Analgesia for Medically Induced Second Trimester Termination of Pregnancy: A Randomized Trial

Medical abortion in the second trimester - an update

The safety and efficacy of medical abortion in the second trimester is provider independent and may therefore offer advantages over surgical second trimester abortion in certain settings. Due to bleeding risk, medical abortions in the second trimester are still mostly performed in a clinic or hospital setting. The most effective regimen for abortion includes pretreatment with oral mifepristone and following doses of misoprostol. An alternative is misoprostol only which should only be used when mifepristone is not available. The optimal dosing of prostaglandin to achieve the highest efficacy with the lowest proportion of complications remains to be established. Complications are rare and serious adverse events uncommon but may include uterine rupture especially in women with a previous cesarean delivery or uterine surgery. Women having second trimester medical abortion are a diverse group with different indications for the abortion. All women should be offered pain relief and respectful care. Staff involved in second trimester medical abortion often find their work challenging. At the same time, staff indicate pride and a conviction of contributing to the 'greater good' for women and society. Staff involved in second trimester abortion should be offered guidance and support through the employer. Post abortion contraception should be offered to all women having second trimester medical abortions, including those who have the abortion due to fetal malformation. All methods of contraception can be started immediately after a second trimester medical abortion except for cycle based methods and diaphragms.

Cervical Dilators Used Concurrently With Misoprostol to Shorten Labor in Second-Trimester Termination of Pregnancy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the use of cervical dilators concurrently with misoprostol to shorten labor in second-trimester medical termination of pregnancy.

METHODS

This multicenter randomized controlled trial compared the efficacy of cervical dilators inserted concurrently with misoprostol with that of misoprostol, alone, to shorten labor for women undergoing termination of pregnancy between 15 0/7 and 27 6/7 weeks of gestation. The primary outcome was the proportion of women with a duration of labor exceeding 12 hours. Secondary outcomes included median duration of labor, time to amniotomy, side effects, complications, NPRS (Numeric Pain Rating Scale) score, and women's distress as measured by the IES-R (Impact of Event Scale-Revised). These outcomes also were studied separately in the nulliparous subgroup. To demonstrate a reduction of 50% of the proportion of women with a duration of labor exceeding 12 hours in the dilator group, with a power of 80% and a 2-sided 0.05 significance level, a sample of 268 women (134 in each group) was required.

RESULTS

Between December 2017 and September 2019, this study enrolled and analyzed 347 women: 174 in the dilator group and 173 in the control group, including 87 and 93 nulliparous patients, respectively. Sociodemographic and obstetric characteristics were similar between groups. The proportion of women with labor exceeding 12 hours was not different between groups (49/174 [28.2%] in the dilator group vs 53/173 [30.6%] in the control group [ P =.61] for the whole population, and 37/87 [42.5%] vs 42/93 [45.2%] [ P =.72], respectively, among nulliparous patients). Median duration of labor was 8.5 hours in the dilator group compared with 9.2 hours in the control group ( P =.65) for the whole population, and 10.5 hours compared with 11.8 hours, respectively, among nulliparous patients ( P =.33). Median time to amniotomy was 3.6 hours in the dilator group compared with 5.0 hours in the control group ( P =.08) for the whole population, and 3.5 hours compared with 6.7 hours, respectively, among nulliparous patients ( P =.003). Side effects, complications, NPRS score, and IES-R score were similar between groups.

CONCLUSION

Cervical dilators inserted concurrently with misoprostol did not reduce the proportion of women whose labor exceeded 12 hours compared with misoprostol alone.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT03194230.

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.

Management of physical pain during induced second-trimester medical abortions: a cross-sectional study of methodological quality and recommendations in local clinical practice guidelines at Swedish hospitals

AIM

The aim was to assess the methodological quality and describe recommendations for pain management in local clinical practice guidelines about induced second-trimester medical abortions at Swedish university and county hospitals.

METHODS

In 2017, Swedish university and county hospitals that provided abortion care in the second trimester of pregnancy were contacted (n = 29), and guidelines from 25 were received (university: n = 6, county: n = 19). Guideline quality was assessed according to two systematic instruments. Recommendations were systematically assessed regarding frequency and tools for pain measurement, prophylactic pharmacologic treatment, as needed pharmacologic treatment and nonpharmacologic treatment.

RESULTS

Overall methodological quality was poor across both instruments, as the majority of the guidelines did not fulfil the investigated quality criteria. For pain measurements, no guideline recommended measurement frequency and four recommended specific measurement tools. Prophylactic pharmacologic treatment, described in 23 (92%) guidelines, included paracetamol (n = 23, 92%), anti-inflammatory drugs (n = 23, 92%) and opioids (n = 18, 72%). As needed pharmacologic treatment, described in 23 (92%) guidelines, included anaesthetics (n = 21, 84%), opioids (n = 21, 84%) and paracetamol (n = 1, 4%). Recommendations for as needed anaesthetics included paracervical block (n = 21, 84%), epidural analgesia (n = 16, 64%) and inhalation of nitrous oxide (n = 5, 20%). Nonpharmacologic treatments were recommended in nine (36%) guidelines.

CONCLUSIONS

The findings indicate that local clinical practice guidelines about induced second-trimester medical abortions are of inadequate methodological quality and that a large majority lack recommendations concerning systematic pain measurements. Although most recommend prophylactic and as needed pharmacologic management, national inconsistencies exist in Sweden with regard to recommendations of epidural analgesia, nitrous oxide and nonpharmacologic methods. In Sweden, there is room for improvement in the development of these guidelines.