Manual Vacuum Aspiration (M.V.A) Versus Conventional Evacuation and Curettage in Early Pregnancy Loss

Objective: The aim of this study is to compare the efficacy of manual vacuum aspiration and conventional evacuation and curettage in early pregnancy loss Study Design: Randomized control trial Place and Duration: Study was conducted at department of obstetrics and gynecology Lady Reading Hospital Peshawar from 1st January 2019 to 31st August 2020. Methods Patients were early pregnancy loss (12 weeks or lesser gestational age) were enrolled. Patients were divided into two groups by lottery method. Group A were the patients who had conventional evacuation and curettage treatment. Group B were patient in which MVA was used. Patients’ demographics were recorded after taking written consent. Gestational age was calculated from first day of last menstrual cycle and by ultrasound. Cervical ripening was done by (misoprostol 400mcg) two hours before procedure. Procedure was carried out under aseptic measures. Complete uterine evacuation by either procedure was assessed by ultrasound after procedure and complications were noted. Data was analyzed by SPSS 24.0. Results: mean age in Group A was 29 years with SD ± 8.65 while mean age in Group B mean age was 30 years with SD ±7.62. Group B (Manual Vacuum Aspiration) was effective in 96% patients while Group A(Conventional Evacuation and Curettage) was effective in 89% patients. Complications were fewer in MVA as compared to conventional evacuation and curettage


INTRODUCTION
The most common complication is early pregnancy is early pregnancy loss which contributes to 10-20% of clinically recognized pregnancies [1]. Around one out of four women will suffer such a failure in her life [2]. In Pakistan, there are about 890,000 women in missing or incomplete miscarriages per year and the annual incidence of miscarriage estimated to be 29 per thousand females aged between 15 and 49 years [3]. Every year 197,000 women in the public health system are being screened for the complication of post-abortion [4]. miscarriage-related complications lead to 10-13 per cent of maternal mortality in developing countries, despite advances in health technology [5]. Treatment Options are expectant, medicinal (Misoprostol) and surgical options like sharp curettage and vacuum aspiration. The reports show that women do not accept medical option because they are unsure about how effective they are. [6] Dilation and evacuation or suction evacuation are the surgical choice for women. Dilatation and evacuation is as successful as 98%, but has sideeffects such as perforation of the uterus, infection 6%, 4% cervical trauma, and blood loss greater than 100ml in 22% of patients. Manual vacuum aspiration is an alternative to the conventional form of surgery. A procedure for uterine evacuation is a manual vacuum aspiration. The MVA technology is simple, secure, effective, portable ,lowcost [7]. Manual vaccume aspiration has a lower blood loss, a lower time consumption, a short hospital stay and thus a lower cost [6]. You are safe to use local anesthetics and nonsteroidal anti-inflammatory medication (NSAID) like ibuprofen in a clinical or physician's office. This technique is in used for last three decades [8] initially for incomplete miscarriage but currently it is being used for missed miscarriage, molar pregnancy, medical termination of pregnancy and endometrial sampling. Complications are rare less than 2%1 Over the last 30 years, clinical studies have demonstrated that MVA has been effective and very safe. As the preferred method for uterine evacuation, the World Health Organization (WHO) recommends MVA [9]. Studies show that MVA's effectiveness is comparable to EVA(electrical vaccum Aspiration) and successfully managed early-choice abortion and early pregnancy loss in approximately 99 percent of cases. Research shows that 98 percent of aspiration procedures are complicated, well above the alternative D&C procedure, which can result in excessive blood loss incidences, a pelvic infection, cervical damage and uterine perforation [10]. It is generally considered that vacuum aspiration take place without gross complications alternative D&C which can cause excessive blood loss, pelvic infections, cervical injuries and uterine perforation. Though MVA use is easy, but clinicians don't know the use of the tool. If the efficacy in early pregnancy loss turns out to be more than evacuation curettage , with no significant MVA complications then MVA should be more widely used in low resourse settings as well as in hospitals.

MATERIAL AND METHODS
All the patients with early pregnancy failure (less than or equal to 12 weeks gestation) wewere enrolled in study.Patients with ectopic pregnancy, pregnancy with fibroids, septic abortion and unwilling patients were excluded from this study. Patients were divided randomly divided into two groups by lottery method. Group A were Uzma Shaheen, Sumaira Yasmin, Nazia Liaqat et al P J M H S Vol. 15, NO.8, AUG 2021 2214 the patients who had conventional evacuation and curettage treatment. Group B were patient in which MVA was used. Patients demographics were recorded after taking written consent. Base line investigation including complete blood picture, blood group, hepatitis serology, coagulation profile was done. Gestational age was calculated from first day of last menstrual cycle and by ultrasound. Cervical ripening was done by (misoprostol 400mcg) two hours before procedure. Procedure was carried out under aseptic measures. . Effectiveness of the procedure was assessed by a complete uterine evacuation by either procedure by a pelvic ultrasound after the procedure frequency of complication were noted among both groups. Categorical variables were measured by percentage and frequency. Numerical variables were calculated by standard deviation. Chi square and T test were used. Complete data was analyzed by SPSS 24.0 version.

DISCUSSION
The pregnancy loss is a bitter experience in a women's life, accounting for 14% to 19 % of all recognized pregnancies . Approximately one out of four women experience such a loss in their lifetime, and local data shows an annual miscarriage of 29 per 1000 in women aged 15-49 years [11]. The methods used for the management of firsttrimester miscarriage consist of expectant, medical or surgical intervention . The choices amongst surgical methods include evacuation and curettage and vacuum aspiration . The Manual Vacuum Aspiration (MVA) h is now a favorable choice over Electrical Vacuum Aspiration (EVA) . in our comparison of MVA and evacuation and curettage both the groups were comparable regarding demographic characteristics mean age in Group A was 29 years with SD ± 7.71 while mean age in Group B was 30 years with SD ± 6.88. In Group A 41% patients were primi para and 59% patients were multi para. Where as in Group B 43% patients were primi para and 57% patients were multi para. . Group A (Manual Vacuum Aspiration) was effective in 97% patients while Group B (Conventional Evacuation and Curettage) was effective in 87% patients.Similar results were observed in another study conducted by Mansoor A et al [12]. in which the efficacy of manual vacuum aspiration for evacuation or retained products of conception was found to be 96.7% Results of our study comply well with Jayashree V et alstudy [13], which found that, contrary to dilatations and curettage, manual aspiration( MVA) was the more efficiently, less time consuming, without a heavy blood loss. Farooq F et al [14]. reported consistently that MVA in an early pregnancy failureis the treatment choice with a lower blood loss rate, less time consumption, less stay in hospital and less complications as compared to dilation and curettage procedures..
Fatima Y et al [15]. have stated that in the dilatation and curettage procedure complications including infection, blood loss, cervical laceration and incomplete evacuation were more as compared with MVA .
In DNC Group the mean VAS score was markedly higher 7.32+2.17 as compared to 4.18+1.16 for MVA Group showing that less post operative pain was experienced by patients who had MVA.
Ara J et al also found less pain in the evacuation by manual vaccume aspiration [16]. This study also shows a substantially greater incidence of cervical trauma and serious bleeding among DNC patients than MVA patients (p=0.001The effectiveness of MVA has been 94.3 percent which is similar to our study and in line with study findings by Gazvani [17].. Our report also compares with the mean age of the study population and the mean gestational age 10 [18]. The findings favor manually vacuum aspiration over the other medical and surgical treatments .thus MVA is the better choice for uterine evacuation in the first quarter of pregnancy and a quicker and more efficient.In addition, a classified gynecologist carried out the operation in our case. This may be one explanation why MVA efficacy was better with a lower complication rate. Other healthcare providers must be adequately qualified or trained to achieve a better outcome in remote areas in which specialists may not be available.
There is a trend towards low cost technology such as the use of manual vacuum aspiration but it is mainly limited to the better resourced tertiary hospitals [19]. The selection for MVA or evacuation and curettage depends on the choice of the surgeon. Current study was a single center analysis and further studies are recommended with a view to assessing the safety and effectiveness of this technique.

CONCLUSION
Manual vacuum aspiration was more effective than conventional suction and curettage in early pregnancy lossand was safe with lesser side effects as compared to conventional evacuation and curettage.