First Trimester Uterine Aspiration


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By the end of this unit, you should be able to:

  • List the equipment and supplies needed for uterine aspiration with the manual vacuum aspirator (MVA) and electric vacuum aspirator (EVA)
  • Summarize the steps of uterine aspiration, or suction dilation and curettage (D&C)
  • Explain the possible complications of uterine aspiration

Uterine Aspiration Indications

  • Induced abortion or miscarriage management up to 13 weeks
    • Evacuation of molar pregnancy
    • Treatment of retained products of conception or hematometra
  • Methods
    • Manual vacuum aspiration (MVA) • Electric vacuum aspiration (EVA)

Choosing a Method

Manual Vacuum Aspiration

  • Outpatient setting is OK
  • No electricity needed
  • Less noise
  • Syringe is inexpensive, reusable
  • May need more passes at later estimated gestational age (EGA)

Electric Vacuum Aspiration

  • Outpatient setting is OK
  • Requires suction machine
  • More noise
  • Consistent, unlimited suction

Equipment Needed

  • Speculum
  • Cleansing solution
  • Gauze
  • Ring forceps for cleansing cervix and removing tissue from the cervix/vagina as needed
  • Lidocaine
  • 10-20 mL syringe with 22 gauge needle extender for paracervical block
  • Tenaculum: Placed on anterior or posterior lip to straighten canal and provide counter-traction for dilation
Materials used in the first trimester uterine aspiration manual vacuum simulation.
Image courtesy of Association of Reproductive Health Professionals. Options for early pregnancy loss: manual vacuum aspiration and medication managements, 2007. Available at:


  • Tapered dilators are preferred
    • Denniston
    • French Pratt
  • Dilate to mm equals gestational age
  • 1 French refers to the circumference of a dilator
  • French system/3 = mm


  • Rigid or flexible
  • Provider preference
  • Generally, use cannula with diameter equal to or 1 mm greater than estimated gestational age


  • Manual
  • Electric
Materials used in the first trimester uterine aspiration manual vacuum simulation.
Image Source: Anne Burke, MD, MPH.

Electric vacuum aspirator.

Pre-evaluation for Uterine Aspiration

  • Informed consent
    • Risks and alternatives
  • Rh Testing
    • RhoGAM required for Rh-negative patients
  • Antibiotic prophylaxis
    • Several regimens acceptable
    • Should be initiated prior to procedure
    • Example: 30 minutes prior
      • Doxycycline 100mg
      • Azithromycin 500mg
  • Discussion of contraceptives
    • Consider immediate post-abortion placement of long-acting acting reversible (LARC)
      • Intrauterine Device (IUD)
      • Implant
  • Testing for sexually transmitted diseases (STDs)
    • Per Centers for Disease Control and Prevention (CDC) guidelines:
    • May treat at time of procedure
    • Delay of procedure for treatment is not necessary
  • Anemia
    • Evaluate for anemia if active/heavy bleeding

Uterine Aspiration Steps

  1. Assemble all materials
  2. Conduct “timeout”
  3. Bimanual exam for size/position of uterus
  4. Insert speculum and prep cervix with iodine or alternative in case of allergy
  5. Place tenaculum
    • Inject 2ml lidocaine at planned tenaculum site
    • Good purchase to anterior or posterior lip
    • Close ratchets slowly to lessen pain
    • Exert gentle traction on cervix for dilation and manipulate cervix to administer paracervical block
  6. Paracervical block
    • Numerous regimens
      • 10-20 ml of 0.5-1% lidocaine
      • Plain or with vasoconstrictor
        • Vasopressin: less tachycardia than epinephrine
      • Evidence-based blocks
        • 20 mL buffered lidocaine total
        • 2mL at tenaculum site
        • Continuous injection in and out to 3 cm of 18ml at 2 or 4 sites at cervico-vaginal junction (2 o’clock, 4 o’clock, 8 o’clock, and 10 o’clock)
      Uterine aspiration.
      Source: ARHP CORE Slides.
    • Lidocaine toxicity
    • 4mg/kg plain lidocaine
    • 7mg/kg with vasoconstrictors
    • Example: 1% lidocaine is 10mg/mL
      • 70 kg, max 1% plain lidocaine = 28mL
  7. Dilate cervix
    • Hold dilator loosely using tapered dilator
    • Redirect dilator if significant resistance
    • Dilation goal: Allow passage of cannula whose diameter correlates with EGA in weeks
    • 1 French refers to the circumference of a dilator
    • French system/3 = mm (e.g., Size corresponding to 9 weeks’ EGA  9mm (+/- 1mm) cannula; 27 French/3=9mm) 

All steps apply to both MVA and EVA unless specified.

Cervical Dilation

Cervical dilation for manual vacuum aspiration.
Courtesy of Manual Vacuum Aspiration, a presentation by Physicians for Reproductive Choice and Health (PRCH) and the Association for Reproductive Health Professionals (ARHP), 2000, updated 2012.

Types of Dilators

  • Pratt (metal, tapered ends)
    • Diameter measured in French (=0.33 mm)
    • Example: 21 French = 7 mm
  • Denniston (plastic, tapered ends)
    • Diameter measured in mm
  • Hegar (metal, more blunt ends)
    • Diameter measured in mm

Uterine Aspiration Steps

This step for MVA only.

  1. Prepare MVA syringe
    • Attach cannula
    • Close (compress) valve
    • Pull back plunger
    Manual vacuum aspiration syringe.
    Image courtesy of PRCH and ARHP “Manual Vacuum Aspiration;” updated 2012.
    Manual vacuum aspiration syringe. 
    Image courtesy of PRCH and ARHP “Manual Vacuum Aspiration;” updated 2012.
    • Attach appropriate tubing
      • Small caliber: size 6-12 cannula
      • Large caliber: size 14-16 cannula
    • Test suction: Adjust to 40-60 mm Hg
  2. Select cannula
    • Typically gestational age (GA) or GA + 1 mm
  3. Inserts cannula, performs curettage
    • MVA: release valves once inserted
    • Electronic: insert or remove cannula with suction off
  4. Uterine aspiration
    • Rotation combined with gentle in and out motion
    • Ultrasound may be used
    • Rotate until signs the uterus is empty
      • “Crie,” gritty texture
      • More difficulty moving the cannula as uterus collapses
    • Sharp curettage not routinely necessary
  5. Complete procedure
    • Remove tenaculum
    • Apply hemostatic treatment if needed
    • Assess for uterine bleeding
    • Remove speculum
  6. Examine tissue to ensure gestational sac is present
    • Strain and rinse the tissue
    • Place tissue in a clear container
    • It is recommended to use a backlight to inspect the tissue

Products of Conception

Examining the products of conception can:

  • Assure successful removal of pregnancy
  • Confirm estimated gestational age
  • Provide evidence of abnormal pregnancy
Doctor looking at products of conception over a light.
Courtesy of PRCH and ARHP “Manual Vacuum Aspiration,” updated 2012.


  • Hemorrhage: treat with uterotonic agents
  • Infection: consider retained products
  • Uterine perforation from dilators or vacuum cannula
  • Retained products of conception

Postoperative Care

  • Observation
    • Observe patient for at least 30 minutes o Monitor for complications related to bleeding
  • RhoGAM if Rh-negative
  • What to expect after discharge
    • Cramping can be normal for up to a few days (mild)
    • Bleeding should be no heavier than period
    • Severe symptoms warrant evaluation
  • Consider immediate post-abortion placement of long-acting acting reversible (LARC): IUD or implant


  • First trimester uterine aspiration is safe
  • Following appropriate steps helps to ensure safety of the procedure
  • Complications are rare but must be recognized


  • Anne Burke, MD, MPH Associate Professor of Gynecology and Obstetrics Johns Hopkins University School of Medicine

Developed in association with Society of Family Planning.

Version 2.0, reaffirmed March 2017