II. Indications
-
Early Pregnancy Loss <13 weeks
- See Early Pregnancy Loss for diagnosis and Ultrasound confirmation
- Uncontrolled uterine Hemorrhage in a hemodynamically Unstable Patient when obstetrics is not available
III. Contraindications
- No absolute contraindications in life-threatening Hemorrhage
- Septic Abortion (risk of uterine perforation, Massive Hemorrhage)
- Suspected Molar Pregnancy (Massive Hemorrhage risk)
- Uterine anatomical abnormalities
IV. Preparation: Equipment
- Antiseptic solution (e.g. Povidone-Iodine, Chlorhexidine)
- Large cotton swabs (procto swabs)
-
Anesthetic for Paracervical Block
- Spinal needles 20 to 22-gauge, 3.5 to 5 cm length
- Two 10 cc Syringes
- Lidocaine 1% 20 ml
- Suction cannulas
- Cannulas are sized for Gestational Age (e.g. size 7 cannula is used for 7 week gestation)
- Large syringe (e.g. 20 to 50 ml) or aspirator (e.g. ipas manual aspirator)
- Tenaculum
- Speculum
- Cervical Dilator
- Aspirator
V. Technique
- Obtain Informed Consent
- Place speculum
- Prepare the Cervix
- Apply antiseptic (Povidone-Iodine or Chlorhexidine) to surface of Cervix
- Apply in circular motion with large cotton swabs (procto swabs)
- Include entire Cervix and cervicovaginal junction
- Perform Paracervical Block (includes Tenaculum application)
- Apply antiseptic (Povidone-Iodine or Chlorhexidine) to surface of Cervix
- Cervical Dilation
- Use sterile technique
- Hold the tenaculum (applied at 12:00 position) for counter traction
- Insert the cervical dilator into Uterus via the cervical os, gently rotating dilator between fingers
- Uterine Aspiration
- Attach suction cannula to aspirator or large syringe
- Activate the vacuum if using an aspirator (e.g. pressing 2 buttons on the aspirator)
- Aspiration cycle
- Insert the suction catheter into the Uterus and gently advance until reaching the fundus
- Withdraw the suction catheter back 2 cm before applying vacuum (prevent uterine wall injury or perforation)
- Pull back the plunger on syringe or aspirator to suction material into syringe
- Slowly withdraw the suction cannula while rotating 360 degrees
- Empty syringe or aspirator after each pass of the suction cannula
- Repeat the aspiration cycle until no further contents is aspirated
- Confirmation
- Send aspirated contents to pathology
- Consider Ultrasound to confirm empty Uterus after procedure
- Disposition
- Close interval follow-up with obstetrics
- Antibiotics
- Some organizations recommend post-procedure prophylaxis with Doxycycline
- If signs of Septic Abortion, hospitalize and initiate broad spectrum IV Antibiotics with anaerobic coverage
VI. Complications
- Uterine Hemorrhage in Early Pregnancy Loss may be life threatening without intervention
- Major events requiring intervention occurred in <0.1% of procedures in stable office-based gynecology procedures
- Uterine Hemorrhage requiring transfusion
- Uterine perforation
- White (2015) Contraception 92(5):422-38 +PMID: 26238336 [PubMed]