Society of Family Planning clinical guidelines pain control in surgical abortion part 1 — local anesthesia and minimal sedation

Understanding patient experiences during gynaecological procedures: a qualitative exploratory study

BACKGROUND

Pain with gynaecological clinic-based procedures is common and undertreated. Prior research has focused on interventions for reducing pain and anxiety with analgesics, yet there remain gaps in understanding the myriad of facilitators and barriers to a person's positive experience. We aimed to start to address these gaps by exploring factors that influence a person's experience during gynaecological procedures beyond quantitative measures of pain.

METHODS

A qualitative thematic analysis approach was used for this exploratory study. Through convenience sampling, we recruited 15 participants with gynaecological procedural experience with intrauterine device (IUD) insertions, surgical abortions, colposcopies and/or endometrial biopsies. We conducted in-depth, semi-structured 1:1 interviews that explored participants' experience of the procedure. We then used a mixed inductive and deductive approach for development of a codebook and thematic analysis based on the Person-Centered Care Framework for Reproductive Health Equity (PCFRHE).

RESULTS

Four themes fundamental to understanding how patients process procedural experiences were identified: (1) Balancing preparation and anxiety, (2) Variable rapport with clinicians, (3) Self-advocacy and autonomy and (4) Clinician responsiveness to pain.

CONCLUSIONS

Person-centred care in an inclusive, trauma-responsive environment is essential for improving gynaecological procedural experience. Ensuring patient access to pre- and post-visit information and offering multiple options to increase comfort are tangible actions clinicians can take to improve patient experience. This study underscores the importance of person-centred care in gynaecological procedures, emphasising better preprocedural education and support.

Best practices for reducing pain associated with intrauterine device placement

Intrauterine devices are highly effective, long-acting, reversible forms of contraception. Despite their benefits, limited uptake persists, particularly among underserved populations, adolescents, and young adults. While most intrauterine device placement procedures are uncomplicated, pain is commonly reported, with more severe pain reported in certain groups. No current standard of care has been established specifically to manage pain with intrauterine device placement, resulting in wide variation in clinical practice. This article aims to provide practical, evidence-based, and expert-informed guidelines for managing pain during intrauterine device placement. The authors (a group of board-certified obstetrician-gynecologists, pediatricians, and a family physician) conducted a virtual expert meeting to develop consensus-based recommendations for pain management. The meeting covered environmental considerations, nonpharmacological, and pharmacological options. Key strategies include using a person-centered care model that focuses on patient values, needs, and preferences to promote shared decision-making around pain relief. Clinicians should assist patients in setting realistic expectations, including a discussion of the placement procedure, anticipated pain, and all options for pain relief, to allow for a comprehensive informed consent process. Nonpharmacological interventions, such as the use of therapeutic language and comforting environmental, complementary and integrative, and mind-body elements, are recommended to reduce patient anxiety and discomfort. In terms of pharmacological options, clinicians may offer pre-procedural-specific nonsteroidal antiinflammatory drugs (eg, naproxen and ketorolac) and anxiolytics to patients with significant anxiety, as well as intraprocedural application of topical anesthesia and paracervical or intracervical blocks. Finally, additional techniques, such as using appropriately sized instruments and ensuring gradual and gentle procedural steps, can also help enhance patient comfort during insertion. These expert guidelines emphasize the importance of personalized, trauma-informed, and evidence-based care, prioritizing patient autonomy and preferences to facilitate a safe and acceptable insertion experience. They are critical to reducing barriers to intrauterine device uptake and improving overall patient outcomes.

Local anaesthesia for pain control in surgical abortion before 14 weeks of pregnancy: a systematic review

BACKGROUND

Abortions are common and associated with procedural pain. We aimed to evaluate benefits and harms of local anaesthesia given for pain control during surgical abortion at less than 14 weeks' gestation.

METHODS

We searched a systematic review on local anaesthesia for pain control for surgical abortion at less than 14 weeks' gestation using uterine aspiration. We searched multiple databases through December 2022. We evaluated study quality using the Cochrane Risk of Bias 2 (RoB2) instrument and assessed the certainty of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Outcomes included intraoperative pain (with dilation, aspiration or procedure), patient satisfaction and adverse events.

RESULTS

Thirteen studies with 1992 participants met the inclusion criteria and the majority were judged as low risk of bias. Intervention protocols were heterogeneous, limiting meta-analysis. A 20 mL 1% lidocaine paracervical block (PCB) reduced pain with dilation compared with sham PCB (mean difference (MD) -37.00, 95% CI -45.64 to -28.36) and aspiration (MD -26.00, 95% CI -33.48 to -18.52; 1 randomised controlled trial (RCT), n=120; high-certainty evidence). A PCB with 14 mL 1% chloroprocaine was associated with a slight reduction in pain during aspiration compared with normal saline PCB injected at two or four sites (MD -1.50, 95% CI -2.45 to -0.55; 1 RCT, n=79; high-certainty evidence). Other RCTs compared a range of local anaesthetic types, PCB techniques and topical anaesthetics. Participants reported moderately high satisfaction with any type of pain control and studies reported few adverse events that were rarely medication-related.

CONCLUSION

RCT evidence supports PCB efficacy but was inconsistent and of low certainty for topical anaesthesia.

Validation of a novel medical device (Chloe SED®) for the administration of analgesia during manual vacuum aspiration: a randomized controlled non-inferiority pilot study

Introduction

Millions of women worldwide annually undergo manual vacuum aspiration (MVA) with no pain medication, which is a violation of their basic human dignity. We designed a novel device (Chloe SED®) to administer paracervical block (PCB) during MVA in countries where pain medication is not typically given due to the high cost of the necessary tools.

Methods

We conducted a single-blinded, randomized controlled non-inferiority trial including 61 patients at two hospitals in Kisumu, Kenya, to validate Chloe SED® for administration of PCB during MVA. PCB administered with Chloe SED® was compared to PCB administered with a standard spinal needle. Patients requiring MVA were block randomized in blocks of six, each provider completing six PCBs-three with the Chloe SED® and three with the standard spinal needle. The trial was registered with the Kenya Pharmacy and Poisons Board, ECCT/19/03/01 (https://ctr.pharmacyboardkenya.org/applications/index/protocol_no:RUNDVC8xOS8wMy8wMQ__/filter:/investigator:/sites:/pages:5/start_date:/end_date:/disease_condition:/users:/ercs:/stages). An intention-to-treat analysis was completed. The primary outcome was the non-inferiority of the pain score during uterine evacuation with a non-inferiority margin of 2 points on an 11-point numerical rating scale. Secondary outcomes included the non-inferiority of the pain score at four other time points and patient satisfaction.

Results

Chloe SED® showed non-inferiority of the primary outcome with a mean pain score during evacuation of 3.8 [90% confidence interval (CI): 3.1-4.6] compared with the spinal needle at 4.1 (90% CI: 3.5-4.7). Non-inferiority of the pain score was shown at all time points. Most patients expressed a desire for the continued use of the device to administer PCB for MVA. No adverse events were noted.

Conclusion

In summary, the Chloe SED® appears non-inferior to the spinal needle and desirable for the administration of PCB during MVA.

Factors associated with a negative Patient Acceptable Symptom State (PASS) response with intrauterine device placement: A retrospective survey of HER Salt Lake participants

OBJECTIVES

In an established cohort of HER Salt Lake Contraceptive Initiative participants with a prior intrauterine device (IUD) placement, we sought to (1) define the proportion of participants who reported a negative Patient Acceptable Symptom State (PASS) response, (2) explore factors associated with an unacceptable PASS response, and (3) identify pain management preferences for IUD placement.

STUDY DESIGN

A retrospective survey was sent to 1440 HER Salt Lake IUD users. A PASS question queried IUD placement pain experience acceptability. We explored associations between an unacceptable PASS response and sociodemographic, reproductive and other individual characteristics using t-tests, chi-square tests, and multivariable logistic regression.

RESULTS

Of those surveyed, 620 responded (43%), and 41.6% reported an unacceptable PASS response. Those with an unacceptable PASS response reported a significantly higher experienced pain level (79.2 mm vs 51.8 mm; p < 0.01) than those with an acceptable response, were more likely to have an anxiety diagnosis (47.7% vs 37.1%; p < 0.01), and have a trauma history (33.7% vs 25.1%; p = 0.02). Most patients were not offered pain control options, but 29.4% used ibuprofen and 25.3% had a support person. Regardless of PASS response, if offered, 59.0% desired numbing medication, 56.8% ibuprofen, 51% heating pad, 33.2% support person, and 31.8% anti-anxiety medication, among others. In our multivariable logistic regression model, higher pain was associated with unacceptable PASS response (OR 1.07, 95% CI 1.05-1.08; p < 0.01).

CONCLUSIONS

The common finding of unacceptable pain experiences with IUD placement may cause negative perceptions of an otherwise desirable method. Incorporation of the PASS response into IUD pain management studies could expand our pain experience understanding.

IMPLICATIONS

IUD placement resulted in unacceptable pain experiences for 41.6% of respondents. Screening for anxiety and trauma history could identify at-risk patients to individualize pain management strategies. Incorporation of the PASS into future IUD pain management studies could result in a more comprehensive, patient-centered measure of patient experiences.

Local anaesthesia for pain control in first trimester surgical abortion

BACKGROUND

Abortions prior to 14 weeks are among the most common outpatient surgical procedures performed on people capable of becoming pregnant. Various methods have been used to control pain; however, many people still experience pain with the procedure.

OBJECTIVES

To evaluate the benefits and harms of local anaesthesia given for pain control during surgical abortion at less than 14 weeks' gestation.

SEARCH METHODS

We searched CENTRAL (Ovid EBM Reviews), MEDLINE (Ovid), Embase, POPLINE, and Google Scholar to December 2022 for randomized controlled trials of pain control in surgical abortion at less than 14 weeks' gestation using suction aspiration. We searched the reference lists of related reviews and articles.

SELECTION CRITERIA

We selected effectiveness and comparative effectiveness randomized controlled trials that studied local anaesthesia with common local anaesthetics and administration routes given for pain control in surgical abortion at less than 14 weeks' gestation using uterine aspiration. Outcomes included intraoperative pain, patient satisfaction, and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We computed mean differences (MD) with 95% confidence intervals (CI) for continuous variables reporting a mean. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

Thirteen studies with 1992 participants met the inclusion criteria. Due to heterogeneity of interventions, we could not pool more than two studies for any outcome. We used 13 mm improvement on a visual/verbal analogue scale to indicate a clinically meaningful difference in pain with surgical abortion (pain with dilation, aspiration, or during procedure). Based on type of pain control, we divided studies into three groups. Paracervical block (PCB) effectiveness trials A 20 mL 1% lidocaine PCB reduced pain with dilation (MD -37.00, 95% CI -45.64 to -28.36), and aspiration (MD -26.00, 95% CI -33.48 to -18.52) compared to a sham PCB (1 RCT, 120 participants; high-certainty evidence). A PCB with 14 mL of 1% chloroprocaine resulted in a slight reduction in pain with aspiration compared to a PCB with normal saline injected at two or four sites (MD -1.50, 95% CI -2.45 to -0.55; 1 RCT, 79 participants; high-certainty evidence). PCB comparative effectiveness trials An ultracaine PCB probably results in little to no clinically meaningful difference in pain during procedure compared to topical cervical lidocaine spray (median 1 point higher, interquartile range (IQR) 0 to 3; P < 0.001; 1 RCT, 48 participants; moderate-certainty evidence). A 1000 mg dose of intravenous paracetamol probably does not decrease pain as much as ultracaine PCB during procedure (median 2 points higher, IQR 1 to 3; P < 0.001; 1 RCT, 46 participants; moderate-certainty evidence). Various local anaesthetics in PCB comparative effectiveness trials A 10 mL buffered 2% lidocaine PCB probably does not result in a clinically meaningful difference in pain with dilation compared to a plain lidocaine PCB (MD -0.80, 95% CI -0.89 to -0.71; 1 RCT, 167 participants; moderate-certainty evidence). A buffered lidocaine PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to plain lidocaine PCB (MD -0.57, 95% CI -1.01 to -0.06; 2 RCTs, 291 participants; moderate-certainty evidence). Non-PCB local anaesthesia or PCB technique effectiveness trials PCB: waiting versus no waiting Waiting three to five minutes between 1% lidocaine PCB injection and dilation probably does not result in a clinically meaningful difference in pain with dilation compared to not waiting (MD -0.70, 95% CI -1.23 to -0.17; 2 RCTs, 357 participants; moderate-certainty evidence). Topical cervical analgesia Topical 10 mL 2% lignocaine gel probably does not result in a clinically meaningful difference in pain with aspiration compared to KY Jelly (MD -0.87, 95% CI -1.60 to -0.14; 1 RCT, 131 participants; moderate-certainty evidence). In participants who also received a PCB, 20 mg topical cervical lidocaine spray probably does not result in a clinically meaningful difference in pain during the procedure compared to two pumps of normal saline spray (median -1 point, IQR -2 to -1; P < 0.001; 1 RCT, 55 participants; moderate-certainty evidence). Intravenous paracetamol 1000 mg compared to two pumps of cervical lidocaine spray probably does not results in a clinically meaningful difference in pain procedure (median 1 point, IQR -2 to 2; P < 0.001; 1 RCT, 48 participants; low-certainty evidence). Non-PCB local anaesthesia or PCB technique comparative effectiveness trials Depth of PCB The evidence suggests that a 3-cm deep PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to a 1.5-cm deep PCB (MD -1.00, 95% CI -1.09 to -0.91; 2 RCTs, 229 participants; low-certainty evidence). PCB: four sites versus two sites A two-site (4-8 o'clock) 20 mL 1% lidocaine PCB does not result in a clinically meaningful difference in pain with dilation compared to a four-site (2-4-8-10 o'clock) PCB (MD 8.60, 95% CI 0.69 to 16.51; 1 RCT, 163 participants; high-certainty evidence). Overall, participants reported moderately high satisfaction with pain control and studies reported few adverse events.

AUTHORS' CONCLUSIONS

Evidence from this updated review indicates that a 20 mL 1% plain lidocaine PCB decreases pain during an abortion procedure. Evidence supports forgoing buffering lidocaine and a wait time between PCB injection and cervical dilation. A 1.5-cm deep injection as opposed to a 3-cm deep injection is sufficient. A two-site PCB injection as opposed to a four-site injection has similar effectiveness. Topical cervical anaesthesia (10 mL 2% lignocaine gel or 20 mg topical cervical lidocaine spray) as compared to placebo did not decrease pain based on moderate-certainty evidence, but then when compared to PCB, pain control was similar. Due to this inconsistency in evidence regarding the effectiveness of topical anaesthesia, its routine use is presently not supported. This review did not include studies of pain management with conscious sedation but, based on the results of our prior Cochrane review and the 2022 WHO guidelines, we recommend that the option of combination of pain management using conscious sedation plus PCB and non-steroidal anti-inflammatory drugs should be offered where conscious sedation is available as it further decreases pain.

Intravenous Ketamine for Pain Control in First-Trimester Surgical Abortion: Interim Analysis of a Randomized Controlled Trial

OBJECTIVES

Surgical abortion is common, with most completed in the first trimester. Gold standard pain control is intravenous (IV) fentanyl and midazolam, requiring continuous cardio-respiratory monitoring, a potential challenge where this monitoring is unavailable. Ketamine is a sedative and analgesic without the cardio-respiratory depression risk associated with IV opioids, representing a potential alternative. Investigating non-opiate pain control methods is imperative given the context of the opioid crisis. This is an interim analysis of 45 participants from a randomized controlled trial comparing IV ketamine, oral morphine, and IV fentanyl for pain control in first-trimester surgical abortion. We hypothesize that ketamine will provide better pain control than morphine.

METHODS

This is a double-blind, single-centre superiority trial of 3 parallel groups. Participants were ≥18 years old with confirmed intrauterine pregnancy of gestational age <12 weeks. Pain was assessed using the Visual Analogue Scale and the Wong-Baker Faces Pain Rating Scale.

RESULTS

In total, 2 participants were excluded post-randomization for 43 treated. Findings indicate that ketamine (n = 14; M = 0.7; 95% CI 0.1-1.3) provides better intra-operative pain control than morphine (n = 15, M = 4.4, 95% CI 2.9-5.9) and fentanyl (n = 14; M = 4.3; 95% CI 3.0-5.6; P < 0.001). The ketamine group was more satisfied with the anaesthetic method than the morphine group (P = 0.017). No group experienced serious adverse events.

CONCLUSIONS

Findings support continuation of the randomized controlled trial and highlight ketamine as a compelling non-opiate pain control option in first-trimester surgical abortion. Ketamine use may represent more optimal pain control in settings where continuous cardio-respiratory monitoring is unavailable.

Helping patients choose between pain control options for outpatient procedural abortion at less than 12 weeks' gestation

OBJECTIVES

This study aimed to identify predictors of patient satisfaction with their chosen pain control regimen for procedural abortion at <12 weeks' gestation in the outpatient setting.

STUDY DESIGN

In this prospective cohort study, we developed an instrument to evaluate predictors of satisfaction with pain control regimens among patients choosing local anesthesia alone (paracervical block with 20 mL of 1% buffered lidocaine) or local anesthesia plus intravenous (IV) moderate sedation with 100 mcg of fentanyl and 2 mg of midazolam. Our primary outcome was to identify predictors of satisfaction with both anesthesia cohorts as measured on a 4-point Likert scale, but due to high satisfaction levels in the IV group, we focused our analysis on the local anesthesia group.

RESULTS

We enrolled 149 patients in the local anesthesia group and 155 in the moderate IV sedation group. The mean procedure pain scores were 6.9 (±2.1) out of 10 in the local group and 4.0 (±2.7) in the IV group (p < 0.0001). More women in the IV group (92%) were satisfied or very satisfied with the amount of pain relief they experienced compared to the local group (66%; p < 0.0001). In the univariable model, only being afraid of a minor medical procedure was predictive of less satisfaction with local anesthesia for pain control (relative risk 0.8 [95% CI, 0.6-0.9]). Age, gestational age, anticipated pain, self-reported pain tolerance, self-reported anxiety, discomfort with the abortion decision, and history of prior vaginal or cesarean delivery or induced abortion did not predict satisfaction levels.

CONCLUSIONS

Fear of minor medical procedures was the only variable that predicted decreased satisfaction with local anesthesia alone for procedural abortion under 12 weeks.

IMPLICATIONS

Reliable predictors for satisfaction with local anesthesia alone for procedural abortion in the outpatient setting remain elusive. Fear of minor medical procedures may serve as an indicator of decreased satisfaction and could be incorporated into patient counseling. Moderate IV sedation is associated with high satisfaction levels.

First-trimester Procedural Abortion

First-trimester abortion is a common and safe procedure. A focused history and physical examination are essential for providing this care. Laboratory assessment can include Rh typing, hemoglobin, and cervicitis testing as indicated by a patient's risk factors. Procedural abortion in the first trimester includes cervical dilation with or without cervical preparation, and uterine evacuation utilizing a manual vacuum aspirator or electric vacuum aspirator. Complications occur rarely and are often easily managed at the time of diagnosis.

Pain Management in Abortion Care

Both medication and procedural abortion are associated with pain. The experiences of pain depend on both physical and emotional factors. Several pain management options are available for abortion, depending on abortion type, clinical setting, and patient considerations, and a comprehensive approach is necessary to optimize pain management.

Fear of procedure and pain in individuals considering abortion: A qualitative study

OBJECTIVES

To explore concerns about procedural abortion and abortion-related pain in a cohort searching for abortion online.

METHODS

The Google Ads Abortion Access Study was a national longitudinal cohort study that recruited people searching for abortion online. Participants completed a baseline demographic survey and a follow-up survey four weeks later evaluating barriers and facilitators to abortion. This qualitative study utilized thematic analysis to produce a descriptive narrative based on overarching themes about procedural abortion and abortion-related pain.

RESULTS

There were 57 separate mentions from 45 participants regarding procedural abortion or abortion-related pain. We identified two main themes: 1) concerns about the procedure (with subthemes, fear of procedural abortion, comparison to medication abortion, lack of sedation) and 2) abortion-related pain (with subthemes fear of abortion-related pain, experiences of pain, fear of complications and cost-barriers to pain control).

CONCLUSIONS

This study highlights the need for improved anticipatory guidance and accessible resources to assuage potential fears and misconceptions regarding abortion.

PRACTICE IMPLIACTIONS

Abortion resources, particularly online, should provide accurate and unbiased information about abortion methods and pain to help patients feel more prepared. Providers should be aware of potential concerns surrounding procedural abortion and pain when counseling patients presenting for care.

Second-trimester abortion care for those with complex medical conditions

PURPOSE OF THE REVIEW

This review focuses on patients who are most likely to experience morbidity associated with second trimester abortion care and risk mitigation strategies.

RECENT FINDINGS

Prior cesarean birth, particularly multiple prior cesarean births, is the most significant risk factor associated with complications during second trimester abortion because of increased risks of hemorrhage, with or without placenta accreta spectrum (PAS), and distorted anatomy, which increases the risk of uterine perforation. Recent data suggests that first trimester ultrasound findings may be predictive of PAS, including multiple lacunae, abnormal uteroplacental interface, and hypervascularity. Multiple common medications interact with mifepristone and are therefore contraindicated; ulipristal shares mifepristone's selective progesterone receptor modulator activity but does not share the same metabolic pathway. Recent data suggests ulipristal may be an effective adjunct for cervical preparation, avoiding potentially mifepristone's drug-drug interactions. Those ending a pregnancy due to severe early-onset hypertensive disorders have a high rate of clinically significant thrombocytopenia: platelet transfusion is recommended for those with platelets <50 000 per cubic millimeter.

SUMMARY

Pregnant people presenting for care in the second trimester may have conditions that make an abortion more technically or medically complex. Clinicians can mitigate much of this increased risk with preprocedural planning, and appropriate intra-operative preparedness.

Pain, Side Effects, and Abortion Experience Among People Seeking Abortion Care in the Second Trimester

Background:

There is limited documentation about pain and side effects associated with dilation and evacuation (D&E) abortion, yet, pain and side effects are important factors that can affect a client's abortion experience. In 2016, Hope Clinic for Women, an independent abortion clinic in Illinois, altered its cervical preparation protocols before D&E to reduce the total time of the abortion process and improve the client experience. This analysis addresses the gap in data on client experience of abortion in the later second trimester by evaluating pain, side effects, and acceptability by gestational age.

Methods:

Abortion clients obtaining services at the clinic between March 2017 and June 2018 were eligible to participate if they had viable singleton pregnancies of 16–23.6 weeks' gestation, spoke English, and were at least 18 years old. Eligible participants completed a two-part survey about their abortion experience.

Results:

We found that respondents seeking abortion care at later gestations in the second trimester were more likely to report pain during their abortions. We did not find any association between side effects and gestational age.

Conclusion:

Although most respondents were prepared for the pain they experienced, some reported experiencing more pain than they expected, and more effective pain relief was commonly reported as a way to improve the service. More research on patient experiences of later abortion is needed, particularly on experiences of pain and options for pain management.

Pain management in outpatient surgical abortion

PURPOSE OF REVIEW

To review the current literature focusing on pain management and experiences during abortion care.

RECENT FINDINGS

Analgesic options in abortion care address pain associated with the procedure, osmotic dilator insertion, and cervical preparation. The paracervical block (PCB) is effective for pain control in first and second trimester abortions. Lower volume PCBs demonstrate non inferiority with osmotic dilator placement compared with higher volume PCBs with lower potential for toxicity. Self-administered vaginal lidocaine gel is noninferior to PCB in first trimester abortions. Preoperative oral narcotics and sedation do not reduce pain in first trimester abortions; however, the latter may reduce anxiety. For second trimester abortions, narcotics or gabapentin do not improve postoperative pain, yet up to half of patients will use narcotics if offered. Nonpharmacological methods have shown success in pain management. Music and doula support do not improve pain; however, patients would recommend these modalities, indicating some benefit that went unmeasured. Auricular acupuncture and transcutaneous electrical nerve stimulation (TENS) reduce pain and anxiety during first trimester abortions.

SUMMARY

Several modalities reduce pain during abortion care; however, pain alone does not reflect patient satisfaction. Development of multidimensional measures for pain control assessment has the potential to capture the patient's overall experience.

Abortion Care Beyond 13 Weeks' Gestation: A Global Perspective

The majority of abortions are performed early in pregnancy, but later abortion accounts for a large proportion of abortion-related morbidity and mortality. People who need this care are often the most vulnerable-the poor, the young, those who experience violence, and those with significant health issues. In settings with access to safe care, studies demonstrate significant declines in abortion-related morbidity and mortality. This review focuses on evidence-based practices for induced abortion beyond 13 weeks' gestation and post-abortion care in both high- and low-resource settings. We also highlight key programmatic issues to consider when expanding the gestational age for abortion services.

Women-specific routes of administration for drugs: A critical overview

The woman's body presents a number of unique anatomical features that can constitute valuable routes for the administration of drugs, either for local or systemic action. These are associated with genitalia (vaginal, endocervical, intrauterine, intrafallopian and intraovarian routes), changes occurring during pregnancy (extra-amniotic, intra-amniotic and intraplacental routes) and the female breast (breast intraductal route). While the vaginal administration of drug products is common, other routes have limited clinical application and are fairly unknown even for scientists involved in drug delivery science. Understanding the possibilities and limitations of women-specific routes is of key importance for the development of new preventative, diagnostic and therapeutic strategies that will ultimately contribute to the advancement of women's health. This article provides an overview on women-specific routes for the administration of drugs, focusing on aspects such as biological features pertaining to drug delivery, relevance in current clinical practice, available drug dosage forms/delivery systems and administration techniques, as well as recent trends in the field.

Society of Family Planning clinical recommendations: Pain control in surgical abortion part 2 - Moderate sedation, deep sedation, and general anesthesia

Analgesic options for surgical abortion (also called procedural abortion) beyond local anesthesia and minimal sedation include moderate sedation, deep sedation and general anesthesia. These clinical recommendations review the effectiveness of various moderate sedation, deep sedation, and general anesthesia regimens for pain control during abortion; medication regimens used to induce analgesia and anesthesia; patient factors affecting anesthesia safety; preoperative and intraoperative protocols to reduce anesthesia risks; personnel qualifications for administration; recommended patient monitoring protocols; and general risks of anesthesia in the context of abortion care. The scope of these recommendations is based on limited available evidence and considerably relies on existing professional society guidelines and recommendations developed by content experts and reviewers. Further research to compare the efficacy and safety of different regimens is needed.

Pain Associated With Cervical Priming for First-Trimester Surgical Abortion: A Randomized Controlled Trial

OBJECTIVE

To compare the effect of cervical priming with mifepristone with that of misoprostol on pain perception during surgical induced abortion under paracervical block.

METHODS

We conducted a randomized, single-blind, two-center study of women undergoing surgical induced abortion at less than 14 weeks of gestation under paracervical block. Participants were randomized to receive cervical priming with 200 mg of oral mifepristone 36 hours or 400 micrograms buccal misoprostol 3 hours before surgery. The primary outcome was pain during mechanical cervical dilation evaluated by a 100-mm visual analog scale (VAS). Secondary outcomes were pain during aspiration, preoperative and postoperative pain, participant satisfaction, duration of the procedure, occurrence of complications, and ease of performing the procedure (assessed by a 100-mm VAS). We estimated that 110 women would have to be included to have 90% power to detect a 13mm-difference of VAS for pain.

RESULTS

Between June 2017 and May 2019, 314 women were eligible and 110 were randomized (55 in each group). Patient characteristics were similar in the two groups. The mean VAS score during mechanical cervical dilation was lower in the mifepristone group (35.6±21 vs 43.5±21, P=.04) as was the mean VAS during aspiration (34±24 vs 47.8±23, P=.003). The preoperative and postoperative mean VAS, satisfaction and duration of procedures were similar between groups. The procedure was significantly easier to perform in the mifepristone group (88±16 vs 80±23, P=.004).

CONCLUSION

Cervical priming with mifepristone for surgical induced abortion under paracervical block up to 14 weeks of gestation is more effective than misoprostol in reducing pain perception.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03043014.

Nitrous oxide for pain management of first-trimester instrumental termination of pregnancy under local anaesthesia and/or minimal sedation: A systematic review and meta-analysis

BACKGROUND

Inhalation of nitrous oxide and oxygen (N₂O/O₂) is used to reduce pain that is spontaneous or induced by procedures. N₂O/O₂ could be useful in the treatment of the pain in first-trimester termination of pregnancy performed under local anaesthesia and/or minimal sedation (FTOPL).

OBJECTIVE

To evaluate the usefulness of N₂O/O₂ to reduce pain in FTOPL.

SEARCH STRATEGY

Electronic databases including PubMed, Embase, and MEDLINE were searched using keywords.

STUDY SELECTION

All studies comparing the use of N₂O/O₂ versus a placebo in the management of pain during FTOPL during the first trimester were included. Of the 199 studies identified, four were deemed eligible for this meta-analysis.

DATA COLLECTION

The extracted results were perioperative pain, immediate and delayed postoperative pain, anxiety scores, and the secondary effects (nausea, vomiting). The data were analysed using Comprehensive Meta-Analysis software version 2.2.064.

MAIN RESULTS

There was a significant difference in favour of N₂O/O₂ for perioperative pain (p = 0.006; SMD = - 0.31; 95 % CI, -0.54 - -0.09). No difference was found, however, in postoperative pain, nor was there a difference in the secondary effects (nausea, vomiting) (p = 0.61). A significant decrease in postoperative anxiety scores was seen in the pooled placebo group (p = 0.049; SMD = 0.41; and 95 % CI, 0.001-0.83).

CONCLUSIONS

N₂O/O₂ reduces the pain of FTOPL. N₂O/O₂ could be recommended in FTOPL.

Gabapentin as an adjunct to paracervical block for perioperative pain management for first-trimester uterine aspiration: a randomized controlled trial

BACKGROUND

Pain management approaches during uterine aspiration vary, which include local anesthetic, oral analgesics, moderate sedation, deep sedation, or a combination of approaches. For local anesthetic approaches specifically, we continue to have suboptimal pain control. Gabapentin as an adjunct to pain management has proven to be beneficial in gynecologic surgery. We sought to evaluate the impact of gabapentin on perioperative pain during surgical management of first-trimester abortion or early pregnancy loss with uterine aspiration under local anesthesia.

OBJECTIVE

We hypothesized that adding gabapentin to local anesthesia will reduce perioperative and postoperative pain associated with uterine aspiration. Secondary outcomes included tolerability of gabapentin and postoperative pain, nausea, vomiting, and anxiety.

STUDY DESIGN

We conducted a randomized double-blinded placebo-controlled trial of gabapentin 600 mg given 1 to 2 hours preoperatively among subjects receiving a first-trimester uterine aspiration under paracervical block in an outpatient ambulatory surgery center. There were 111 subjects randomized. The primary outcome was pain at time of uterine aspiration as measured on a 100-mm visual analog scale. Secondary outcomes included pain at other perioperative time points. To assess changes in pain measures, an intention to treat mixed effects model was fit with treatment groups (gabapentin vs control) as a between-subjects factor and time point as a within-subjects factor plus their interaction term. Because of a non-normal distribution of pain scores, the area under the curve was calculated for secondary outcomes with comparison of groups utilizing Mann-Whitney U tests.

RESULTS

Among the 111 randomized, most subjects were Black or African American (69.4%), mean age was 26 years (±5.5), and mean gestational age was 61.3 days (standard deviation, 14.10). Mean pain scores at time of uterine aspiration were 66.77 (gabapentin) vs 71.06 (placebo), with a mean difference of -3.38 (P=.51). There were no significant changes in pain score preoperatively or intraoperatively. Subjects who received gabapentin had significantly lower levels of pain at 10 minutes after surgery (mean difference [standard error (SE)]=-13.0 [-5.0]; P=.01) and 30 minutes after surgery (mean difference [SE]=-10.8 [-5.1]; P=.03) compared with subjects who received placebo. Median nausea scores and incidence of emesis pre- and postoperatively did not differ between groups. Similarly, anxiety scores did not differ between groups, before or after the procedure. At 10 and 30 minutes after the procedure, most participants reported no side effects or mild side effects, and this did not differ between groups.

CONCLUSION

Preoperative gabapentin did not reduce pain during uterine aspiration. However, it did reduce postoperative pain, which may prove to be a desired attribute of its use, particularly in cases where postoperative pain may be a greater challenge.

Pain management for medical and surgical termination of pregnancy between 13 and 24 weeks of gestation: a systematic review

Background

High‐quality care for termination of pregnancy (TOP) requires pain to be effectively managed; however, practices differ, and the available guidelines do not specify optimal strategies.

Objective

To guide providers in effective pain management for second‐trimester medical and surgical TOP.

Search strategy

We searched PubMed, Cochrane and Embase databases, and the US National Library of Medicine clinical trials registry, from inception to the end of June 2019, and hand‐searched reference lists.

Selection criteria

Trials comparing pain management strategies with no treatment, placebo or active interventions during induced medical or surgical TOP, occurring between 13 and 24 weeks of gestation, and reporting direct or indirect measures of pain.

Data collection and analysis

Both authors summarised and systematically assessed the evidence and risk of bias using standard tools.

Main results

We included seven medical and four surgical TOP studies, with 453 and 349 participants, respectively. The heterogeneity of interventions and outcomes prevented pooled analyses. Medical TOP: women receiving routine or continuous epidural analgesia experienced mild pain. The prophylactic use of nonsteroidal anti‐inflammatory drugs (NSAIDs) decreased pain (mean difference −0.5, P < 0.001) and additional opioid requirements (3.5 versus 7 mg, P = 0.04) compared with placebo/other treatment. Paracervical block was ineffective. No studies assessed intramuscular (IM)/intravenous (IV) opioid or nonpharmacological treatment. Surgical TOP: general anaesthesia/deep IV sedation alleviated pain. Nitrous oxide was ineffective. No studies assessed moderate IV sedation, IV/IM opioid, paracervical block without sedation, NSAID or nonpharmacological treatment.

Conclusion

Based on limited data, regional analgesia and NSAIDs mitigated second‐trimester medical TOP pain; general anaesthesia/deep IV sedation alleviated surgical TOP pain.

Tweetable abstract

Although women experience intense pain during second‐trimester termination of pregnancy, few data are available to inform their treatment.

Although women experience intense pain during second‐trimester termination of pregnancy, few data are available to inform their treatment.