of pregnancy.
In medical abortion also results show that in up to 6 week pregnancy
3(12%) patient had incomplete expulsion, in up to 8 week 11(20%)
patient had incomplete expulsion. Hemlin J, Mollor B, (2001) study done
in Sweden including 170 patients who were randomized in VA and MVA, 88
and 91 patients respectively[5]. Two patients in each group has
incomplete evacuation.
Excessive bleeding:
In our study one patient at 10 weeks gestation had excessive bleeding
which was managed without any further complication. Das Vinita and Jain
Swati studied cases and found that incidence of blood loss was 50%
lower with MVA than sharp curettage [6]. In one study pattern and
predictors of bleeding after early abortion with mifeprstone and
misoprostol or MVA were determined [7]. 212 Women were enrolled in
which 80% women completed the study. Mean days of bleeding were higher
in medical (14 days) than MVA (9 days) group. In medical abortion group
4 patients (13.33%) had excessive bleeding.
Incidence of side effects:
There was pain during MVA in 7(23.33%) cases out of 30 cases. In
medical abortion group 6(20%) patients had abdominal pain and camps.
Side effects like nausea, vomiting, diarrhea were not reported in our
study. [8]
Duration of Hospital Stay:
Mean duration of hospitals stay in present study was 5.9 hr. In medical
abortion patients can be given drugs in outdoor setup. There is no need
of hospitalization. In Hemlin J, Mollor B, (2001) study including 200
patients (80% completed the study) mean duration of hospital stay was 2
hr.[5]
Failure Rate: Over
All Failure rate with MVA was 6.67 % and with medical abortion was
13.33%. Hemlin J, Mollor B (2001) study done in Sweden included 179
patients[5]. They were randomized in VA and MVA group (91 in MVA
& 88 in VA group). There was no significant difference in
frequency of complete abortion. Two patients in each group subsequently
needed re-curettage because incomplete evacuation.
Success Rate/ Effectiveness: In present study over all success rate
with MVA was 93.33% whereas with medical abortion success rate is found
to be 86.67%. Given the potential of MVA in allowing simplification of
requirement for safe abortion service as suggested by the evidence
presented earlier it is today our best hope in promoting widespread,
nationwide decentralized safe abortion services through the
governmental WHO and private sectors. In keeping traditions of
medicine, MVA is a relatively low cost, low tech procedure with few
logistic demands that has the potential to decentralize and democratize
safe legal abortion services in India, contribute to the cause of safe
motherhood and ensure every enemy couple the right and an option to
cope with unwanted pregnancy with safe and dignity.
Conclusion
It is concluded from present study that MVA is a very simple, safe and
easy procedure. It is very convenient and free from any side effects.
It does not require any special skill for it. Need of anesthesia and
analgesia is also minimal. It is very effective in setups where minimal
facilities are available. But with these advantages it has some
disadvantage like patients need hospitalization for the procedure,
which is not necessary in medical method.
Funding:
Nil, Conflict of
interest: None initiated.
Permission
from IRB:
Yes
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How to cite this article?
Bhardwaj M, Bhargava S. Comparative study to evaluate the
success rate of manual vaccum aspiration and Medical abortion in
termination the first trimester pregnancy. Int J Med Res Rev
2015;3(8):884-890. doi: 10.17511/ijmrr.2015.i8.166.