Phase I

The service was introduced in the Women’s Health Unit in 2009 with a maximum of two procedures per week. The Unit offers outpatient clinics and procedures (eg, hysteroscopy) and has dedicated access to ultrasound scanning. Nurse practitioners could directly book healthy women up to 10⁺⁰ weeks' gestation, confirmed by ultrasound, for MVA. In general, women were able to access MVA within 1–2 weeks following the initial outpatient assessment.

Women self-administered 400 µg misoprostol vaginally approximately 2 hours pre-procedure. They were simultaneously given azithromycin 1 g and codeine phosphate 30 mg orally. MVA was performed in the lithotomy position. Following a bimanual vaginal examination, a Cusco speculum was inserted and the cervix visualised. Lidocaine hydrochloride 2% (4–5 mL) with epinephrine 1:80 000 were injected intracervically at 12, 3, 6 and 9 o’clock using a dental syringe with a 35 mm x 0.4 mm Solo Supra needle. Cervical dilation was subsequently performed (if needed) using graded Hegar dilators. A flexible cannula (Woman Care Global) was then attached to a 60 mL double-valve aspirator (Woman Care Global) with a self-locking mechanism. The cannula size in millimetres selected was generally equivalent to the number of weeks of gestation. Uterine aspiration was then performed and repeated until no new products of conception (POC) were obtained and the uterus felt empty. An abdominal ultrasound scan was then performed to check that the uterine cavity was empty. Rarely, where it was not possible to visualise the uterus clearly transabdominally, a transvaginal scan was performed. Metronidazole 1 g was administered rectally. If the woman had opted for a contraceptive implant or an intrauterine contraceptive device this was then inserted. POC were examined to confirm the presence of chorionic villi. Throughout the procedure women had the option of using Entonox for pain relief if necessary.

A review of the service in 2014 showed that few women were choosing MVA. A service evaluation which included a patient satisfaction survey was therefore performed. Results revealed a clear preference for quick access to TOP, with half the women stating that they would have wished to have the procedure on the same day as their initial consultation.

Phase II

A pilot study was performed over a 6-month period to assess the acceptability of a ‘one-stop’ MVA service for women up to 9⁺⁰ weeks' gestation. The clinic and same-day MVA service were provided by JS who had been trained in MVA by both SR and the British Pregnancy Advisory Service. A revised limit of 9⁺⁰ weeks was chosen to reflect JS’s experience.

Women contacting or referred to the TOP service who were less than 9⁺⁰ weeks' gestation according to their last menstrual period were offered assessment at the one-stop clinic. Women interested in attending that clinic were e-mailed information regarding management options including MVA, surgical TOP and medical TOP. The information clearly stated that MVA would only be possible if the patient was at no more than 9⁺⁰ weeks' gestation and sure of her decision. Four clinic assessment slots were available between 09:00 and 11:00 and MVAs were performed once the clinic had finished. Access to MVA was also available via other TOP clinics run by nurse practitioners. A maximum of six MVA slots were available each week.

Phase I

Between 2009 and 2014, 72 MVAs were performed (table 1).

One woman had a complicated procedure; cervical dilatation was difficult and complete uterine evacuation was not achieved, requiring evacuation of retained POC under general anaesthetic. Fifty-eight (80.6%) women stated that they would have MVA again.

Phase II

Ninety-three women were seen at the one-stop clinic. Seventy-five had a viable pregnancy of ≤ 9⁺⁰ weeks' gestation on ultrasound scan, of whom 70 decided to undergo TOP; 52 opted for MVA and 51 had the procedure on the same day. One woman returned for MVA the following week at her request. Twenty women who attended other TOP clinics opted for MVA. Thus 72 MVAs were performed during the 6-month pilot (table 1), of which 71% were same-day MVAs. By chance the number of women in Phases I and II was identical.

Three women experienced complications. Two procedures were abandoned as cervical dilatation was difficult and one patient returned with vaginal bleeding at 1 week; an ultrasound scan was reported as showing retained POC and surgical evacuation was performed. Sixty-three (88%) women stated that they would have MVA again, six (8%) stated that they would not, and no data were recorded for three (4%) women. All women who had a same-day MVA stated that they thought this clinic was a good idea and that they would recommend it to a friend.

To our knowledge this is the first report of a one-stop service for MVA that was specifically established as a one-stop service with a consistent care pathway in place. We found that offering women the opportunity to have a procedure on the same day strongly influenced their choice; the much higher take up of MVA in Phase II strongly suggests that having timely access to TOP is more important to women than the choice of procedure. Many women work full time or have children and may struggle to attend multiple hospital appointments at short notice. As MVA avoids a general anaesthetic or sedation women can come to the appointment by themselves and are usually able to leave soon afterwards and drive home. This supports women’s right to confidentiality.