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Rydelius J, Hognert H, Kopp-Kallner H, Brandell K, Romell J, Zetterström K, Teleman P, Gemzell-Danielsson K. First dose of misoprostol administration at home or in hospital for medical abortion between 12-22 gestational weeks in Sweden (PRIMA): a multicentre, open-label, randomised controlled trial. Lancet 2024; 404:864-873. [PMID: 39216976 DOI: 10.1016/s0140-6736(24)01079-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 03/07/2024] [Accepted: 05/21/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Medical abortion after 12 gestational weeks often requires a stay in hospital. We hypothesised that administering the first misoprostol dose at home could increase day-care procedures as compared with overnight care procedures, shorten inpatient stays, and improve patient satisfaction. METHODS This multicentre, open-label, randomised controlled trial was done at six hospitals in Sweden. Participants were pregnant people aged 18 years and older who were undergoing medical abortion at 85-153 days of pregnancy. Randomisation was done in blocks 1:1 to mifepristone administered in-clinic followed by home administration or hospital administration of the first dose of misoprostol. Allocation was done by opening of opaque allocation envelopes. Due to the nature of the intervention, masking was not feasible. Between 24-48 h after mifepristone 200 mg, the participants administered 800 μg of misoprostol either at home 2 h before admission to hospital or in hospital. The primary outcome was the proportion of day-care procedures (defined as abortion completed in <9 h). The intention-to-treat analysis included all participants randomly assigned to receive the study drug and who had known results for the primary outcome. Individuals who received any treatment were included in the safety analyses. This trial is registered at ClinicalTrials.gov, NTC03600857, and EudraCT, 2018-000964-27. FINDINGS Between Jan 8, 2019, and Dec 21, 2022, 457 participants were randomly assigned to treatment groups. In the intention-to-treat-population, 220 participants were assigned to the home group and 215 to the hospital group. In the home group, 156 (71%) of 220 participants completed the abortion as day-care patients, compared with 99 (46%) of 215 in the hospital group (difference 24·9%, 95% CI 15·4-34·3; p<0·0001). In total, 97 (22%) of 444 participants in the safety analysis had an adverse event. Seven (2%) of 444 participants aborted after mifepristone only. Two (1%) of 220 in the home group aborted after the first dose of misoprostol, before hospital admission. INTERPRETATION Home administration of misoprostol significantly increases the proportion of day-care procedures in medical abortion after 12 gestational weeks, offering a safe and effective alternative to in-clinic protocols. FUNDING Region Västra Götaland, Hjalmar Svensson's Fund, the Gothenburg Society of Medicine, Karolinska Institutet-Region Stockholm, and The Swedish Research Council.
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Affiliation(s)
- Johanna Rydelius
- Department of Gynecology and Obstetrics, University of Gothenburg, Gothenburg, Sweden.
| | - Helena Hognert
- Department of Gynecology and Obstetrics, University of Gothenburg, Gothenburg, Sweden
| | - Helena Kopp-Kallner
- Department of Clinical Sciences Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Karin Brandell
- Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Joanna Romell
- Department of Gynecology and Obstetrics, Stockholm South General Hospital, Stockholm, Sweden
| | - Karin Zetterström
- Department of Gynecology and Obstetrics, University Hospital of Örebro, Örebro, Sweden
| | - Pia Teleman
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Fierro G, Milan B, Buelli E, Bugada D, Casarotta E, Rizzo F, Ongaro L, Gritti P, Previdi F, Lorini FL. Sublingual sufentanil for patient-controlled analgesia during labor induction for pregnancy termination: an effective and well-tolerated approach. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:41. [PMID: 38973007 PMCID: PMC11229235 DOI: 10.1186/s44158-024-00177-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Effective pain management during labor induction for pregnancy termination is essential. However, to date, no effective treatment has been identified. The primary aim of this study was to measure the analgesic efficacy of a sufentanil sublingual tablet system during pregnancy termination and patient satisfaction by comparing nulliparous and multiparous women. The secondary aims were to characterize the safety profile by reporting any side effects or adverse events and to determine the need for rescue therapy. METHODS We conducted an observational, retrospective, single-center study involving 48 women. The data retrieved for analysis included the total and hourly doses of sublingual sufentanil, evaluations of pain management satisfaction using a 5-point rating scale (ranging from 1, indicating "not satisfied" to 5, denoting "completely satisfied"), occurrence of side effects and adverse events, and the rate of rescue analgesic use. Categorical and numerical variables were compared between the two groups, and a correlation analysis was performed. RESULTS The median total dose of sufentanil required was 60 mcg. Nulliparous women required a higher dose of sufentanil compared with multiparous women (105 mcg vs. 45 mcg; P = 0.01). Additionally, they underwent a longer labor, indirectly measured by the time of device usage (625 min vs. 165 min; P = 0.05). Regarding satisfaction, 40 patients (83.4%) were satisfied or completely satisfied, whereas only 8 patients (16.6%) reported dissatisfaction. Multiparous women exhibited higher satisfaction levels than did nulliparous women (P = 0.03). No adverse events were reported, and the most common side effects were nausea and vomiting (31.2%). Four patients (12%) required acetaminophen due to insufficient analgesia, with only one patient necessitating a switch to intravenous morphine. CONCLUSIONS Sublingual sufentanil was effective in both nulliparous and multiparous women with minimal side effects. Therefore, sublingual sufentanil can be considered a valid strategy for analgesia during labor induction for pregnancy termination.
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Affiliation(s)
- Giulia Fierro
- Department of Emergency and Intensive Care, ASST Papa Giovanni XXIII, P.Za OMS, Bergamo, 24127, Italy
| | - Barbara Milan
- Department of Emergency and Intensive Care, ASST Papa Giovanni XXIII, P.Za OMS, Bergamo, 24127, Italy.
| | - Elena Buelli
- Department of Emergency and Intensive Care, ASST Papa Giovanni XXIII, P.Za OMS, Bergamo, 24127, Italy
| | - Dario Bugada
- Department of Emergency and Intensive Care, ASST Papa Giovanni XXIII, P.Za OMS, Bergamo, 24127, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica Delle Marche, Via Tronto 10/a, Ancona, 60020, Italy
| | - Francesco Rizzo
- Department of Emergency and Intensive Care, ASST Papa Giovanni XXIII, P.Za OMS, Bergamo, 24127, Italy
| | - Laura Ongaro
- Department of Emergency and Intensive Care, ASST Papa Giovanni XXIII, P.Za OMS, Bergamo, 24127, Italy
| | - Paolo Gritti
- Department of Emergency and Intensive Care, ASST Papa Giovanni XXIII, P.Za OMS, Bergamo, 24127, Italy
| | - Fabio Previdi
- Department of Management, Information and Production Engineering, University of Bergamo, Viale G. Marconi 5, Dalmine, BG, 24044, Italy
| | - Ferdinando Luca Lorini
- Department of Emergency and Intensive Care, ASST Papa Giovanni XXIII, P.Za OMS, Bergamo, 24127, Italy
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Taghinejadi N, McCulloch H, Krassowski M, McInnes-Dean A, Whitehouse KC, Lohr PA. Opt-in versus universal codeine provision for medical abortion up to 10 weeks of gestation at British Pregnancy Advisory Service: a cross-sectional evaluation. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024; 50:114-121. [PMID: 38296263 DOI: 10.1136/bmjsrh-2023-201893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/29/2023] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To assess patient experiences of pain management during medical abortion up to 10 weeks' gestation with opt-in versus universal codeine provision. METHODS We invited patients who underwent medical abortion up to 10 weeks of gestation to participate in an online, anonymous, English-language survey from November 2021 to March 2022. We performed ordinal regression analyses to compare satisfaction with pain management (5-point Likert scale) and maximum abortion pain score (11-point numerical rating scale) in the opt-in versus universal codeine provision groups. RESULTS Of 11 906 patients invited to participate, 1625 (13.6%) completed the survey. Participants reported a mean maximum pain score of 6.8±2.2. A total of 1149 participants (70.7%) reported using codeine for pain management during their abortion. Participants in the opt-in codeine provision group were significantly more likely to be satisfied with their pain management than those in the universal group (aOR 1.48, 95% CI 1.12 to 1.96, p<0.01). Maximum abortion pain scores were lower on average among the opt-in codeine provision group (OR 0.80, 95% CI 0.66 to 0.96, p=0.02); however, this association was not statistically significant in the model adjusted for covariates (aOR 0.85, 95% CI 0.70 to 1.03, p=0.09). CONCLUSION Our findings suggest that patients have a better experience with pain management during medical abortion when able to opt-in to codeine provision following counselling versus receiving this medication routinely.
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Affiliation(s)
- Neda Taghinejadi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hannah McCulloch
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
| | - Michał Krassowski
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Amelia McInnes-Dean
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
| | - Katherine C Whitehouse
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
| | - Patricia A Lohr
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
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Tascón Padrón L, Emrich N, Strizek B, Gass A, Link C, Hilbert T, Klaschik S, Meissner W, Gembruch U, Jiménez Cruz J. Implementation of a piritramide based patient-controlled analgesia (PCA) as a standard of care for pain control in late abortion induction: A prospective cohort study from a patient perspective. Eur J Obstet Gynecol Reprod Biol X 2023; 20:100251. [PMID: 37876769 PMCID: PMC10590719 DOI: 10.1016/j.eurox.2023.100251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/30/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023] Open
Abstract
Objective To assess whether the implementation of patient-controlled analgesia (PCA) with piritramide using an automatic pump system under routine conditions is effective to reduce pain in late abortion inductions. Study design Prospective observational cohort study. Setting Patients requiring medically indicated abortion induction from 14 weeks of pregnancy onwards between July 2019 and July 2020 at the department of Obstetrics and Prenatal Medicine of the Bonn University Hospital in Germany. Methods Evaluation of pain management after implementation of a PCA system compared with previous nurse-controlled tramadol-based standard under routine conditions. Patients answered a validated pain questionnaire and requirement of rescue analgesics was assessed. Pain intensity and satisfaction were measured on a ten-point numeric rating scale. Main Outcome Measure Maximal pain intensity. Results Forty patients were included. Patients using Piritramide-PCA complained of higher pain sores than those in the standard group (6.90 (± 2.34) vs. 4.83 (± 2.87), (p < 0.05)). In both groups the level of satisfaction with the analgesia received was comparable (8.00 (± 2.45) vs 7.67 (± 2.62), (p = 0.7)). Patients in the PCA group suffered more nausea (63.2 % vs 30 % respectively, OR 4.0, 95 % CI 1.05-15.20, p < 0.05) and expressed more the desire for more analgesic support compared to the control group (OR 5.7 (1-33.25), p = 0.05). Conclusion Women with abortion induction after 14 weeks of gestation suffer from relevant severe pain, which requires adequate therapy. However, addition of PCA does not seem to bring any advantage in patients undergoing this procedure.
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Affiliation(s)
- L. Tascón Padrón
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - N.L.A. Emrich
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - B. Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - A. Gass
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - C. Link
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - T. Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - S. Klaschik
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - W. Meissner
- Department for Anesthesiology and Intensive Care Medicine/Department of Palliative Care, University Hospital of Jena, 07740 Jena, Germany
| | - U. Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - J. Jiménez Cruz
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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Kopp Kallner H. Medical abortion in the second trimester - an update. Curr Opin Obstet Gynecol 2023; 35:490-495. [PMID: 37873766 DOI: 10.1097/gco.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
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.
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Affiliation(s)
- Helena Kopp Kallner
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet
- Department of Obstetrics and Gynaecology, Danderyd Hospital, Stockholm, Sweden
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How much will it hurt? Factors associated with pain experience in women undergoing medication abortion during the first trimester. Contraception 2023; 119:109916. [PMID: 36470325 DOI: 10.1016/j.contraception.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Few studies have investigated the features associated with pain levels during abortion. We aimed to investigate the risk factors for experiencing pain during medication abortion, focusing on women's psychological distress and anxiety levels. STUDY DESIGN We carried out this observational study at two centers in Bologna, Italy. We included women aged 18 years or more with a viable intrauterine pregnancy of up to 63 days of amenorrhea, who chose medication abortion. Women received 600 mg of Mifepristone orally and after 48 hours 400 mcg of buccal misoprostol, repeated after 3 hours according to local and regional medication abortion guidelines, as well as prophylactic analgesia. We evaluated the clinical characteristics which may represent risk factors for severe pain (Visual Analogue Scale ≥ 70) through a multivariate model. RESULTS Two hundred forty-two patients were included in our analysis; 92 (38.0%) reported severe pain during medication abortion. Women with higher baseline anxiety levels (General Health Questionnaire 12 score ≥ 6 and General Anxiety Disorder 7 score ≥ 10) had a higher probability of experiencing pain with a Visual Analogue Scale ≥70 (OR = 3.33, 95% CI 1.43-7.76), as well as those who reported dysmenorrhea in the past year (OR = 6.30, 95% CI 2.66-14.91). Previous vaginal deliveries were inversely correlated with pain intensity (OR 0.26, 95% CI 0.14 - 0.50). CONCLUSIONS Increased baseline anxiety levels, dysmenorrhea and no previous vaginal deliveries are associated with severe pain in women undergoing medication abortion. IMPLICATIONS The identification of women at risk for severe pain based on clinical and historical factors as well as the definition of an adequate analgesic regimen may help to improve women's care and pain management during medication abortion.
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Zeng Y, Jiang T, Zheng YH, He WR, Wang XW, Wei H, Wang L, Liu ZR, Zhang XF, Yi C, Chen KM. Evaluation efficacy and safety of epidural analgesia in second-trimester induced labor: A single-center, prospective, non-randomized, controlled study. Medicine (Baltimore) 2022; 101:e30767. [PMID: 36197253 PMCID: PMC9509083 DOI: 10.1097/md.0000000000030767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Second-trimester induced labor in pregnant women was often more likely to suffer from psychological and physiological double pain. However, the analgesic management received less attention, and the optimal analgesic mode for second-trimester induced labor had not been determined. Our objective was to evaluate the feasible of epidural analgesia (EA) in second-trimester induced labor. METHODS From January 2020 to December 2021, Primipara who planned to undergo second-trimester induced labor in the First Affiliated Hospital of Yangtze University were collected. The method of labor induction was oral mifepristone + amniotic cavity injection of Ethacridine Lactate. Based on whether or not patients received epidural analgesia, which were divided into EA group (30 cases) and non-EA (NEA) group (30 cases). The primary outcome were visual analog scale (VAS) score of pain and result of follow-up, the secondary outcomes included relative clinical parameter and labor duration. RESULTS Vaginal induction of labor was successful in both groups. There was no statistically significant difference in VAS of pain between the two groups before analgesia (P > .05), but the VAS of pain in the EA group was significantly lower than the NEA group (P < .05) after analgesia or at delivery. The following outcomes showed no statistical difference between two groups: labor duration, postpartum hemorrhage, hemorrhage ≥ 500 mL, intrapartum injury, second days hemoglobin, C-reactive protein, antibiotic therapy days, hospitalizations days, and placenta residue (P > .05). The median hospitalization costs of EA group was 4697.5 yuan, and NEA group was 3673 yuan, the difference was statistically significant (P < .001). No adverse events related to EA occurred during hospitalization, only 3 patients showed mild lumbago and back pain after follow-up to three months postpartum, which was significantly relieved after proper rest. CONCLUSION EA can significantly reduce the pain of parturients, which may be effective and safe in the second-trimester induced labor.
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Affiliation(s)
- Yong Zeng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Tao Jiang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Ya-Hong Zheng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Wen-Rong He
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Xiao-Wen Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Hua Wei
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Li Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Zu-Rong Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Xu-Feng Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Cunjian Yi
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
| | - Ke-Ming Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Yangtze University, Jingzhou City, China
- *Correspondence: Ke-Ming Chen, 8 Hangkong Road, Shashi District, Jingzhou City, Hubei Province 434000, China (e-mail:)
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Kemppainen V, Mentula M, Palkama V, Heikinheimo O. Patient-controlled intravenous versus on-demand oral, intramuscular or intravenous administration of oxycodone during medical induced abortion from 64 to 128 days of gestation: a randomized controlled trial. Contraception 2022; 115:6-11. [PMID: 35872235 DOI: 10.1016/j.contraception.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/06/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare oxycodone administration via intravenous patient-controlled analgesia (IVPCA) vs on-demand administration during late-first- and second-trimester medically induced abortion. STUDY DESIGN A prospective randomized controlled study. We enrolled women between 64 to 128 days of gestation in the study between June 2016 and August 2018. Participants were randomized to receive oxycodone either via IVPCA or given on-demand orally, intramuscularly or intravenously. Pain intensity and satisfaction with care were measured using the visual analogue scale (VAS, 0-100mm). RESULTS Altogether 99 participants were randomized: 48 in IVPCA group and 51 in on-demand group. Median gestational age was similar between groups (74 days [Interquartile range, IQR 69-81] in the IVPCA group vs 72 [69-80] in the control group, p=0.587). Peak maximal pain was severe in both groups (median pain VAS was 62 [IQR 44-84] and 71 [IQR 56-90], p=0.52). The odds for severe pain (highest pain VAS≥70) were similar between the groups (IVPCA group OR 0.51 [95% Confidence Interval 0.22-1.18], p=0.118). In contrast, the odds for mild or tolerable pain (highest pain VAS≤40) were higher in the IVPCA group (OR 4.06 [95% CI 1.05-16.04], p=0.043). Nevertheless, satisfaction with care was high (VAS 94 [89-100]) in both groups. Of those experiencing severe pain, 94.0% declared pain medication as adequate. CONCLUSIONS Women often experience severe pain during medical abortion irrespective of the mode of opiate administration. Oxycodone administration via IVPCA permits women to self-administer analgesics when experiencing pain, raising the odds for mild or tolerable pain during abortion care. Satisfaction with care was high.
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Affiliation(s)
- Venla Kemppainen
- The Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University hospital, Helsinki, Finland
| | - Maarit Mentula
- The Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University hospital, Helsinki, Finland
| | - Vilja Palkama
- The Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Oskari Heikinheimo
- The Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University hospital, Helsinki, Finland.
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Meurice ME, Whitehouse KC, Blaylock R, Chang JJ, Lohr PA. Client satisfaction and experience of telemedicine and home use of mifepristone and misoprostol for abortion up to 10 weeks’ gestation at British Pregnancy Advisory Service: A cross-sectional evaluation. Contraception 2021; 104:61-66. [DOI: 10.1016/j.contraception.2021.04.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/28/2022]
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Women's experiences with information before medication abortion at home, support during the process and follow-up procedures - A qualitative study. SEXUAL & REPRODUCTIVE HEALTHCARE 2020; 27:100582. [PMID: 33296849 DOI: 10.1016/j.srhc.2020.100582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 10/18/2020] [Accepted: 11/21/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To explore women's experiences of having a medication abortion at home in regard to their perceptions of the information provided before the abortion, support throughout the process and follow-up procedures. STUDY DESIGN A qualitative study based on interviews with 23 women between October 2019 and January 2020. Systematic text condensation was used for data analysis. RESULTS Three themes were identified from the analysis. The first theme covers how the women found the information given before the abortion to be inadequate and how this affected their feelings of safety. In the second theme, the participants described how they experienced lack of acknowledgement from health care professionals, and how this affected their feeling of support. The third theme covers how the women perceived access to health care professionals during the home abortion, and how this affected their feeling of well-being. CONCLUSIONS In general, the women stated that the information provided was inadequate, especially in regard to bleeding and pain. The women also found support during and after the abortion to be insufficient and would have preferred more help and information throughout the process. This suggests that health care professionals should improve their procedures for providing information, support and care.
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Kemppainen V, Mentula M, Palkama V, Heikinheimo O. Pain during medical abortion in early pregnancy in teenage and adult women. Acta Obstet Gynecol Scand 2020; 99:1603-1610. [DOI: 10.1111/aogs.13920] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Venla Kemppainen
- The Department of Obstetrics and Gynecology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Maarit Mentula
- The Department of Obstetrics and Gynecology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Vilja Palkama
- The Department of Anesthesiology and Intensive Care Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Oskari Heikinheimo
- The Department of Obstetrics and Gynecology University of Helsinki and Helsinki University Hospital Helsinki Finland
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Jackson E, Kapp N. Pain management for medical and surgical termination of pregnancy between 13 and 24 weeks of gestation: a systematic review. BJOG 2020; 127:1348-1357. [PMID: 32162427 PMCID: PMC7539983 DOI: 10.1111/1471-0528.16212] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2020] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
| | - N Kapp
- Ipas, Chapel Hill, NC, USA
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Platais I, Tsereteli T, Maystruk G, Kurbanbekova D, Winikoff B. A prospective study of mifepristone and unlimited dosing of sublingual misoprostol for termination of second-trimester pregnancy in Uzbekistan and Ukraine. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:bmjsrh-2018-200167. [PMID: 31164394 DOI: 10.1136/bmjsrh-2018-200167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 04/16/2019] [Accepted: 05/16/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION We aimed to assess the feasibility and acceptability of a second-trimester medical abortion regimen using mifepristone and sublingual misoprostol with no maximum number of misoprostol doses in Uzbekistan and Ukraine. METHODS This prospective open-label study enrolled 306 women with pregnancies of 13-22 weeks in Uzbekistan (n=134) and Ukraine (n=172). Women took 200 mg mifepristone at a place of their choosing, and 24-48 hours later received 400 μg sublingual misoprostol every 3 hours until the expulsion of both fetus and placenta. Study staff interviewed women about the intensity of pain, side effects, and satisfaction with the procedure. The primary outcome was the rate of complete uterine evacuation without surgical intervention or oxytocin at 15 hours after the first dose of misoprostol. RESULTS The median gestational age was 18.1 weeks, and half of the women (n=149, 48.9%) chose to take mifepristone at home. The majority of women (n=266, 86.9%, 95% CI 82.6% to 90.5%) expelled by 15 hours after the start of misoprostol treatment, and by 48 hours complete uterine evacuation was achieved in 296 (96.7%) women. Most women found pain (76.1%) and side effects (89.0%) to be acceptable or very acceptable, and reported high satisfaction (89.8%) with the procedure. CONCLUSION Medical abortion in pregnancies of 13-22 weeks with 200 mg mifepristone followed 24-48 hours later by 400 μg sublingual misoprostol administered every 3 hours until complete expulsion is effective, safe and acceptable to women. Women can be given the option to take mifepristone at home and return to the hospital. CLINICAL TRIALS REGISTRATION NUMBER ClinicalTrials.gov, www.clinicaltrials.gov, NCT02415894, NCT02235155.
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Affiliation(s)
| | | | - Galyna Maystruk
- Woman Health & Family Planning Charity Foundation, Kiev, Ukraine
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Palma Manríquez I, Moreno Standen C, Álvarez Carimoney A, Richards A. Experience of clandestine use of medical abortion among university students in Chile: a qualitative study. Contraception 2017; 97:100-107. [PMID: 28947389 DOI: 10.1016/j.contraception.2017.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 09/11/2017] [Accepted: 09/17/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To explore the ways in which medical abortion pills are obtained and used by university students in Chile in a clandestine context. STUDY DESIGN Using a qualitative approach, we conducted in-depth interviews with 30 young women who had had a medical abortion between 2006 and 2016 while attending university. We recorded the details of their pathways to abortion and their experience of abortion, and how they used networks in the university to find the pills and learn how to use them. The interviews were analyzed using narrative content analysis. RESULTS The findings show that medical abortion did not take place completely outside the healthcare system for these students, who accessed ultrasound scans pre- and post-abortion and post-abortion care. However, even with help and support from contacts, partners and friends, the clandestine situation created uncertainty and fear, which dominated the whole process, from finding and purchasing the pills, to uncertainty about correct doses and whether the abortion was going as it should and was complete or not. There was a high perception that failure and complications might be occurring, which led many of them to seek post-abortion care. The process was very demanding, requiring information, time, privacy to have the abortion, support and resources, and the ability to deal with risk. CONCLUSIONS Medical abortion allowed these young women to have safe abortions in terms of reduced risks to health and autonomy through self-management. However, clandestinity made them physically, socially and emotionally vulnerable and exposed them to the risk of normative, violent judgments during post-abortion care. IMPLICATIONS Access to medical abortion has transformed the experience of abortion in Chile, where abortion is illegal, because it is possible to use it safely and effectively outside healthcare settings. However, uncertainty, fear and risk will continue to dominate the experience, which can only be transformed by making abortion legal and available.
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Affiliation(s)
- Irma Palma Manríquez
- Facultad de Ciencias Sociales, Universidad de Chile, Avda. Capitán Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile
| | - Claudia Moreno Standen
- Facultad de Ciencias Sociales, Universidad de Chile, Avda. Capitán Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile.
| | - Andrea Álvarez Carimoney
- Facultad de Ciencias Sociales, Universidad de Chile, Avda. Capitán Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile
| | - Alondra Richards
- Facultad de Ciencias Sociales, Universidad de Chile, Avda. Capitán Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile
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Pain and Analgesia During Labor and Delivery Between 16 0/7 and 22 6/7 Weeks of Gestation. Obstet Gynecol 2017; 127:1161-1165. [PMID: 27159759 DOI: 10.1097/aog.0000000000001447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe severity of pain during labor at previable estimated gestational age and to determine the effectiveness of various methods of analgesia in this population. METHODS In this retrospective review of the records of women undergoing induction or augmentation of labor between 16 0/7 and 22 6/7 weeks of gestation, we examined pain scores (numeric rating scale 0-10) documented throughout labor and analgesia method (none, systemic, or neuraxial). We compared relevant patient and labor characteristics such as gestational age, fetal weight, time interval from induction to delivery as well as pain data including analgesia type and pain scores before and after analgesia. We compared analgesia response in patients who received neuraxial analgesia and those who did not. RESULTS A total of 80 patients met inclusion criteria: four requested no analgesia, 56 used systemic analgesia only, 11 used systemic analgesia initially and then requested neuraxial analgesia, and nine used neuraxial without using systemic analgesia first. Median peak pain score was 7 among all patients. Patients who chose neuraxial analgesia had higher estimated gestational age (21 compared with 20 weeks of gestation, P=.03), fetal weight (362 compared with 268 g, P=.047), and admission-to-delivery time intervals (19.25 compared with 10.3 hours, P=.003) than those who chose no or systemic analgesia. Immediate preanalgesia peak pain scores were not different between groups, but patients who received neuraxial analgesia had lower immediate postanalgesia nadir scores than those who chose systemic pain relief. CONCLUSION Pain during induction of labor at previable gestational ages may be greater than is commonly appreciated. Neuraxial analgesia may provide more optimal pain relief for patients with higher estimated gestational age and fetal weight, particularly after 22 weeks of estimated gestational age.
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Cavet S, Fiala C, Scemama A, Partouche H. Assessment of pain during medical abortion with home use of misoprostol. EUR J CONTRACEP REPR 2017; 22:207-211. [DOI: 10.1080/13625187.2017.1315092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sandra Cavet
- Department of General Medicine, Faculty of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Christian Fiala
- Gynmed Clinic, Vienna, Austria
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
| | - Agathe Scemama
- Department of General Medicine, Faculty of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Henri Partouche
- Department of General Medicine, Faculty of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
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Louie KS, Chong E, Tsereteli T, Avagyan G, Abrahamyan R, Winikoff B. Second trimester medical abortion with mifepristone followed by unlimited dosing of buccal misoprostol in Armenia. EUR J CONTRACEP REPR 2016; 22:76-80. [DOI: 10.1080/13625187.2016.1258461] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | | | | | - Gayane Avagyan
- Department of Obstetrics and Gynaecology No2, Yerevan State Medical University, Yerevan, Armenia
| | - Ruzanna Abrahamyan
- Republican Institute of Reproductive Health, Perinatology, Obstetrics and Gynaecology, Yerevan, Armenia
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Simultaneous Administration Compared With a 24-Hour Mifepristone–Misoprostol Interval in Second-Trimester Abortion. Obstet Gynecol 2016; 128:1077-1083. [DOI: 10.1097/aog.0000000000001688] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Freeman MD, Porat N, Rojansky N, Elami-Suzin M, Winograd O, Ben-Meir A. Physical symptoms and emotional responses among women undergoing induced abortion protocols during the second trimester. Int J Gynaecol Obstet 2016; 135:154-157. [PMID: 27539053 DOI: 10.1016/j.ijgo.2016.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 05/15/2016] [Accepted: 07/25/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the physical and emotional effects of two medical protocols for induced abortion during the second trimester. METHODS The present study was part of a prospective randomized controlled trial comparing mifepristone followed by oxytocin or misoprostol that was conducted at the Hadassah Hebrew University Medical Center, Jerusalem, Israel, from January 10, 2009, to February 22, 2012. Inclusion criteria were pregnancy (14-24weeks), epidural analgesia, and medical induction of abortion (either elective or following missed abortion). A structured questionnaire was used to assess the participants' physical symptoms and emotional responses. The primary outcome for the present analysis was the degree of physical symptoms reported. RESULTS Overall, 68 women in the oxytocin group and 67 in the misoprostol group received epidural analgesia and completed the questionnaire. As assessed using a five-point Likert scale, women in the misoprostol group were more likely than those in the oxytocin group to experience diarrhea (1.34±0.84 vs 1.10±0.55; P=0.05) and shivers (3.03±1.75 vs 1.75±1.21; P<0.001). No other between-group differences were detected for the physical or emotional variables evaluated. CONCLUSION Differences in physical symptoms experienced by the two treatment groups did not influence the participants' subsequent emotional response. ClinicalTrials.gov: NCT00784797.
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Affiliation(s)
- Martine D Freeman
- Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Nurit Porat
- Quality, Safety and Accreditation Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Nathan Rojansky
- Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Matan Elami-Suzin
- Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Orit Winograd
- Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Assaf Ben-Meir
- Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Feng X, Ye T, Wang Z, Chen X, Cong W, Chen Y, Chen P, Chen C, Shi B, Xie W. Transcutaneous acupoint electrical stimulation pain management after surgical abortion: A cohort study. Int J Surg 2016; 30:104-8. [PMID: 27142864 DOI: 10.1016/j.ijsu.2016.04.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 04/19/2016] [Accepted: 04/26/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Transcutaneous acupoint electrical stimulation (TEAS) is a standard therapy for painful conditions. This study evaluated pain-relieving effects of treatment with TEAS before and after surgical abortion. METHODS In this cohort study 140 nulliparae requesting pregnancy termination with intravenous anesthesia from August to December 2013 at the outpatient clinic of Wenzhou Medical University First Affiliated Hospital were recruited and divided into three cohorts who received TEAS pre-, post-, and both pre- and post-operation, alongside a control group. The cohorts underwent TEAS treatment for 30 min before and/or after the procedure while the control group received no TEAS treatment. Pain levels were evaluated upon recovery at 10, 30, and 45 min, respectively, after abortion. RESULTS Mean Visual Analog Scale (VAS) scores in pre-operation cohorts, but not the post-operation cohort, were significantly lower than those obtained for the control group at 10 min (p < 0.01). VAS scores at 30 min and 45 min postoperatively were similar in each cohort but lower than control values (p < 0.001). More cohort patients reported mild or no pain than control patients (p < 0.05); the pre-operation cohorts had more women with no pain compared with the post-operation group (p < 0.05). There were no differences among groups in medical treatment required after 45 min. There were fewer complications of nausea and vomiting in the cohorts compared with the control group (p < 0.05). CONCLUSIONS Performing TEAS before and after surgical abortion provides postoperative pain relief. However, receiving TEAS before surgery allowed more women to experience mild or no pain. IMPLICATIONS Transcutaneous acupoint electrical stimulation shows potential as an adjunct to conventional pain treatment following surgical abortion in nulliparae.
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Affiliation(s)
- Xiaozhen Feng
- Department of Acupuncture & Physiotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Tianshen Ye
- Department of Acupuncture & Physiotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zedong Wang
- Department of Acupuncture & Physiotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiufang Chen
- Department of Geriatric Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenjie Cong
- Department of Acupuncture & Physiotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yong Chen
- Department of Acupuncture & Physiotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Pinjie Chen
- Department of Acupuncture & Physiotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chong Chen
- Department of Acupuncture & Physiotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Beibei Shi
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
| | - Wenxia Xie
- Department of Acupuncture & Physiotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
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Abstract
OBJECTIVE This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care. INTENDED USERS Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services. TARGET POPULATION Women with an unintended first trimester pregnancy. EVIDENCE Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1). BENEFITS, HARMS AND/OR COSTS Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability. SUMMARY STATEMENTS Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care RECOMMENDATIONS Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.
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Analgesia for Medically Induced Second Trimester Termination of Pregnancy: A Randomized Trial. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:147-53. [PMID: 27032739 DOI: 10.1016/j.jogc.2015.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/09/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare the efficacy between intravenous patient-controlled analgesia (IVPCA) and patient-controlled epidural analgesia (PCEA) in women undergoing medically induced second trimester termination of pregnancy (TOP). METHODS We conducted a randomized trial in a Canadian quaternary care hospital. We included in the study women of gestational age 12 weeks to 23+6 weeks who were undergoing second trimester induction of labour between June 2012 and January 2014. Participants were computer-randomized to receive either IVPCA with fentanyl or PCEA with bupivacaine and fentanyl, with the option to cross over between treatment groups. We administered Quality of Recovery-40 (QoR-40) questionnaires pre-procedure, at the time of discharge, and 24 hours after discharge. Pain scores, satisfaction scores, and obstetrical complications also were noted. RESULTS One hundred thirty-eight women were approached for participation in the study; 80 declined and 16 were ineligible, leaving 42 participants. Three women subsequently withdrew consent, and two were not included in the results because of protocol violations. A total of 37 women completed the study. Twenty (54%) were allocated to the IVPCA group and 17 (46%) to the PCEA group. Although the QoR-40 values at the time of discharge and at 24 hours after discharge were significantly higher in the PCEA group, they also were significantly higher before the procedure in that group. The within-group differences in QoR-40 (between QoR-40 at discharge and QoR pre-procedure, and between QoR-40 at 24 hours after discharge and QoR pre-procedure), maximum pain scores, satisfaction, and obstetrical complication rates did not differ significantly between the two groups. CONCLUSION IVPCA and PCEA provide similar quality of recovery, quality of analgesia, and satisfaction for women undergoing second trimester TOP.
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Andersson IM, Benson L, Christensson K, Gemzell-Danielsson K. Paracervical block as pain treatment during second-trimester medical termination of pregnancy: an RCT with bupivacaine versus sodium chloride. Hum Reprod 2015; 31:67-74. [PMID: 26573530 DOI: 10.1093/humrep/dev286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/23/2015] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Can paracervical block (PCB) administered before the onset of pain decrease women's pain experience during second-trimester medical termination of pregnancy (MToP)? SUMMARY ANSWER There were no clinically significant differences between groups receiving PCB with bupivacaine or saline with regard to the highest and lowest pain intensity, morphine consumption or induction-to abortion interval. WHAT IS KNOWN ALREADY The most common side effect of misoprostol is pain; nevertheless, there are sparse studies in pain and pain treatment during MToP, especially in second-trimester abortion. Pain reported in second-trimester medical abortion is often intense, and peaks when the fetal expulsion occurs. STUDY DESIGN, SIZE, DURATION A double-blinded RCT was carried out from May 2012 until April 2015. A power calculation was based on a previous pilot study showing that the proportion of women with severe pain [visual analogue scale (VAS) ≥7] was 63%. A clinically significant reduction was considered to yield 35% with severe pain, and with a power of 80% and significance level of 5% (two-sided) 112 women were needed. Accounting for a 20% drop-out rate, a total of 140 women were needed. The primary outcome, pain intensity measured as any VAS ≥7, was analysed using a generalized estimating equations model. The level of significance was set to P < 0.05 two-sided. A computer generated randomization list with block size of 10 was used. The treatment allocation was placed in a sealed, opaque, envelope and picked consecutively. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 589 women attending a gynaecological clinic had a second-trimester abortion during the study period and 276 were invited to participate. A total of 113 women undergoing abortion from 13 weeks of gestation and above were recruited, of which 55 were randomly allocated to receive a PCB with bupivacaine and 58 a PCB with sodium chloride 1 h after the first dose of misoprostol. The full analysis set (FAS) population was defined as all randomized women that had at least one value for any of the outcomes (n = 102). The per-protocol (PP) population was defined as a subset of the FAS excluding patients with major protocol deviations or without a value for the primary outcome (n = 99). Pain was measured by VAS at misoprostol initiation (baseline) and repeated every 30 min until fetal expulsion. The primary outcome was the highest VAS pain intensity at any time point. MAIN RESULTS AND THE ROLE OF CHANCE The highest pain intensity, did not show any differences at a cut-off of VAS ≥7 [risk ratio (RR): 1.1; 95% confidence interval (CI): 0.9-1.5; P = 0.0.292]. In the PP analyses, there were 75% women in the bupivacaine group and 64% in the sodium chloride group with VAS ≥7 (RR: 1.2; 95% CI: 0.9-1.5; P = 0.235). Most women did not experience pain at the misoprostol start, 19 women scored a VAS of >0, ranging from 1 to 4 with a mean of 1.8 and median of 2 (P = 1.000). Immediately prior to PCB, 61 women scored a VAS of >0, from 1 to 10 with a mean of 2.0 and median of 1 (P = 0.771). There was a 48% loss of VAS scores at the time of expulsion and the remaining scores did not differ between groups (RR: 1.5; 95% CI: 0.9-2.5). A subgroup analysis of primipara did not show any difference in highest pain intensity VAS ≥7 (RR: 1.2; 95% CI: 0.9-1.6; P = 0.283). No statistically significant differences were observed between groups with regard to the highest and lowest (P = 553 and 0.182) pain intensity and morphine consumption (P = 0.772). Side effects were reported by 28 women (14 women in each group), with no differences between groups. Most common was nausea and vomiting in connection to morphine injection. LIMITATIONS, REASONS FOR CAUTION Nearly 60% of the invited women did not want to participate in the study (fear of needles and fear of receiving the placebo) therefore women who tolerate pain may have been overrepresented in the study population. Data collection was stopped, in error, when 113 participants had been recruited. The loss to follow-up was, however, only 11 women (10%), which was lower than expected but intrinsically the study did not fully reach the intended number of women, which may have influenced the results. In addition, the obstetrical and gynaecological background of participating women differs. The participants were informed that they had a 50% chance of receiving a PCB with active substance, which could theoretically have affected their expectations and pain experience (placebo effect). The frequent attention at VAS scoring and the overall care provided may also have affected the participants in a positive way, and helped women to feel supported and more relaxed during the abortion. WIDER IMPLICATIONS OF THE FINDINGS The highest pain intensity was severe (VAS: 7-10) among 65-75% of the participants, as reported for first-trimester medical abortion; however, the maximal pain scores remain high despite the PCB. There is, therefore, a clear need for more optimal pain treatment but only limited data exist on pain treatment during MToP over all gestational lengths. As PCB was well tolerated, did not cause any serious side effects and had no negative impact on the abortion process and efficacy, another approach may be worth exploring, namely PCB given on demand at the onset of painful contractions. STUDY FUNDING/COMPETING INTERESTS The study was supported by grants from the Swedish Research Council (grant no: 2012-2844), ALF (Karolinska Institutet - Stockholm County Council, Agreement on Medical Research and Training) funding, the Karolinska Institutet, Stockholm South General Hospital, and Swedish Nurses in the Area of Pain - SSOS together with GlaxoSmithKline. None of the authors have any conflicts of interest. TRIAL REGISTRATION NUMBER The trial was registered with ClinicalTrials.gov (identifier: NCT01617564) and The EudraCT (number: 2010-020780-21) and was approved by The Regional Ethical Review Board at Karolinska Institutet (dnr: 2007/1277-31/2 and 2010/410-31/1). TRIAL REGISTRATION DATE Clinical trial registration was done in May 2012 before initiation of patient recruitment. DATE OF FIRST PATIENT'S ENROLMENT 29 May 2012.
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Affiliation(s)
- I-M Andersson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm South General Hospital, 118 83 Stockholm, Sweden
| | - L Benson
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm South General Hospital, 118 83 Stockholm, Sweden
| | - K Christensson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - K Gemzell-Danielsson
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, WHO Centre, Karolinska University Hospital, Stockholm, Sweden
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Saurel-Cubizolles MJ, Opatowski M, David P, Bardy F, Dunbavand A. Pain during medical abortion: a multicenter study in France. Eur J Obstet Gynecol Reprod Biol 2015; 194:212-7. [DOI: 10.1016/j.ejogrb.2015.09.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/07/2015] [Accepted: 09/17/2015] [Indexed: 10/23/2022]
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Mentula M, Kalso E, Heikinheimo O. Same-day and delayed reports of pain intensity in second-trimester medical termination of pregnancy: a brief report. Contraception 2014; 90:609-11. [DOI: 10.1016/j.contraception.2014.06.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 06/15/2014] [Accepted: 06/17/2014] [Indexed: 11/30/2022]
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Shokry M, Fathalla M, Hussien M, Eissa AA. Vaginal misoprostol versus vaginal surgical evacuation of first trimester incomplete abortion: Comparative study. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2014. [DOI: 10.1016/j.mefs.2013.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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A review of evidence for safe abortion care. Contraception 2013; 88:350-63. [DOI: 10.1016/j.contraception.2012.10.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 09/04/2012] [Accepted: 10/22/2012] [Indexed: 11/19/2022]
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29
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Medicaltermination of pregnancy. Contraception 2013. [DOI: 10.1017/cbo9781107323469.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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30
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Avraham S, Gat I, Duvdevani NR, Haas J, Frenkel Y, Seidman DS. Pre-emptive effect of ibuprofen versus placebo on pain relief and success rates of medical abortion: a double-blind, randomized, controlled study. Fertil Steril 2012; 97:612-5. [DOI: 10.1016/j.fertnstert.2011.12.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 12/17/2011] [Accepted: 12/21/2011] [Indexed: 10/14/2022]
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Kopp Kallner H, Fiala C, Gemzell-Danielsson K. Assessment of significant factors affecting acceptability of home administration of misoprostol for medical abortion. Contraception 2011; 85:394-7. [PMID: 22067756 DOI: 10.1016/j.contraception.2011.08.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 08/07/2011] [Accepted: 08/15/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Knowledge on factors affecting acceptability of medical abortion with mifepristone followed by home administration of misoprostol is scarce. The objective of this study was therefore to assess factors affecting acceptability and experience of home use of misoprostol for medical abortion up to 63 days' gestation. STUDY DESIGN Prospective observational study with acceptability assessed through questionnaires. Factors affecting acceptability were analyzed using multivariate logistic regression. RESULTS A total of 395 women were included. Independent factors for acceptability were having a partner/friend present and having a positive low-sensitivity urine hCG at follow-up, although most of these patients had successful abortions. Age, gestational length and requirement of extra pain medication did not affect acceptability. CONCLUSION Home administration of misoprostol is highly acceptable. Increasing the number of complete abortions should be a focus of future research. Women should be encouraged to have a partner/friend present during home administration of misoprostol.
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Affiliation(s)
- Helena Kopp Kallner
- Division of Obstetrics and Gynaecology, Department of Woman and Child Health, Karolinska Institutet/Karolinska University Hospital, 171 77 Stockholm, Sweden.
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Suhonen S, Tikka M, Kivinen S, Kauppila T. Pain during medical abortion: predicting factors from gynecologic history and medical staff evaluation of severity. Contraception 2011; 83:357-61. [DOI: 10.1016/j.contraception.2010.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 08/04/2010] [Accepted: 08/07/2010] [Indexed: 10/19/2022]
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Jackson E, Kapp N. Pain control in first-trimester and second-trimester medical termination of pregnancy: a systematic review. Contraception 2011; 83:116-26. [DOI: 10.1016/j.contraception.2010.07.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 06/29/2010] [Accepted: 07/14/2010] [Indexed: 11/27/2022]
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The level of unpleasantness of pain influences the choice of home treatment during medical abortion. Scand J Pain 2011; 2:19-23. [DOI: 10.1016/j.sjpain.2010.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2009] [Accepted: 09/27/2010] [Indexed: 11/19/2022]
Abstract
Abstract
Background and aims
Medical abortion is often performed at outpatient clinics or gynaecological wards. Yet, some women may stay at home during medical abortion. Pain has been reported to be one of the main side effects of the procedure.
Methods
We studied whether perceived abortion pain was related to the subjectively evaluated ability to stay at home during medical abortion. The size of the study group was 29 women. We also studied how well these women remembered the intensity and unpleasantness of the abortion pain in a control visit performed 3–6 weeks after abortion.
Results
Especially, the unpleasantness associated with the pain during abortion was an important predictor when women evaluated their ability to stay at home during medical abortion. In those women who might have been able to stay at home in their own view, midwives looking after these women at the outpatient clinic estimated the pain intensity and unpleasantness also about 50% lower than in those who were not able to stay home in their own view. There were no significant differences in intensity, unpleasantness in hindsight of menstruation pain, or the area of this pain in the pain drawings in those women who considered that they might have stayed at home during medical abortion when compared with those who did not. No difference was found in age, gestational age, magnitude of previous pregnancies, miscarriages, vaginal deliveries, induced abortions, Beck’s Depression Index (BDI), Beck’s Anxiety Index (BAI) or AUDIT scores between those who could have stayed at home or those who would not have been able to stay at home during abortion. Components of abortion pain decreased significantly during the second post-abortion day. The more deliveries the subject had experienced the less pain she had during abortion. Multiparous women reported less than a fourth of the pain magnitude of the nulliparous women during abortion. Parity explained both intensity and unpleasantness of abortion pain better than the expected ability to stay at home. The remembrance of the intensity or unpleasantness of abortion pain correlated with actual pain reported at the time of abortion. However, this remembrance did not correlate with the ability to stay at home during the medical abortion.
Conclusions
The unpleasantness of pain during and immediately after abortion was recalled, not as a measure of the pain itself, but as a deciding factor in their judgement of whether or not they would be able to undergo medical abortion at home. Abortion pain is an important factor in enhancing home-based management of medical abortions. Medical staff may be able to detect those women who do not cope at home during the process by observing the intensity of pain. Therefore, proper treatment of pain might reduce the need for hospital-based medical abortions.
Implications
These patients need better care and guidelines for the care of women undergoing medical abortions should include clear recommendations for analgesic treatments, at the least adequate doses of nonopioid analgesics such as paracetamol in combination with NSAIDs like ibuprofen or diclofenac.
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Dubar G, Benhamou D. Anesthesiologists’ practices for late termination of pregnancy: a French national survey. Int J Obstet Anesth 2010; 19:395-400. [DOI: 10.1016/j.ijoa.2010.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2009] [Revised: 03/06/2010] [Accepted: 05/26/2010] [Indexed: 11/27/2022]
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Shokry M, Shahin AY, Fathalla MM, Shaaban OM. Oral misoprostol reduces vaginal bleeding following surgical evacuation for first trimester spontaneous abortion. Int J Gynaecol Obstet 2009; 107:117-20. [PMID: 19616778 DOI: 10.1016/j.ijgo.2009.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 05/18/2009] [Accepted: 06/11/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the effectiveness and tolerability of misoprostol to reduce the amount and duration of vaginal bleeding following surgical evacuation for first trimester spontaneous abortion. METHODS A total of 160 patients who underwent surgical evacuation for first trimester spontaneous abortion between 8 and 12 weeks of pregnancy were randomized into 2 groups to receive either 200 microg of oral misoprostol immediately after evacuation followed every 6 hours for 48 hours or no misoprostol. Pain scores, duration and amount of bleeding, and endometrial thickness were assessed over 10 days. RESULTS Women who received misoprostol had significantly fewer bleeding days after evacuation (4.11+/-2.69 vs 5.89+/-3.06; P<0.001), fewer patients reported vaginal bleeding lasting 10 days or more (3.8% vs 15.0%; P=0.014), and endometrial thickness 10 days after evacuation was less (6.25+/-2.38 vs 7.23+/-1.94; P=0.05). Pain scores were comparable in both groups (1.54+/-0.65 vs 1.63+/-0.83; P=0.40) after 10 days. CONCLUSION Oral misoprostol is effective in reducing the prevalence and amount of vaginal bleeding after surgical evacuation for first trimester spontaneous abortion.
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Affiliation(s)
- Mahmoud Shokry
- Department of Obstetrics and Gynecology, Women's Health Centre, Assiut University, Assiut, Egypt
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38
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Livshits A, Machtinger R, David LB, Spira M, Moshe-Zahav A, Seidman DS. Ibuprofen and paracetamol for pain relief during medical abortion: a double-blind randomized controlled study. Fertil Steril 2009; 91:1877-80. [DOI: 10.1016/j.fertnstert.2008.01.084] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Revised: 01/22/2008] [Accepted: 01/22/2008] [Indexed: 11/29/2022]
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Gemzell-Danielsson K, Lalitkumar S. Second trimester medical abortion with mifepristone-misoprostol and misoprostol alone: a review of methods and management. REPRODUCTIVE HEALTH MATTERS 2009; 16:162-72. [PMID: 18772097 DOI: 10.1016/s0968-8080(08)31371-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Second trimester abortions constitute 10-15% of all induced abortions worldwide but are responsible for two-thirds of major abortion-related complications. During the last decade, medical methods for second trimester induced abortion have been considerably improved and become safe and more accessible. Today, in most cases, safe and efficient medical abortion services can be offered or improved by minor changes in existing health care facilities. Second trimester medical abortion can be provided by a nurse-midwife with the back-up of a gynaecologist. Because of the potential for heavy vaginal bleeding and serious complications, it is advisable that second trimester terminations take place in a health care facility where blood transfusion and emergency surgery (including laparotomy) are available. This article provides basic information on regimens recommended for second trimester medical abortion. The combination of mifepristone and misoprostol is now an established and highly effective method for second trimester abortion. Where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective, although a higher total dose is needed and efficacy is lower than for the combined regimen. Therefore, whenever possible, the combined regimen should be used. Efforts should be made to reduce unnecessary surgical evacuation of the uterus after expulsion of the fetus. Future studies should focus on improving pain management, the treatment of women with failed medical abortion after 24 hours, and the safety of medical abortion regimens in women with a previous caesarean section or uterine scar.
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Affiliation(s)
- Kristina Gemzell-Danielsson
- Department of Woman and Child Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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40
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Ho P, Blumenthal P, Gemzell-Danielsson K, Gómez Ponce de León R, Mittal S, Tang O. Misoprostol for the termination of pregnancy with a live fetus at 13 to 26 weeks. Int J Gynaecol Obstet 2007; 99 Suppl 2:S178-81. [DOI: 10.1016/j.ijgo.2007.09.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mazouni C, Guidicelli B, Gamerre M, Voiret C, Pellegrin V. Influence of epidural analgesia on labor in mid and late termination of pregnancy: an observational study. Int J Obstet Anesth 2007; 16:383-4. [PMID: 17275280 DOI: 10.1016/j.ijoa.2006.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
MESH Headings
- Abortifacient Agents, Nonsteroidal/administration & dosage
- Abortifacient Agents, Steroidal/administration & dosage
- Abortion, Induced/statistics & numerical data
- Adult
- Age Factors
- Amides/administration & dosage
- Amides/adverse effects
- Analgesia, Epidural/adverse effects
- Analgesia, Obstetrical/adverse effects
- Anesthetics, Intravenous/administration & dosage
- Anesthetics, Intravenous/adverse effects
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Female
- Humans
- Labor, Induced
- Mifepristone/administration & dosage
- Misoprostol/administration & dosage
- Pain/prevention & control
- Pregnancy
- Pregnancy Trimester, Second
- Pregnancy Trimester, Third
- Retrospective Studies
- Ropivacaine
- Sufentanil/administration & dosage
- Sufentanil/adverse effects
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Benhamou D. Pain, epidural analgesia and late termination of pregnancy: a new challenge for obstetric anaesthesiologists. Int J Obstet Anesth 2007; 16:307-9. [PMID: 17869998 DOI: 10.1016/j.ijoa.2007.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Indexed: 11/21/2022]
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Bracken H, Ngoc NTN, Schaff E, Coyaji K, Ambardekar S, Westheimer E, Winikoff B. Mifepristone Followed in 24 Hours to 48 Hours by Misoprostol for Late First-Trimester Abortion. Obstet Gynecol 2007; 109:895-901. [PMID: 17400851 DOI: 10.1097/01.aog.0000259319.18958.76] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the efficacy of mifepristone and misoprostol for the termination of pregnancies in the late first trimester. METHODS This was a prospective study of 321 women seeking termination of pregnancy with gestations from 64 days to 84 days (+/-3 days) by vaginal ultrasonography. Women were enrolled at three sites: University of Rochester Reproductive Health Program in Rochester, New York; Hung Vuong Hospital in Ho Chi Minh City, Vietnam; and K.E.M. Hospital in Pune, India. Eligible women received 800 mcg of misoprostol vaginally between 24 hours and 48 hours after administration of 200 mg mifepristone. Two additional doses of 400 mcg of misoprostol were administered either orally or vaginally as needed every 3 hours for a maximum of two additional doses (total 1,600 mcg). The primary study outcome measure was complete abortion without surgical intervention. RESULTS Eighty-nine percent of women who completed the study successfully terminated their pregnancies. Most women were either satisfied (64.8%) or very satisfied (28.6%) with their experience. Ninety-four percent of women reported that they would recommend the procedure to a friend. Most women (90.4%) also agreed they would request a medical abortion if they required another abortion at this gestational age. CONCLUSION Medical abortion is acceptable and effective in the late first trimester and offers women an acceptable alternative to surgical abortion. LEVEL OF EVIDENCE II.
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Lalitkumar S, Bygdeman M, Gemzell-Danielsson K. Mid-trimester induced abortion: a review. Hum Reprod Update 2006; 13:37-52. [PMID: 17050523 DOI: 10.1093/humupd/dml049] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Mid-trimester abortion constitutes 10-15% of all induced abortion. The aim of this article is to provide a review of the current literature of mid-trimester methods of abortion with respect to efficacy, side effects and acceptability. There have been continuing efforts to improve the abortion technology in terms of effectiveness, technical ease of performance, acceptability and reduction of side effects and complications. During the last decade, medical methods for mid-trimester induced abortion have shown a considerable development and have become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of pregnancy (TOP). Advantages and disadvantages of medical versus surgical methods are discussed. Randomized studies are lacking, and more studies on pain treatment and the safety of any method used in patients with a previous uterine scar are debated, and data are scarce. Pain management in abortion requires special attention. This review highlights the need for randomized studies to set guidelines for mid-trimester abortion methods in terms of safety and acceptability as well as for better analgesic regimens.
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Affiliation(s)
- S Lalitkumar
- Department of Woman and Child Health, Division for Obstetrics and Gynaecology, Karolinska University Hospital/Karolinska Institute, Stockholm, Sweden
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45
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Abstract
Although more than one method of abortion has been available for many years, in most countries the provider chooses the method and may be skilled in one method only. This paper discusses choice and acceptability of medical abortion from the perspective of both women and abortion providers and argues that choice of method is important for both. Safety, efficacy, number of visits, how the method works, how long it takes for the abortion to be complete and cost all affect acceptability. Medical abortion is considered more natural because it happens in women's own bodies and can take place at home before nine weeks of pregnancy; surgical abortion with vacuum aspiration is simple and over quickly. Unless the costs of both methods are similar, however, women and providers will tend towards whichever is the cheaper option, limiting choice. Medical abortion is effective from when a woman misses her period through 24 weeks of pregnancy, and more women and providers need to be made aware of this. In legally restricted situations, complications tend to be less serious and easier to treat with early medical abortion than after unsafe invasive methods. Ideally, both medical and surgical methods should be available, but each can be provided without the other.
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Affiliation(s)
- Marge Berer
- International Consortium for Medical Abortion, London, UK.
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Lafaurie MM, Grossman D, Troncoso E, Billings DL, Chávez S. Women's Perspectives on Medical Abortion in Mexico, Colombia, Ecuador and Peru: A Qualitative Study. REPRODUCTIVE HEALTH MATTERS 2005; 13:75-83. [PMID: 16291488 DOI: 10.1016/s0968-8080(05)26199-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
In Latin America, where abortion is almost universally legally restricted, medical abortion, especially with misoprostol alone, is increasingly being used, often with the tablets obtained from a pharmacy. We carried out in-depth interviews with 49 women who had had a medical abortion under clinical supervision in rural and urban settings in Mexico, Colombia, Ecuador and Peru, who were recruited through clinicians providing abortions. The women often chose medical abortion to avoid a surgical abortion; they thought medical abortion was less painful, easier or simpler, safer or less risky. They commonly described it as a natural process of regulating their period. The fact that it was less expensive also influenced their decision. Some, who experienced a lot of pain, heavy bleeding or a failed procedure requiring surgical back-up, tended to be more negative about it. Regardless of legal restrictions, medical abortion was being provided safely in these settings and women found the method acceptable. Where feasible, it should be made available but cost should not have to be women's primary reason for choosing it. Psychosocial support during abortion is critical, especially for those who are more vulnerable because they see abortion as a sin, who are young or poor, who have limited knowledge about their bodies, whose partners are not supportive or who became pregnant through sexual violence.
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Hamoda H, Ashok PW, Flett GMM, Templeton A. Home self-administration of misoprostol for medical abortion up to 56 days' gestation. ACTA ACUST UNITED AC 2005; 31:189-92. [PMID: 16105279 DOI: 10.1783/1471189054483915] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Studies from the USA have suggested the feasibility and acceptability of home medical abortion, however the issue has not been addressed in the UK. This study aimed to assess the feasibility, efficacy and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. METHODS Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 600 microg and advised to take them sublingually 36-48 hours later. The main outcome measures were (1) feasibility, assessed through successful completion of abortion at home without the need for hospital admission, (2) efficacy, assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure as assessed by questionnaire. RESULTS A total of 49 women participated in this study. Of these, 48 women aborted at home while one opted to be admitted to hospital after receiving misoprostol at home. One woman underwent surgical evacuation 5 weeks following abortion for excessive bleeding and retained products of conception. A total of 43/44 (98%) women were satisfied with having the abortion at home. Side effects experienced by women included nausea [32/40 (80%], vomiting [17/41 (42%)], diarrhoea [17/41 (42%)], shivering [26/40 (65%)], tiredness [32/40 (80%)], headache [12/39 (31%)], hot flushes [14/40 (35%)], dizziness [24/39 (62%)] and unpleasant mouth taste [19/38 (50%)]. CONCLUSIONS This study suggests the feasibility and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. These findings need to be assessed in the context of a randomised trial.
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Affiliation(s)
- Haitham Hamoda
- Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen, UK.
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48
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Fiala C, Swahn ML, Stephansson O, Gemzell-Danielsson K. The effect of non-steroidal anti-inflammatory drugs on medical abortion with mifepristone and misoprostol at 13–22 weeks gestation. Hum Reprod 2005; 20:3072-7. [PMID: 16055455 DOI: 10.1093/humrep/dei216] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit the biosynthesis of prostaglandins and concerns have been expressed that they might attenuate the effects of exogenous prostaglandins. This randomized study was conducted to evaluate whether NSAID given during medical abortion with mifepristone/misoprostol in the second trimester has a negative effect on the efficacy of the abortifacient by prolonging the induction-to-abortion interval. METHODS Seventy-four women were treated with the anti-progesterone mifepristone, followed by repeated doses of misoprostol 36-48 h later. They were randomized to receive a prophylactic pain treatment of either paracetamol and codeine or diclofenac with the first dose of misoprostol. RESULTS Co-treatment of NSAID with misoprostol did not attenuate the efficacy of mifepristone and misoprostol. There was no significant difference between the NSAID and the non-NSAID group in the induction-to-abortion interval (5.4 versus 6.5 h) or the total doses of misoprostol needed (2 versus 3). The frequency of surgical intervention was similar (55.6 versus 52.6%). Women in the group treated with NSAID required significantly less opiates (P = 0.042). CONCLUSION Co-treatment with NSAID and misoprostol does not interfere with the action of mifepristone and/or misoprostol to induce uterine contractions and pregnancy expulsion in medical abortion. Prophylactic NSAID administration reduces the need for opiate injections.
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Affiliation(s)
- C Fiala
- Department of Woman and Child Health, Division for Obstetrics and Gynaecology, Clinical Epidemiology Unit, Karolinska Institute, 171 76 Stockholm, Sweden.
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49
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Rodger F. Yen and Jaffe's Reproductive Endocrinology: Physiology, Pathophysiology, and Clinical Management. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2005. [DOI: 10.1783/1471189054483843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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50
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Hamoda H, Flett GMM. Medical termination of pregnancy in the early first trimester. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2005; 31:10-4. [PMID: 15720840 DOI: 10.1783/0000000052972906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.
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Affiliation(s)
- Haitham Hamoda
- Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen Maternity Hospital, Foresterhill, UK.
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