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

Procedural abortion in individuals with opioid dependence: patient characteristics and pain experience

OBJECTIVES

To describe the prevalence and characteristics of individuals with opioid-dependence who have procedural abortions, and to compare their experience of procedural pain to individuals without opioid-dependence.

STUDY DESIGN

Cross-sectional study of procedural abortion patients at a high-volume ambulatory abortion practice. We offered an anonymous survey to all procedural abortion patients which included medical and demographic information, assessment of opioid dependence with the Rapid Opioid Dependence Screen (RODS), measurement of procedural pain, and satisfaction with pain control.

RESULTS

We approached 1888 individuals, 1553 (82%) completed the survey and 1525 were included in analysis. Eighty-eight participants screened positive for opioid-dependence (5.9%). Opioid-dependent participants were older, more likely to use other drugs, pay for abortion with insurance, report chronic pain, disability, anxiety, depression, prior abortion, and more frequently presented at 15+ weeks. Opioid-dependent patients reported higher mean pain scores (35 vs. 22.5, p=0.002), with a mean difference of 7.73 in logistic regression analysis accounting for relevant demographic and medical characteristics (p=0.041). No interaction was seen between opioid-dependence and effect of intravenous (IV) moderate sedation, with reduction in mean pain scores of 13.76 points in opioid-dependent patients versus 14.54 among those without (p=0.937). The odds unacceptable pain control did not differ between opioid-dependent and non-dependent individuals (OR 1.73, p=0.18).

CONCLUSION

Procedural abortion patients with opioid-dependence differ from those without along several reproductive and demographic factors. They have higher mean pain scores but similar improvement in pain with IV moderate sedation. Satisfaction with pain control is similar for patients with and without opioid dependence.

IMPLICATIONS

Intravenous moderate sedation is effective in reducing pain in patients with opioid-dependence, despite their overall higher pain scores. It should not be restricted in these patients due to concerns for ineffectiveness as it may be an important factor in improving the abortion experience for these marginalized patients.

Weight and Procedural Abortion Complications: A Systematic Review

OBJECTIVE

To systematically assess the existing empiric evidence regarding a potential relationship between higher body weight and procedural abortion complications.

DATA SOURCES

EMBASE, MEDLINE, CINAHL, Web of Science, Google Scholar, and Clinicaltrials.gov were searched.

METHODS OF STUDY SELECTION

Our search identified 409 studies, which were uploaded to Covidence for review management; 133 duplicates were automatically removed. A team of two reviewers screened 276 studies, and a third reviewer resolved conflicts. Studies were included if they 1) consisted of peer-reviewed research published between 2010 and 2022, 2) were conducted in the United States, 3) included people with a higher body weight (body mass index [BMI] 30 or higher) in the study sample, and 4) assessed at least one outcome of procedural abortion safety stratified by a measure of body weight.

TABULATION, INTEGRATION, AND RESULTS

We extracted study data using Covidence and calculated an odds ratio for each study to facilitate the synthesis of results. Six studies assessing a total of 38,960 participants were included. No studies found a significant relationship between procedural abortion complications and higher body weight overall. Subgroup analysis from one study identified a significant increase in complications specifically among participants with BMIs higher than 40 who had second-trimester abortions. All studies used a retrospective cohort design and fulfilled Newcastle-Ottawa Scale criteria to be considered good quality. Studies varied in terms of clinical settings, patient populations, gestations assessed, clinician training levels, and care protocols.

CONCLUSION

Overall, higher body weight was not associated with an increased risk of procedural abortion complications in the included studies. The practice of referring patients undergoing procedural abortion with a higher body weight for hospital-based care is not based on recent safety evidence. On the contrary, this practice threatens the health of people with a higher body weight by potentially delaying their access to abortion care, extending their pregnancies into later gestations, and blocking their ability to access an abortion altogether.

Substance Use and Anxiety About Pain Among Patients Seeking Abortion Services

OBJECTIVES

To evaluate how recent opioid, marijuana, and cannabidiol use affects pre-procedure pain-related anxiety for patients seeking abortion.

METHODS

We conducted a prospective, cross-sectional anonymous survey of patients seeking abortion assessing recent substance use and anxiety about pain during and after abortion. We compared substance users' and non-users' anxiety scores.

RESULTS

Among 217 participants, recent opioid users (5.3%) had higher median anxiety scores for pain during (7.0 vs 6.0; p=0.33) and after (8.0 vs 6.0; p=0.01) abortion than non-opioid users. Anxiety scores were similar for marijuana and cannabidiol users.

CONCLUSIONS

Assessing recent opioid use may help guide counseling for anxiety about abortion.

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.

Reconsidering the use of urine drug testing in reproductive settings

The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.

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.

The association of patient age, race, and demographic features on reported pain and sedation dosing during procedural abortion: A retrospective cohort study

OBJECTIVES

To explore impact of age, racial, demographic, and psychosocial factors on patients' dosage of analgesia and maximum pain score during procedural abortion.

STUDY DESIGN

We performed retrospective chart review of pregnant individuals undergoing procedural abortion at our hospital-based abortion clinic from October 2019 through May 2020. Patients were stratified into age groups,<19 years, 19 to 35 years, and>35 years. We conducted the Kruskal-Wallis H test to evaluate for medication dosing or maximum pain score differences among groups.

RESULTS

We included 225 patients in our study. We found no difference in fentanyl or midazolam dosing by age. The median fentanyl dose was 75 mcg and median midazolam dose was 2 mg in all three groups (p = 0.61, p = 0.99). White patients received higher median midazolam dosing than Black patients (2 and 3 mg, respectively, p < 0.01) despite similar pain scores. Despite no difference in pain scores, patients terminating for genetic anomaly received more fentanyl than those terminating for socioeconomic reasons (75 and 100 mcg, respectively, p < 0.01).

CONCLUSIONS

In our limited study, we found that White race and induced abortion for genetic anomaly were associated with increased medication dosing, though age was not. Multiple demographic and psychosocial factors, as well as perhaps provider bias, play into both a patient's perception of pain and the dosage of fentanyl and midazolam they receive during abortion procedures.

IMPLICATIONS

By acknowledging both patient factors and provider biases in medication dosing, we can provide more equitable abortion care.

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.