Article, Obstetrics

Manual vacuum aspiration in the emergency department for management of early pregnancy failure

Correspondence

Manual vacuum aspiration in the emergency department for management of early pregnancy failure

To the Editor,

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 [1,2]. 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) [3,4]. 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 [5,6]. Manual vacuum aspiration is a simple, timesaving, and cost-effective option for incomplete miscarriage [7,8]. The procedure is carried out at the bedside, and the manual aspirator is autoclavable and easily stored (Figs. 1 and 2) [9,10]. Manual vacuum aspiration is as effective and safe as the electric vacuum alternative and is highly acceptable to patients and providers [4,11]. However, studies evaluating the use of MVA in the ED setting specifically (EDMVA) are lacking.

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 interven-

Fig. 1 Ipas MVA Plus (Ipas, Chapel Hill, NC, USA) uterine aspirator.

tion. 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.

Fig. 2 Ipas EasyGrip cannulae (Ipas, Chapel Hill, NC, USA). Written permission obtained from Ipas.

0735-6757/$ – see front matter (C) 2013

Correspondence 245

Table 2 Manual vacuum aspiration procedure details (N = 9)

Time triage to procedure (min), mean (SD) 372 (146) Time procedure to exit from ED (min), mean (SD) 99 (79) Time triage to exit from ED (min), mean (SD) 471 (176) Discharged home 5 (56)

Admitted to hospital 4 (44)

pelvic painadmission diagnosis 1 (11)

“Incomplete abortion” admission diagnosis 1 (22)

“Endometriosis” admission diagnosis 1 (11)

Previous emergency department visit for 5 (56) same complaint

We ascertained vital signs, gestational age, serum hemoglobin and human chorionic gonadotropin, and ultra- sound findings. Descriptive statistics were calculated. Frequencies and proportions summarized categorical vari- ables. Means and standard deviations or medians and interquartile ranges summarized continuous variables.

Table 1 General 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 65 (11.3) period (d), mean (SD)

Vaginal bleeding present on admission 9 (100) Duration of vaginal bleeding (d), 4.5 (4.1) mean (SD)

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 ?-hCG, mean (SD) 3898 (4149) Patients receiving red blood cell 2 (22)

transfusions

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.

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

BP: 172/90 mm Hg 11.8

BP, blood pressure; hgb, hemoglobin.

Early embryonic demise, Gestational sac in lower uterine segment, and endocervical canal indicative of abortion in progress

Thickened endometrium with heterogeneous hyper/hypoechoic material, open cervical os, abortion in progress

Low-lying irregularly shaped intrauterine sac without fetal Cardiac activity

No

Yes

7

Incomplete abortion

10.4

Yes

8

Incomplete abortion

11.2

Low-lying irregular Intrauterine gestational sac, no embryo, likely threatened abortion of anembryonic gestation

Yes

Vaginal bleeding (3 d)

Abdominal pain Nausea

Vaginal bleeding (4 d)

Abdominal pain Weakness Shortness of breath Vaginal bleeding (14 d)

Abdominal pain

6 Incomplete abortion

12.3

2

Intrauterine gestational sac with embryo and no cardiac activity

Vaginal bleeding (8 d)

Abdominal pain Dizzy/lightheaded Vaginal bleeding (2 d)

Incomplete abortion

Previous ED visit this pregnancy

Yes

Serum hgb ultrasound findings

(g/dL)

10.4

Abnormal vital signs

Complaints

MVA

indication

Incomplete abortion

1

Table 3 Discharged home after MVA

ID

246 Correspondence

Table 4 Patients admitted to hospital after MVA

BP, blood pressure; HR, heart rate; PRBC, Packed red blood cells; RR, respiratory rate; TAB, therapeutic abortion; TVUS, Transvaginal ultrasound.

a Induced abortion.

b Spontaneous vaginal delivery of infant.

c spontaneous abortion, miscarriage.

ID

MVA

indication

Presenting complaints

Abnormal vital signs

First serum hgb (g/dL)

Second serum hgb (g/dL)

Ultrasound

findings

Transfusion of PRBC

(number units)

Admission diagnosis

Previous ED visit for this pregnancy

3

Retained

Vaginal

HR: 106

12.1

Heterogeneous

No

1. Retained

No

POC after

TAB a

bleeding

(2 d)

beats/min

uterine material

consistent with

POC

Abdominal

BP: 147/87

retained products

2. Pelvic pain,

pain

mm Hg

of conception

R peritoneal

inclusion cyst

around R ovary

Nausea

4

Incomplete

Vaginal

HR: 124

7.8

5.8

Thickened

Yes (1 unit

1. Incomplete

Yes

abortion

bleeding

beats/min

heterogeneous

in ED, 2 units

abortion

(4 d)

echogenic lower

during

Abdominal

BP: 92/70

uterine segment

admission)

pain

mm Hg

compatible with

incomplete abortion

5

Retained

Vaginal

11.8

11.3

(No ultrasound

No

1. Endometritis

No

POC after

SVD b

bleeding

(3 d)

reported)

Low back

2. Retained

pain

POC

9

Retained

Vaginal

HR: 102

9.3

6.3

Endometrial stripe

Yes (2)

Incomplete

No

POC after

SAB c

bleeding

(1 d)

beats/min

with echogenicity

and shadowing

abortion

Abdominal

RR: 27

suggestive of

Hemorrhage

pain

breaths/min

retained POC

Dizzy/

lightheaded

symptomatic First-trimester pregnancy. There were no complications from the EDMVA procedure in any patient.

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.

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 [7]. 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-inftammatory 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.

Correspondence

Mira Kinariwala MD Department of Emergency Medicine Hospital of the University of Pennsylvania Philadelphia, PA 19104, USA

247

The cause of Paroxysmal atrial fibrillation: Hyperbaric oxygen therapy or carbon monoxide poisoning?

To the Editor,

E-mail address: [email protected]

Kelly E. Quinley BA

Perelman School of Medicine University of Pennsylvania, Philadelphia, PA 19104, USA

Elizabeth M. Datner MD* Department of Emergency Medicine Hospital of the University of Pennsylvania Philadelphia, PA 19104, USA

Courtney A. Schreiber MD, MPH* Department of Obstetrics and Gynecology Hospital of the University of Pennsylvania Philadelphia, PA 19104, USA

http://dx.doi.org/10.1016/j.ajem.2012.07.014

References

  1. Warburton D, Fraser FC. Spontaneous abortion risks in man: data from reproductive histories collected in a medical genetics unit. Hum Genet 1964;16:1-25.
  2. Wittels KA, Pelletier AJ, Brown DFM, et al. United States emergency department visits for Vaginal bleeding during early pregnancy, 1993-2003. Am J Obstet Gynecol 2008;198: 523.e1-6.
  3. Forna F, Gulmezoglu AM. Surgical procedures to evacuate incomplete miscarriage. (Review) Cochrane Collaboration 2012:1-4.
  4. MacIsaac L, Darney P. Early surgical abortion: an alternative to and backup for medical abortion. Am J Obstet Gynecol 2000;183(2): 76-83.
  5. Milingos DS, Mathur M, Smith NC, et al. Manual vacuum aspiration: a safe alternative for the surgical management of early pregnancy loss. BJOG 2009;116:1268-71.
  6. Castleman LD, et al. Introduction of the dilation and evacuation procedure for second-trimester abortion in Vietnam using manual vacuum aspiration and buccal misoprostol. Contraception 2006;74: 272-6.
  7. Blumenthal PD, Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. IInt J Obstet Gyneco 1994;45:261-7.
  8. Rausch M, Lorch S, Chung K, et al. A cost-effectiveness analysis of surgical versus medical management of early pregnancy loss. Fertil Steril 2012;97(2):355-60.
  9. Warriner IK, Meirik O, Hoffman M, et al. 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. Lancet 2006;368:1965-72.
  10. Jejeebhoy SJ, Kalyanwala S, Zavier AJ, et al. Can nurses practice manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India. Contraception 2011;81:615-21.
  11. Dean G, et al. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception 2003;67: 201-6.

* co-principal investigators.

I enjoyed reading the article entitled “Paroxysmal atrial fibrillation after hyperbaric oxygen therapy” recently published online in American Journal of Emergency Medicine [1]. The authors presented a 78-year-old woman referring to them with loss of consciousness and the diagnosis of Carbon monoxide poisoning (carboxyhemoglobin of 42.6% in arterial blood gases analysis) who underwent Hyperbaric oxygen therapy. After HBO therapy, they noticed Atrial fibrillation in their patient, which responded to treatment with amiodarone. The authors have claimed that no study has reported AF after HBO therapy to date. However, a very important point about this case is that although the patient has developed AF after HBO therapy, CO poisoning itself can cause AF [2]. This may especially be more common in an aged patient (as the authors have themselves declared Aging as a risk factor for development of AF) because the prevalence of AF rises markedly with age: approximately 0.1% at age 40 years, 6% at age 65 years, and 10% at age 80 and older [3,4]. It seems that the authors assumed AF to be due to HBO therapy because it reoccurred after the second session of HBO therapy on the second day of admission. However, as we know, cardiac dysrhythmias may occur as long as the patient is in the Acute phase of CO poisoning. How could the authors exclude CO poisoning itself as a potential cause of AF in their patient? Thank you for this Interesting case report.

Nasim Zamani Department of Clinical Toxicology Loghman-Hakim Poison Hospital

Shahid Beheshti University of Medical Scienses

Tehran, Iran E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2012.07.015

References

  1. Celbek G, Boz BV, Caglar SO, Aydin LY, Kandis H, Saritas A. Paroxysmal atrial fibrillation after hyperbaric oxygen therapy. Am J Emerg Med 2012; http://dx.doi.org/10.1016/j.ajem.2012.03.021.
  2. Huang YC, Liu H, Ho K, Lien F. Carbon monoxide intoxication presented as paroxysmal atrial fibrillation. Acta Cardiol Sin 2006;22: 45-8.
  3. Kannel WB, Benjamin EJ. Current perceptions of the Epidemiology of atrial fibrillation. Cardiol Clin 2009;27:13-24.
  4. Benjamin EJ, Levy D, Vaziri SM, D’Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA 1994;271:840-4.

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