Comparative risk of death from induced abortion at less than or equal to 12 weeks' gestation performed with local versus general anesthesia

[Complications of termination of pregnancy]

The legalization of abortion in France allowed to disappear almost maternal deaths caused by induced abortions. Nevertheless, the practice of abortion in a medical framework is encumbered with a number of immediate complications. Similarly, the late consequences of the practice of surgical abortion have generated an abundant literature, which it is important to analyse, both to meet the legitimate concerns of patients as to prevent any spread of false ideas under the influence of movements opposed to abortion.

Comparison of lidocaine spray and paracervical block application for pain relief during first-trimester surgical abortion: A randomised, double-blind, placebo-controlled trial

Surgical abortion is one of the most frequently performed gynaecological procedures and its associated pain has always been a problem in gynaecology. Here we studied the analgesic efficacy of lidocaine spray and paracervical block (PCB) in patients undergoing first-trimester surgical abortion. A randomised double-blind placebo-controlled study was conducted on 108 women requesting pregnancy termination. The subjects were randomly assigned into four groups: Group 1 (PCB plus lidocaine spray) (n=27), Group 2 (PCB) (n=27), Group 3 (lidocaine spray) (n=27) and Group 4 (placebo) (n=27). Intra-procedural and post-procedural pain scores were measured with a standard visual analogue scale (VAS). The median VAS scores during procedure in placebo, lidocaine spray, PCB plus lidocaine spray and PCB groups were 8 (7-9), 5 (4-8), 4 (3-4) and 5 (3-5), respectively. The most effective method of pain relief during first-trimester abortion can be achieved through a combined use of PCB plus lidocaine spray. Therefore, lidocaine spray is a non-invasive complementary anaesthetic method versus traditional PCB for first-trimester surgical abortion.

Safety of induced abortions at less than 12 weeks of pregnancy in Japan

OBJECTIVE

To assess the safety of various methods of induced abortion when used before 12 weeks of pregnancy in Japan.

METHODS

A retrospective study was undertaken of induced abortions conducted between January 1 and December 31, 2012. Questionnaires were sent to 4154 institutions that employed doctors who were licensed to conduct induced abortions. Information was obtained about the numbers of induced abortions performed before 12 weeks, methods, complications, and routine management.

RESULTS

Completed questionnaires from 2434 institutions showed that 100 851 induced abortions had been performed. Vacuum aspiration (VA) was used in 20 458 (20.3%) abortions, VA with sharp curettage in 47 148 (46.8%), dilatation and curettage (D&C) in 32 958 (32.7%), and medical abortion in 287 (0.3%). Overall, 358 complications were reported (355.0 per 100000 procedures). The rate of complications was significantly higher after D&C than after VA and after VA with sharp curettage (P<0.001 for both). However, incomplete abortion requiring repeat procedures was the only complication that was significantly associated with D&C (P<0.001).

CONCLUSION

D&C can be safely used for induced abortion before 12 weeks of pregnancy, but changing from D&C to VA could reduce incomplete abortions and improve the safety of induced abortions before 12 weeks of pregnancy in Japan.

Anaesthesia for evacuation of incomplete miscarriage

BACKGROUND

An incomplete miscarriage occurs when all the products of conception are not expelled through the cervix. Curettage or vacuum aspiration have been used to remove retained tissues. The anaesthetic techniques used to facilitate this procedure have not been systematically evaluated in order to determine which provide better outcomes to the patients.

OBJECTIVES

To assess the effects of general anaesthesia, sedation or analgesia, regional or paracervical block anaesthetic techniques, or differing regimens of these, for surgical evacuation of incomplete miscarriage.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 January 2012), CENTRAL (The Cochrane Library 2012, Issue 1), PubMed (1966 to 23 January 2012), EMBASE (1974 to 23 January 2012), CINAHL (1982 to 23 January 2012), LILACS (1982 to 23 January 2012) and reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished randomised controlled trials (RCTs) or cluster-RCTs comparing the use of any anaesthetic technique (defined by authors as general anaesthesia, sedation/analgesia, regional or paracervical local block (PCB) procedures) to perform surgical evacuation of an incomplete miscarriage. We excluded quasi-randomised trials and studies that were only available as abstracts.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and assessed risk of bias. Data were independently extracted and checked for accuracy.

MAIN RESULTS

We included seven trials involving 800 women. The comparisons revealed a very high clinical heterogeneity. As a result of the heterogeneity in the randomisation unit, we did not combine trials but reported the individual trial results in the 'Data and analysis' section and in the text. Half of trials have unclear or high risk of bias in several domains.We did not find any trial reporting data about maternal mortality. In terms of postoperative pain, PCB does not improve the control of postoperative pain when it is compared against sedation/analgesia or versus no anaesthesia/no analgesia. In the comparison of PCB with lidocaine versus PCB with saline solution, significant differences favouring the group with lidocaine were found in one trial (moderate or severe postoperative pain) (risk ratio (RR) 0.32; 95% confidence interval (CI) 0.18 to 0.59).When opioids were used, postoperative nausea and vomiting was more frequent in two trials comparing those versus PCB. In terms of requirement of blood transfusion, two trials showed conflicting results.

AUTHORS' CONCLUSIONS

Particular considerations that influence the choice of anaesthesia for this procedure such as availability, effectiveness, safety, side effects, practitioner's choice, costs and woman's preferences of each technique should continue to be used until more evidence supporting the use of one technique or another.

Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care

Early pregnancy failure and induced abortion are often managed differently, even though safe uterine evacuation is the goal in both. Early pregnancy failure is commonly treated by curettage in operating room settings in anesthetized patients. Induced abortion is most commonly managed by office vacuum aspiration in awake or sedated patients. Medical evidence does not support routine operating room management of early pregnancy failure. This commentary reviews historical origins of these different care standards, explores political factors responsible for their perpetuation, and uses experience at University of Michigan to dramatize the ways in which history, politics, and biomedicine intersect to produce patient care. The University of Michigan initiated office uterine evacuations for early pregnancy failure treatment. Patients previously went to the operating room. These changes required faculty, staff, and resident education. Our efforts blurred the lines between spontaneous and induced abortion management, improved patient care and better utilized hospital resources.

Pain management of first-trimester surgical abortion: effects of selection of local anesthesia with and without lorazepam or intravenous sedation

OBJECTIVE

This prospective observational study compared the effectiveness and acceptability of three commonly used regimens to reduce pain during first-trimester surgical abortion with local anesthesia.

METHOD

Women undergoing suction curettage at less than 14 weeks gestation received preoperative ibuprofen and an intraoperative paracervical block. Participants then selected (1) no additional medication (local arm), (2) sublingual lorazepam (0.5 to 1 mg, approximately 20 min preoperatively) or (3) intravenous sedation with fentanyl and midazolam (doses from 50 to 125 microg of fentanyl and 1-2 mg of midazolam). Our primary outcome was intraoperative pain as measured on an 11-point verbal rating scale (0=no pain and 10=worst pain ever).

RESULTS

Three-hundred thirty women were enrolled, 105 chose local, 106 opt for lorazepam and 119 picked intravenous sedation. Mean pain scores were 6.2 for local, 6.8 for lorazepam and 5.7 for intravenous sedation. Increased preoperative anxiety, depression and expected pain and a lower volume of local anesthesia used (10 mL vs. 20 mL) were positive predictors of intraoperative pain. Using multivariable analyses to control for these confounders, plus gestational age, alcohol use and body mass index, intravenous sedation was associated with a 0.86 point lower pain score (p<.005), and the local and lorazepam groups were not significantly different. Compared with the referent group (local), participants who received lorazepam were significantly less satisfied with pain control (23.8% vs. 6% unsatisfied; OR=1.93, 95% CI=1.13 to 3.26).

CONCLUSION

In women who self-selected their type of anesthesia, intravenous sedation using fentanyl and midazolam decreased pain with suction curettage under local anesthesia. Sublingual lorazepam as studied did not decrease pain compared with local anesthesia alone and was associated with more dissatisfaction with pain control.

Complications immédiates de l’IVG chirurgicale

While medical abortion is now available in non hospital facilities, abortions by vacuum aspiration remain illegal in non hospital settings. It is therefore important to assess through the literature the real risks associated with this method. All the most recent and large-scale studies showed that legal abortion by vacuum aspiration is an extremely safe procedure. It is less risky than other medical or surgical procedures performed outside the hospital. According to the studies, the death rate varies from 0 to 0.7 per 100,000 abortions, and is smaller when the procedure is done under local anesthesia than general anesthesia. The overall early complication rate (hemorrhage, uterine perforation, cervical injury) is between 0.01 and 1.16%. Complications are not more frequent than with medical abortions. In view of these low complication rates, surgical abortion by vacuum aspiration could be performed outside the hospital setting in France, as it is the case in many other countries.

Paracervical block in incomplete abortion using manual vacuum aspiration: randomized clinical trial

OBJECTIVE

To estimate the effectiveness of paracervical block in controlling pain among women treated with manual vacuum aspiration for an incomplete abortion

METHODS

A randomized clinical trial was conducted at Nuestra Señora de Altagracia, a maternal and perinatal referral hospital in the Dominican Republic. The sample size was based on a clinical difference of 1.5 points in the level of pain measured with the visual analog scale using 90% power and a sampling error of 0.04. Women who were at 12 weeks of gestation or less with an incomplete abortion were eligible to participate. They were randomly assigned to receive either the standard treatment of care (manual vacuum aspiration for uterine evacuation with psychological support but no paracervical block) or manual vacuum aspiration treatment with psychological support and paracervical block using 1.0% lidocaine. Patients with active infections, severe illnesses, psychiatric disorders, or allergies to lidocaine were excluded. Intraoperative pain as reported by the women and as documented by an external observer was measured.

RESULTS

Although the paracervical block technique used showed a slight reduction in severe pain, there were no clinically or statistically significant differences in intraoperative pain between the 2 groups (relative risk 0.73; 95% confidence interval 0.43, 1.23) with 50% of all patients registering 7 or higher score on a visual analog pain scale of 0-10. However, statistically significant differences were found in each group when comparing the level of preoperative and intraoperative pain described by the patient (P <.001). The manual vacuum aspiration technique and the paracervical block were not accompanied by complications.

CONCLUSION

The paracervical block technique used in this study along with psychological support was comparable with pain control using psychological support alone; neither pain management regimen provided sufficient pain control. It is recommended that randomized comparative studies be designed to determine the effectiveness of other paracervical block techniques and the efficacy of the use of analgesics in patients suffering from incomplete abortion treated with manual vacuum aspiration.

Best practices in surgical abortion

Surgical abortion in the first trimester comprises the majority of voluntary pregnancy interruptions performed in the United States. The majority of these procedures are done in outpatient settings with the patient under local anesthesia. Appropriate volume of and deep injection of local anesthetic can reduce pain associated with the procedure. Waiting between administration of the paracervical block and initiating the procedure does not affect pain. Intravenous administration of sedation and analgesia improves patient satisfaction but does not significantly affect pain ratings. Antibiotic prophylaxis is warranted. Vasopressin is useful for prevention of hematometra and hemorrhage. Less evidence supports the routine use of ergots. Preoperative cervical priming reduces the risk of cervical injury and uterine perforation. Attention to operative technique can reduce the risk of incomplete abortion. Routine postoperative care at 2 or 3 weeks is timed to identify complications and to reinforce pregnancy and sexually transmitted disease prevention.

Buying safety: the economics of reproductive risk and abortion in Egypt

This article examines the economics of abortion safety in Egypt. Under Egyptian law induced abortion is restricted to cases in which two physicians certify that the pregnancy presents a danger to the health or life of the mother. Despite this legal restriction, the available data indicate that abortion is quite widely practiced. Multifaceted strands of legal, religious, economic, and health care policy influence both discourse about and access to abortion in Egypt. Interviews with 18 Egyptian women who sought to terminate their pregnancies revealed a wide range of abortion methods that varied in both safety and cost. Three levels of safety were identified: (1) indigenous (wasfa baladi) methods were potentially the least safe; (2) biomedical abortions at clandestine clinics appeared safer than indigenous methods, but were not without risk: and (3) biomedical abortions administered by private gynecologists, were the most safe. Safety is expensive. Wealthy women can literally buy safety, while poor women's lack of financial resources put their lives at great risk.

Effect of deep injections of local anesthetics and basal dilatation of cervix in management of pain during legal abortions. A randomized, controlled study

The present study was designed to investigate whether deep injections of local anesthetics provide better pain control than regular injections of local anesthetics, and to evaluate the influence of basal cervical dilatation and dilatation increase obtained on the painfulness of abortion procedure during legal abortions. A total of 66 women undergoing legal abortion were randomly allocated to treatment with deep injection (n = 31) or regular injection (n = 35) group. Subjects in the deep injection group had paracervical block involving four injections approximately 3 cm deep. Subjects assigned to the regular injection group had paracervical block involving four injections approximately 1.5 cm deep. A pain scale was administered at the end of the dilatation and end of curettage. Both groups were found to be similar with respect to age, parity, previous legal abortion, gestational age, anxiety score, procedure time, basal cervical dilatation, and dilatation increase obtained. The mean pain score during cervical dilatation was less for the deep injection versus the regular injection group (3.3 +/- 1.5 versus 4.0 +/- 1.6, p < 0.05). The mean pain score during curettage was significantly less for the deep injection versus the regular injection group (3.0 +/- 1.2 versus 3.9 +/- 1.4, p < 0.05). In conclusion, deep injection of local anesthetics is a safe adjunct in the management of legal abortion. Irrespective of injection technique, dilatation pain is correlated negatively with basal cervical dilatation and correlated positively with dilatation increase obtained.

Reducing pain of first trimester abortion under local anaesthesia

The study aimed to estimate the pain related to first trimester abortion under local and general anaesthesia. One hundred and eighty-one women undergoing abortion of first trimester under local anaesthesia and 198 under general anaesthesia were interviewed 1 h after the end of the procedure. About 50% of all women described their experience as less painful than expected. Over 50% of the women described the pain during the procedure as mild or moderate according to the verbal rating scale. The step-up logistic regression analyses identified four important variables: time interval less than 2 min from local anaesthesia injection to the beginning of the procedure (RR = 3), lack of choice between local and general anaesthesia (RR = 1.9), history of frequent use of analgesics (RR = 1.9) and nulliparity (RR = 1.7). These data indicate that skillfully performed abortion with local anaesthesia is a procedure tolerated by most women. Moreover, because it carries lower risk of complications and costs less, its use should be encouraged.

Pain control in abortion

OBJECTIVE

To reduce the pain experienced during abortion.

METHODS

A four-phase study was conducted at a free-standing abortion clinic. Phase 1: a double-blind, randomized, placebo-controlled trial of 600 mg ibuprofen given preoperatively was carried out in 193 women. Pain during the procedure and 30 min postoperatively was compared. Phase 2: a double-blind, randomized trial compared 1% lidocaine, buffered 1% lidocaine and 0.25% bupivacaine in terms of the pain of the injection and the pain of the procedure in 200 women. Phase 3: waiting times of 0, 3 and 10-20 min between the end of the injection and the beginning of the procedure were compared in terms of pain during the procedure in 139 women. Phase 4: local anesthetic was injected into one side of the cervix slowly and one side quickly and the pain of the injections was compared in 87 women.

RESULTS

Phase 1: ibuprofen reduced pain scores more than placebo with the improvement being greatest for the postoperative period. Phase 2: buffered lidocaine was significantly less painful to inject than plain lidocaine or bupivacaine. Phase 3: waiting between the injection and the procedure did not improve pain control. Phase 4: slower injections were found to be less painful than fast injections.

CONCLUSIONS

Several methods were found to improve pain control during abortions.

Comparison of the efficacy of different local anesthetics and techniques of local anesthesia in therapeutic abortions

OBJECTIVES

The objectives of this study were to determine whether carbonated or plain lidocaine provides better pain control during abortions and to determine whether deep injections of lidocaine provide better pain control than regular injections of lidocaine.

STUDY DESIGN

Phase 1 was a prospective, randomized, double-blind trial comparing 10 cm3 of 2% carbonated lidocaine with plain lidocaine. In phase 2 the plain lidocaine group in phase 1 was compared prospectively with the next group of patients, in whom a new technique of deep injection was used. A pain scale was administered by the counselor after dilatation and at the end of the procedure.

RESULTS

The improvement in pain scores with carbonated lidocaine was 8%. The improvement with the deep injection technique was 25%.

CONCLUSION

The improvement in pain scores with deep injection was clinically significant and is recommended.

General anaesthesia, a risk factor for complication following induced abortion?

Of the 10,000 abortions performed at the Regional hospital at Modena in Italy between 1982 and 1986, 199 (2%) led to early complications. Investigation of the relationship between the risk of haemorrhage, injury, other complications and all complications and eight explanatory variables revealed that the adjusted odds ratio associated with the use of general anaesthetic compared with local anaesthetic was 4.6 (95% CI, 2.2-9.5) for haemorrhage, 1.3 (95% CI, 0.78-2.2) for injury, 1.6 (95% CI, 1.0-2.6) for other complications and 1.8 (95% CI, 1.4-2.5) for all complications. It is speculated that if the relationship between use of general anaesthetic and risk of complication is causal there could be about 40% fewer cases of complications and 75% fewer cases of haemorrhage following induced abortion if local anaesthesia were used rather than general anaesthesia.

Control of pain for women undergoing abortion

To reduce the anxiety and pain experienced by women undergoing abortion, pre-abortion psychological counseling should be given the first priority. Additional techniques for reducing pain are described, including the use of local anesthetic, sedatives, analgesics, and systemic anesthetic agents. Recommendations for practice include an improved technique for paracervical block, modified abortion technique to reduce painful stimulus, and safe use of low dose intravenous sedatives. General anesthesia should be avoided to improve abortion safety.

Legal abortion mortality and general anesthesia

Legal abortion-related mortality as reported to the Centers for Disease Control declined eightfold between 1972 and 1981. However, the causes of legal abortion mortality have changed over time. We reviewed all legal abortion-related deaths that occurred between 1972 and 1985 in the United States. We found that, although the absolute number of legal abortion-related deaths caused by general anesthesia complications did not increase, the proportion of such deaths increased significantly, from 7.7% between 1972 and 1975 to 29.4% between 1980 and 1985. Women who died of general anesthesia complications did not differ by age, presence of preexisting medical conditions, or type of facility from women who died of other causes. However, the proportion of deaths from general anesthesia complications was significantly higher among women of black and other races, women obtaining abortions during the first trimester, and women obtaining abortions in the Northeast. Our results indicate that at least 23 of the 27 deaths were due to hypoventilation and/or loss of airway resulting in hypoxia. Persons administering general anesthesia for abortion must be skilled in airway management as well as the provision of general anesthesia.

Deaths attributable to tubal sterilization in the United States, 1977 to 1981

In 1979, the Centers for Disease Control began surveillance of deaths attributable to tubal sterilization in order to determine why they occur and what may be done to prevent them. Since that time, 29 such deaths have been identified as occurring in the United States from 1977 through 1981. Of these 29 deaths, 11 followed complications of general anesthesia, seven were due to sepsis, four were due to hemorrhage, three were due to myocardial infarction, and four deaths were related to other causes. Some of these deaths might have been prevented by use of endotracheal intubation for general anesthesia, particularly for laparoscopic sterilization, safer use of unipolar coagulation or use of alternative techniques, careful insertion of the needle and trocar for laparoscopy, and discontinuation of oral contraceptives before sterilization. Further surveillance may help to make tubal sterilization even safer.