Sexual Health Supplies
Pain management for MVA - details from papers
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VAT Registration Number: GB 757080813 Company Registration Number: 3626868
Directors: L.Morgan B.Pharm. (Hons). MRPharmS. C.Gleen B.Pharm. (Hons). MRPharmS.
Sexual Health Supplies
This document is a summary of details regarding pain management from several papers discussing the Manual Vacuum Aspiration technique. It could be useful for units wanting to prepare an MVA pain management protocol. We have listed the papers and their references so you can look them up (or ask us for a copy). We have not listed in this document the references cited within the papers themselves.
You may also wish to read ‘Manual Vacuum Aspiration (MVA) for Uterine Evacuation: Pain Management’ Authors: Laura Castleman, MD, MPH and Carol Mann, CRNA, MS, and the BPAS protocol, both available on our website, link http://www.durbin.co.uk/key-divisions/sexual-health-supplies/a1v2m3i4m5o
Further, at the last RCOG MVA Training Course (11th Feb , 2016), Dr. Patricia Lohr gave the following as BPAS routine:
Gentle technique – avoiding fundus.
Pain is very short-lived.
Ibuprofen 800 mg orally 60-90 minutes before procedure.
Entonox available on demand but no proof of any effect. (Continuous nitrous oxide would probably be effective ?)
Paracervical block – 18ml lignocaine with sodium bicarbonate solution (to reduce stinging) administered by 4 deep SLOW injections at 2, 4, 8 and 10 o’clock positions.
They are currently trialling conscious sedation for MVA.
Sharma M. Manual Vacuum Aspiration: an outpatient alternative for surgical management of miscarriage. The Obstetrician and Gynaecologist 2015;17: 157-61
One of the most important factors for the success of outpatient MVA is the appropriate management of pain during and after the procedure. Women’s experience with pain during MVA varies widely, with some women feeling no pain while others describe considerable pain. The source of the pain could be anxiety, cervical dilatation and/or uterine manipulation and evacuation. Adequate pain relief should be offered through pre-procedure and post-procedure analgesia, and adequate use of local anaesthesia. Nitrous oxide is useful for women who have severe pain during the procedure. A woman’s anxiety level strongly influences her perception of pain. Her level of comfort can be improved by different factors such as a procedure room that is quiet, comfortable and relaxing, and a clear explanation of what to expect before, during and after the procedure. Healthcare professionals who are calm, friendly, empathetic, unhurried and efficient can also make a considerable difference.
The uterine fundus is enervated by T10 to L1 spinal nerves. These Nerves follow along the ovarian plexus and uterosacral and utero-ovarian ligament. They are not fully accessible by the paracervical block since they accompany the ovarian vessels and are higher in the pelvis than the local infiltration will reach. Ibuprofen 400-800mg or naproxen 500mg given 30-60 minutes prior to the procedure are recommended to decrease the pain caused by uterine cramping.
For pre-emptive pain relief, 500mg naproxen or 400- 800mg ibuprofen can be given orally 1 hour before the procedure. In women with contraindications to nonsteroidal anti-inflammatory drugs, paracetamol and/or codeine can be used.
Lidocaine hydrochloride 2% anaesthetic gel may be applied topically to the cervix, followed by paracervical injection of local anaesthetic, (30mg/ml prilocaine and 0.03IU/ml felypressin) into the four quadrants using a dental needle (0.40 x 35mm, 27g). About 1-5 ml, that is half to two-and-half cartridges of the local anaesthesia can be given.
Milingos D, Mathur M, Smith N, Ashok P: Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss. BJOG 2009;116:1268-1271
During the MVA, Anaesthetic gel (Instillagel®, lidocaine hydrochloride 2%; Claimed Ltd, Loud water, UK) was applied to the cervix and subsequently local anaesthetic (Citanest with Octapressin®, 3% prilocaine; Dentsply Ltd, Addlestone UK) was administered intracervically at 2-,4-,8- and 10-O’clock. This was administered using a Terumo dental needle (0.40 x 35mm, 27G).
Vinod Kumar, Jonathan Chester, Janesh Gupta, Manjeet Shehmar: Manual vacuum aspiration under local anaesthetic for early miscarriage: 2 years experience in a university teaching hospital in the UK. Gynaecol Surg; DOI 10.1007/s10397-013-0804-6
All patients were given the option of further intra-operative analgesia or Entonox® (50% nitrous oxide and 50% oxygen; BOC healthcare, Manchester, UK) should they require it.
The LA consisted of a direct intracervical block using 6.6ml 3% mepivacaine hydrochloride (Scandonest, Septodont ltd.) infiltration deep at the cervical isthmus level at 12, 3, 5, 6, 7, and 9 o’clock positions using dental needle (Solo Supra).
Immediately, post-procedure, 50-100 mg diclofenac and 1 g paracetamol were given rectally for pain relief. When patients could not be prescribed diclofenac due to contraindications then co-dydramol two tablets or Tramadol 100 mg was given orally. In all emergency cases, IV morphine was given in a titrated 5-mg bolus dose up to a maximum of 20-mg dose with Entonox®
Oxygen saturation monitoring was carried out for at least 2 h prior to discharge in women who underwent emergency MVA and had IV morphine. Patients were usually discharged within 2 h of the procedure. All women were advised to rest for the remainder of the day and were advised to return to work usually within 24-48 h.
On discharge, the patient was given the ward’s contact number, in case of problems, and analgesia in the form of diclofenac or co-dydramol.
The patient was instructed to get in contact if experiencing heavy bleeding, pyrexia, severe abdominal pain, abnormal vaginal discharge or had a positive pregnancy test.
Pillai M, Welsh V, Sedgeman K, et al: Introduction of a manual vacuum aspiration service: a model of service within a NHS Sexual Health Service.
J FamPlann Reprod HealthCare Published Online First: doi:10.1136/jfprhc-2013-100700
On arrival, women self-administered 2×200 mg misoprostol tablets sublingually or vaginally, and they were offered diclofenac 100 mg rectally, which most chose to
self-administer. Some 60–90 minutes later, 11 ml Instillagel® (2% lidocaine gel with chlorhexidine) was inserted through the cervix into the extra amniotic space using an Instillaquill, as described elsewhere. In a minority of cases the cervix was found to be tight, so a further 200 mg misoprostol was administered and more time allowed for cervical preparation. The MVA procedure was otherwise performed approximately
20–30 minutes after the Instillagel administration. Additional analgesia was given by means of a paracervical block with 3×2.2 ml ampoules of 3% mepivicaine injected at the 12, 3 and 9 o’clock positions using a dental syringe with a long 27g needle, in the manner described by Hamoda et al. Entonox® was available on request.
There are two elements to the technique that we employed for pain relief. One is extra-amniotic instillation of lidocaine gel. Instillation of 5 ml 4% lidocaine through the cervix 3 minutes before first-trimester abortion has been shown to provide significant reduction in pain during cervical dilation and suction aspiration,8 while instillation of
1% lidocaine failed to provide pain relief.9 However, there was a high rate of toxicity with instillation of the higher concentration. We instilled 11 ml 2% lidocaine gel, but allowed considerably longer for absorption (20–30 minutes). This technique also provided an opportunity to assess cervical priming and to extend this where the cervix did not admit the quill or gel with ease. Extending the duration of priming in
potentially more difficult cases may also have influenced pain scores. The second element, paracervical injection of mepivicaine, has been studied for a range of gynaecological interventions. A recently updated Cochrane review found that deep local anaesthetic injection was associated with significantly less pain during cervical dilatation and uterine intervention than placebo injection (saline or water) but concluded that clinically this difference may be unimportant. Overall there is a lack of clear evidence on the best method of local anaesthesia for minor gynaecological
procedures, including abortion. We did not include conscious sedation as part of
our procedure as we aimed to introduce a technique that is safe and suitable for an outpatient setting where anaesthetist support is not available and that would allow women to leave the service directly, without requiring a supervising adult.
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VAT Registration Number: GB 757080813 Company Registration Number: 3626868
Directors: L.Morgan B.Pharm. (Hons). MRPharmS. C.Gleen B.Pharm. (Hons). MRPharmS.
Sexual Health Supplies
______
VAT Registration Number: GB 757080813 Company Registration Number: 3626868
Directors: L.Morgan B.Pharm. (Hons). MRPharmS. C.Gleen B.Pharm. (Hons). MRPharmS.