Pain control in first-trimester surgical abortion: a systematic review of randomized controlled trials

ED50 of remimazolam combined with different doses butorphanol for first trimester artificial abortion

Introduction

Remimazolam (RMZ) is a novel intravenous sedative drug of ultra-short benzodiazepine. The optimal dose of RMZ plus butorphanol for sedation during first trimester artificial abortion is unknown. Therefore, the present study aimed to evaluate the median effective dose (ED50) of RMZ combined with different doses of butorphanol on the sedative effect for first-trimester artificial abortion.

Methods

Sixty-one female patients were randomly assigned to Group B10 (31 patients) and Group B15 (30 patients). RMZ was administered 5 min after IV butorphanol at doses of 10 μg/kg (Group B10) and 15 μg/kg (Group B15). Cervical dilatation at the time of using a cervical dilating rod, if the patient has body movement and affects the gynecologist's operation, we define it as "Ineffective." Therefore, the dose of RMZ was increased in the next patient. Otherwise, it was defined as "Effective," and the dose of RMZ was reduced in the next patient. According to the pre-experiment, the first dose of RMZ in the first patient was 0.35 mg/kg, and the adjacent geometric dose ratio was 0.9. The centered isotonic regression was performed to determine the ED50 of RMZ. The total RMZ dose administered, recovery time, and anesthesia-related adverse events were all recorded.

Results

The ED50 (90% CI) of RMZ was 0.263 (0.215-0.310) mg/kg in Group B10, and 0.224 (0.191-0.261) mg/kg in Group B15, respectively. The recovery time in Group B10 was significantly shorter than in Group B15 (9.8 ± 2.3 vs. 12.5 ± 3.6 min, p ≤ 0.001). There was no significant difference in the incidence rate of all anesthesia-related adverse events between the two groups (p > 0.05).

Conclusion

The ED50 of RMZ combined with a 10 μg/kg or 15 μg/kg dose of butorphanol was 0.263 and 0.224 mg/kg during painless first trimester artificial abortion. However, RMZ combined with a 10 μg/kg dose of butorphanol seems to have a shorter recovery time.

Clinical trial registration

https://www.chictr.org.cn/bin/project/edit?pid=166623.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Remimazolam versus propofol in combination with esketamine for surgical abortion: A double-blind randomized controlled trial

Remimazolam is a new benzodiazepine with a short half-life, good efficacy, and safety profiles in general anesthesia. Combining esketamine with propofol (P + E) could reduce propofol consumption and injection pain. It is, however, unclear if a low dose of remimazolam co-administrated with esketamine (R + E) is comparable to the increasingly used P + E for surgical abortion with general anesthetic. We conducted a double-blind randomized controlled trial to compare the efficacy and safety of R + E and P + E. Two hundred patients scheduled for a surgical abortion were randomized to receive remimazolam 0.3 mg/kg plus esketamine 0.3 mg/kg (R + E), and propofol 2 mg/kg plus esketamine 0.3 mg/kg (P + E). Sedative effectiveness was evaluated by measuring the time to lose consciousness (LOC), recovery time, and successful sedation rate. Safety was assessed by hemodynamics and adverse events during and postoperation. The time to LOC and recovery time in R + E was 5 s shorter and 1 min longer than that in P + E, respectively (both p < 0.001). Success sedation rate did not differ between groups (p = 0.73). Bradycardia incidence and injection site pain were less frequent in the R + E group than that in the P + E group. More rash was observed in the R + E group compared with the P + E group (32% vs. 5%, p < 0.001), but all were mild (only chest rash) and resolved subsequently. Low dose of remimazolam when combined with esketamine has favorable profiles with rapid onset and recovery, but mild hemodynamic side effects and adverse events. It can be used as an alternative for surgical abortion with general anesthetic.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Vomiting and risk of endotracheal intubation related to preoperative doxycycline use for dilation and evacuation

OBJECTIVE

To describe the rate of vomiting from oral doxycycline 200 mg given the night before second trimester dilation and evacuation (D&E), proportion of anesthesia modalities, and anesthetic complications.

STUDY DESIGN

We conducted a single-institution retrospective cohort study of patients presenting for second trimester D&E (14-0/7 to 23-6/7 weeks gestation) July 1, 2019-June30, 2020 following their scheduled preoperative visit as identified by billing codes. We recorded vomiting within 30 minutes of ingestion, anesthetic modality, and anesthetic complications. We tested for associations using chi-square or Fisher's exact test for categorical variables and Wilcoxon-rank sum for non-normal numeric variables.

RESULTS

We reviewed 702 charts, of which 461 (66%) met inclusion criteria and 420 (60%) took doxycycline as prescribed. Of those who took doxycycline as prescribed, 30 (7.14%) reported vomiting within 30 minutes of ingestion. Nulliparity, primigravida and age less than 30 were significantly associated with vomiting (p = 0.005, p < 0.001 and p = 0.03, respectively), but gestational age (p = 0.53), BMI (p = 0.93), and gastrointestinal conditions (p > 0.99) were not. Only gravidity (p < 0.001) and parity (p = 0.01) remained significant in each of their respective multivariate models. None of the 10 patients who received general endotracheal tube anesthesia (2.4%) had vomited from doxycycline preoperatively. We observed 5 (1.2%) anesthetic complications (postoperative nausea or vomiting, anaphylaxis, and aspiration) that occurred only in those without vomiting.

CONCLUSIONS

Vomiting rates following doxycycline were lower than those previously published. We found no significant association between doxycycline-associated vomiting and increased need for general endotracheal tube anesthesia or anesthetic complications; however, our study is underpowered to draw further conclusions.

IMPLICATIONS

The findings of this study are consistent with guidelines indicating deep sedation as an effective anesthetic modality with low complication rates. Nulliparous patients may benefit from administration of an antiemetic prior to doxycycline prophylaxis, but routine antiemetic use may not be necessary.

Ketamine Compared With Fentanyl for Surgical Abortion: A Randomized Controlled Trial

OBJECTIVE

To compare patient satisfaction with anesthesia after first-trimester surgical abortion among patients receiving intravenous (IV) ketamine compared with IV fentanyl for procedural sedation.

METHODS

This was a randomized noninferiority trial comparing IV ketamine to IV fentanyl for first-trimester surgical abortion up to 13 6/7 weeks of gestation. Patients were randomized to receive either ketamine 200-500 micrograms/kg IV over 2 minutes, repeated every 5 minutes until appropriate analgesia was achieved, or fentanyl 0.5-1 micrograms/kg IV over 2 minutes, repeated every 5 minutes until appropriate analgesia was achieved. All patients received midazolam 2 mg IV. The primary outcome, patient satisfaction, was measured using the Iowa Satisfaction with Anesthesia Scale immediately postprocedure. Secondary outcomes included postoperative pain, additional pain medication necessary during the procedure and on discharge, physician satisfaction, and time to discharge. We calculated a sample size of 84 with a noninferiority margin of 0.6 on the Iowa Satisfaction with Anesthesia Scale with 80% power, one-sided type 1 error of 0.025, and further increased this number to 110 to account for potential dropout.

RESULTS

From April to October 2021, 184 patients were screened and 110 were randomized (57 to ketamine and 53 to fentanyl). Demographics were similar between groups. The primary outcome, patient satisfaction with anesthesia, was noninferior in the ketamine group (mean score 2.4, SD 0.8) as compared with the fentanyl group (mean score 2.2, SD 0.9) with a risk difference of 0.20 (95% CI 0.11-0.52). More hallucinations were reported in the ketamine group. Otherwise, secondary outcomes were similar between the groups.

CONCLUSION

Compared with IV fentanyl, IV ketamine is noninferior for patient satisfaction with anesthesia when used for procedural sedation for first-trimester outpatient surgical abortion.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04871425.

Analgesic efficacy and safety of paracervical block versus conscious sedation in the surgical evacuation of the uterus following first-trimester incomplete miscarriages: A randomised controlled trial

Objective:

To compare the analgesic efficacy and safety of paracervical block and conscious sedation in the surgical evacuation of the uterus following a first-trimester miscarriage.

Methods:

This is an open-label, randomised control trial comparing pain relief by paracervical block versus conscious sedation during manual vacuum aspiration of first-trimester incomplete miscarriages. One-hundred and sixty-two women were equally randomised into two groups. Group A (paracervical group) received a paracervical block of 4 ml of lidocaine each at the 4 and 8 o’clock positions. Group B (conscious sedation group) received intravenous 30 mg pentazocine and 10 mg diazepam. Data obtained were presented using a frequency table, student t-test, chi-square and Mann–Whitney test and bar chart. A P-value of ⩽0.05 was taken to be statistically significant.

Results:

The mean pain score was lower in the paracervical block group compared to the conscious sedation group (P < 0.05); however, there was no significant difference in women’s satisfaction between the groups (P ⩾ 0.05). Conscious sedation had more negative side effects compared to paracervical block which was significant (P < 0.05).

Conclusion:

Paracervical block has better pain control compared with conscious sedation and has a good side effect profile.

Trial registration:

Pan African Clinical Trial Registry (registered trial no. PACTR202108841661192).

Synopsis

Paracervical block for manual vacuum aspiration (MVA) during first-trimester miscarriage is associated with less pain among women compared with conscious sedation.

A randomized controlled study of acupuncture for pain relief during first trimester surgical termination of pregnancy performed under local analgesia

BACKGROUND

Acupuncture reduces pain levels in many painful conditions. This study compared pain levels during surgical termination of first trimester pregnancy by suction evacuation (SE) under local analgesia with and without the use of acupuncture.

METHODS

In all, 60 nulliparous women undergoing SE before 10 weeks of gestation were randomly assigned into one of the following three groups in a 1:1:1 ratio according to a computer-generated randomization list. In the control group, women received oral diazepam 5 mg and intramuscular (i.m.) injection of pethidine 30 and 15 min, respectively, prior to SE. In the acupuncture group, women received acupuncture 10 min before SE until the end of SE while oral diazepam 5 mg and i.m. injection of normal saline were given. In the combined group, women received acupuncture in addition to the drugs in the control group. Data from 52 participants were analysed. Pain scores during and after SE, post-operative side-effects and satisfaction levels were compared.

RESULTS

The three groups had similar baseline characteristics. The median pain levels during SE differed significantly between the control, acupuncture, and combined groups (80, 50 and 66 mm, respectively, p = 0.03). Pain levels during SE in the acupuncture and combined groups were significantly lower than that of the control group. However, the anxiety scores did not differ between the three groups after SE (p = 0.86).

CONCLUSION

Acupuncture can provide additional benefit in terms of pain relief in women undergoing first trimester termination of pregnancy by SE under local analgesia.

Comparison of Analgesic Effects between Nalbuphine and Sufentanil in First-Trimester Surgical Abortion: A Randomized, Double-Blind, Controlled Trial

Introduction

Surgical abortion is one of the commonly conducted procedures worldwide. Nevertheless, pregnant women still complain of procedural and postoperative pain despite the use of advanced anesthesia. It is vital to women’s reproductive healthcare to improve postsurgical pain management to achieve the lowest level of pain.

Methods

This randomized, double-blind, parallel-controlled clinical trial compared the analgesic effects between nalbuphine and sufentanil in patients who underwent first-trimester surgical abortion. In total, 224 patients were allocated randomly into (a) the sufentanil group that received sufentanil (0.1 ug/kg) combined propofol, and (b) the nalbuphine group that received nalbuphine (0.1 mg/kg) combined propofol. Postoperative pain scores, propofol injection pain, intraoperative analgesic effect, adverse events, and degree of satisfaction were recorded as outcome measures.

Results

The pain scores in the nalbuphine group were lower than those in the sufentanil group at 15 min, 30 min, 1 h, and 6 h after surgical abortion. In addition, the incidence and intensity of propofol injection pain were lower in the nalbuphine group. The degree of satisfaction of the patients in the nalbuphine group was higher than that in the sufentanil group. The intraoperative analgesic effect, hemodynamic fluctuation, and adverse events were comparable between the two groups.

Conclusions

Nalbuphine combined with propofol is superior to sufentanil combined with propofol for first-trimester abortion surgeries.

Clinical Trial Registration

The trial was registered at www.chictr.org.cn, identifier ChiCTR2000040243.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-021-00334-0.

Transcutaneous Electrical Nerve Stimulation for Pain Management of Aspiration Abortion up to 83 Days of Gestation: A Randomized Controlled Trial

OBJECTIVE

To evaluate high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) as an inexpensive, noninvasive pain management approach for first-trimester aspiration abortion.

METHODS

We conducted a noninferiority, single-blind, randomized controlled trial of patients seeking aspiration abortion at up to 83 days of gestation. Participants received TENS (placed posteriorly, T10-L1 and S2-S4) or intravenous (IV) sedation (fentanyl, midazolam). The primary outcome was pain with aspiration, as self-reported by visual analog scale (VAS, 100 mm). To detect at least a 15 mm mean difference on the 100 mm VAS with 90% power and a significance level of .05, a total of 90 participants were required.

RESULTS

Between January 2018 and October 2019, we enrolled 109 participants (55 TENS, 54 IV). Participant median gestation was 53 days (range 36-82) in the TENS group and 58 days (range 35-82) in the IV group (P=.65). Group demographics and clinical histories were similar. Intention-to-treat analysis (n=109) yielded noninferior results for the primary outcome (mean difference 4.8 mm, 95% CI -5.9 to 13.5 mm). In the per-protocol analysis, 9 (16%) in the TENS group were excluded after receiving IV sedation; 100 participants were included (46 TENS, 54 IV). Median (range) reported VAS for aspiration was 73 mm (13-97) and 66 mm (0-99) in the TENS and IV groups, respectively (P=.40). With a mean difference of 4.4 mm (95% CI -5.6 to 14.5 mm), we found TENS to be noninferior to IV. Physicians underestimated participant pain, perceiving pain to be 34 mm (6-91) in the TENS group and 25 mm (0-83) in the IV group (P=.003).

CONCLUSION

We found TENS to be a noninferior alternative to IV sedation for aspiration pain during first-trimester abortion. Expanding pain management options can improve quality of and access to abortion. Transcutaneous electrical nerve stimulation could be a standalone or adjunct approach for abortion pain management for those without access to or are ineligible to receive IV sedation due to the lack of sedation practitioner, designated driver, or local restrictions.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03187002.

A Comparison of Paracervical Block Volumes Before Osmotic Dilator Placement: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether a 12-mL paracervical block is noninferior to a 20-mL block in reducing pain with osmotic dilator insertion.

METHODS

In this single-blinded noninferiority trial, we randomized individuals undergoing insertion of osmotic dilators before second-trimester abortion to receive either a 12-mL or 20-mL 1% lidocaine paracervical block. The primary outcome was pain immediately after insertion of osmotic dilators. Prespecified secondary outcomes included pain with paracervical block administration, overall pain, and side effects, with 88 participants being required for a noninferiority margin of 15 mm on a 100-mm visual analog scale assuming an SD of 28. We analyzed data using Wilcoxon rank sum, χ2, and t tests and performed analysis of variance to account for repeated measures. Secondary analysis included multivariable regression to explore potential confounders.

RESULTS

From January 2018 to October 2020, of 232 eligible individuals, 174 were approached and 96 randomized (48 participants to each group); 91 were available for analysis (45: 12 mL, 46: 20 mL). Group demographics were similar, with a mean gestation of 21 weeks and four osmotic dilators placed. The 12-mL paracervical block was noninferior to the 20-mL paracervical block for pain with osmotic dilator insertion with a difference in means of -1.36 (95% CI -12.56 to 9.85) favoring 12 mL. Median pain scores after dilator placement were 47 mm (interquartile range 22-68) and 50 mm (interquartile range 27-67) in 12-mL compared with 20-mL paracervical block, respectively (P=.81). No difference was seen in median pain at baseline, with paracervical block administration, postprocedure or with overall pain or experience. At least one lidocaine-related side effect occurred in 4% of participants in the 12-mL group compared with 13% for those receiving 20 mL (P=.15), with metallic taste, ringing in ears, and lightheadedness being most common.

CONCLUSION

A 12-mL paracervical block is noninferior to a 20-mL block for pain reduction with osmotic dilator insertion.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03356145.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Participation of the opioid receptor - nitric oxide - cGMP - K+ channel pathway in the peripheral antinociceptive effect of nalbuphine and buprenorphine in rats

The aim of this study was to examine if the peripheral antinociceptive effects of the opioid agonist/antagonist nalbuphine and buprenorphine involve the sequential participation of nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) synthesis followed by K⁺ channel opening in the formalin test. Wistar rats (180-220 g) were injected in the dorsal surface of the right hind paw with formalin (1%). Rats received a subcutaneous (s.c.) injection into the dorsal surface of the paw of vehicles or increasing doses of nalbuphine (50-200 μg/paw) or buprenorphine (1-5 μg/paw) 20 min before formalin injection into the paw. Nalbuphine antinociception was reversed by the s.c. injection into the paw of the inhibitor of NO synthesis (N^G-nitro-l-arginine methyl ester (L-NAME)), by the inhibitor of guanylyl cyclase (1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ)), by the K_ir6.1-2, ATP-sensitive K⁺ channel inhibitors (glibenclamide and glipizide), by the K_Ca2.1-3, small conductance Ca²⁺-activated K⁺ channel blocker (apamin), by the K_Ca1.1, large conductance Ca²⁺-activated K⁺ channel blocker (charybdotoxin), and by the K_V, voltage-dependent K⁺ channel inhibitors (4-aminopyridine (4-AP) and tetraethylammonium chloride (TEA)). The antinociceptive effect produced by buprenorphine was blocked by the s.c. injection of 4-AP and TEA but not by L-NAME, ODQ, glibenclamide, glipizide, apamin, or charybdotoxin. The present results provide evidence for differences in peripheral mechanisms of action between these opioid drugs.

Buffered lidocaine for paracervical blocks in first-trimester abortions: a randomized controlled trial

Objective

The objective was to evaluate if buffered lidocaine decreases injection pain as compared to plain lidocaine for paracervical blocks during first-trimester outpatient surgical abortions.

Study design

We conducted a randomized, double-blind, placebo-controlled trial among women undergoing outpatient uterine aspiration of a first-trimester pregnancy or an early pregnancy loss. Subjects received a paracervical block with either lidocaine 1% 20 mL or lidocaine 1% 18 mL plus sodium bicarbonate 8.4% 2 mL. The primary outcome was pain from injection of the paracervical block measured on a 100-mm visual analog scale (VAS). Secondary outcomes included pain after cervical dilation, uterine aspiration and overall satisfaction with pain control. Scores were compared using the Mann–Whitney U test. We aimed to detect a 15-mm difference in pain from injection of the paracervical block.

Results

From May 2017 to October 2018, 48 women received plain lidocaine and 50 women received buffered lidocaine. Groups were similar in demographics. We found no clinically or statistically meaningful difference in pain when evaluating median VAS scores for paracervical block injection between the buffered and plain lidocaine [30.0 (interquartile range (IQR) 15.3–64.5); 44.5 (IQR 18.3–65), respectively, p = .32]. We found no difference in secondary outcomes between buffered and plain lidocaine.

Conclusion

Buffered lidocaine for paracervical blocks in first-trimester outpatient surgical abortions does not decrease injection pain as compared to plain lidocaine.

Implications statement

Buffering the paracervical block in first-trimester outpatient surgical abortions does not decrease injection pain as compared to plain lidocaine, nor does it increase patient satisfaction. Eliminating sodium bicarbonate allows for a more cost-effective and readily available solution for paracervical blocks.

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

Background

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

Objective

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

Search strategy

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

Selection criteria

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

Data collection and analysis

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

Main results

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

Conclusion

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

Tweetable abstract

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

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

Impact of music therapy before first-trimester instrumental termination of pregnancy: a randomised controlled trial

OBJECTIVES

To evaluate the impact of preoperative Music Therapy (MT) on pain in first-trimester termination of pregnancy (TOP) under local anaesthesia.

DESIGN

Randomised controlled trial comparing women undergoing a first-trimester TOP under local anaesthesia with or without a preoperative MT session.

SETTING

University Hospital of Angers from November 2016 to August 2017.

POPULATION

Women who underwent first-trimester TOP under local anaesthesia.

METHODS

Women allocated to the MT group underwent a preoperative 20-minute session of MT.

MAIN OUTCOME MEASURES

Pain was assessed using a visual analogue scale (VAS) just before the procedure, during the procedure, at the end of the procedure and upon returning to the ward.

RESULTS

A total of 159 women were randomised (80 in the MT group, and 79 in the control group). Two women were excluded from the control group and six from the MT group. Therefore, 77 women were analysed in the control group and 74 in the MT group. The intensity of pain was similar in the two groups just before the procedure (VAS 4.0 ± 2.9 versus 3.6 ± 2.5; P = 0.78), during the procedure (VAS 5.3 ± 2.5 versus 4.9 ± 2.9; P = 0.78), at the end of the procedure (VAS 2.7 ± 2.4 versus 2.6 ± 2.4; P = 0.43) and upon returning to the ward (VAS 1.8 ± 2.0 versus 1.5 ± 2.0; P = 0.84). The difference in pain between entering the department and returning to the room after the procedure was similar between the MT and control groups (difference in VAS 0.3 ± 2.5 versus 0.3 ± 2.4; P = 0.92).

CONCLUSION

An MT session before a TOP under local anaesthesia procedure resulted in no improvement in patient perception of pain during a first-trimester TOP.

TWEETABLE ABSTRACT

Music therapy before first-trimester termination of pregnancy under local anaesthesia did not improve the perception of pain.

Providing Abortion Services in the Primary Care Setting

Patients commonly present with unintended pregnancy in the primary care setting, and 1 in 4 women has an abortion in her lifetime. Early abortion services can be safely provided in the primary care setting. Abortion options provided in primary care settings include both medication abortion and early uterine aspiration abortion. Medication abortion, provided up to 10 weeks' gestational age, includes mifepristone (a progestin antagonist) and misoprostol (a prostaglandin). Uterine aspiration can be provided via manual or electronic vacuum in the first trimester.

Diffusional interaction behavior of NSAIDs in lipid bilayer membrane using molecular dynamics (MD) simulation: Aspirin and Ibuprofen

In this research, for the first time, molecular dynamics (MD) method was used to simulate aspirin and ibuprofen at various concentrations and in neutral and charged states. Effects of the concentration (dosage), charge state, and existence of an integral protein in the membrane on the diffusion rate of drug molecules into lipid bilayer membrane were investigated on 11 systems, for which the parameters indicating diffusion rate and those affecting the rate were evaluated. Considering the diffusion rate, a suitable score was assigned to each system, based on which, analysis of variance (ANOVA) was performed. By calculating the effect size of the indicative parameters and total scores, an optimum system with the highest diffusion rate was determined. Consequently, diffusion rate controlling parameters were obtained: the drug-water hydrogen bond in protein-free systems and protein-drug hydrogen bond in the systems containing protein.

A prospective study of the frequency of severe pain and predictive factors in women undergoing first-trimester surgical abortion under local anaesthesia

OBJECTIVE

To determine the frequency of severe pain among women and to identify the associated predictive factors during first-trimester surgical abortion under local anaesthesia (LA).

STUDY DESIGN

A prospective cohort study from November 2013 to January 2014 at the Department of Gynecology and Obstetrics, Rennes, France. The study population was composed of one hundred and ninety-four patients who underwent an elective first-trimester surgical abortion under LA. In an anonymized questionnaire, the participants were asked to self-record their perceived pain level 30 min after the completion of the procedure using a 10 cm visual analogue scale (VAS). The main outcome measure was the frequency of severe pain among women, defined as VAS ≥ 7. Secondary outcome measure was the risk factor(s) for severe pain.

RESULTS

Severe pain (i.e. VAS ≥ 7) was experienced by 46% (95% CI: 39%-53%) of the population. Multivariate analysis confirmed that >10 weeks of gestation (OR: 2.530 [95% CI: 1.1-5.81], p = .0287) and having 0 or 1 child (OR: 5.206 [95% CI: 1.87-14.49], p = .0016) were significant independent factors of severe pain.

CONCLUSION

Nearly half of the women experienced severe pain. More than 10 weeks of gestation and parity were predictive factors of severe pain. These findings should be useful in counselling women undergoing surgical abortion under LA.

Relationship between UGT1A9 gene polymorphisms, efficacy, and safety of propofol in induced abortions amongst Chinese population: a population-based study

The present study aimed to investigate the influence of UGT1A9 gene polymorphisms on the efficacy of propofol in patients undergoing the painless induced abortion method. A total of 156 women seeking voluntary pregnancy termination procedures were selected for the study, and subsequently underwent painless induced abortions, following anesthesia by means of propofol administration. PCR-restriction fragment length polymorphism (PCR-RFLP) was performed to detect the polymorphisms of UGT1A9 gene at -440C/T, -1818C/T, and -1887T/G loci. The time, effect-site concentration, and bispectral index (BIS) for the Observer's Assessment of Alertness/Sedation (OAA/S) (up to 4 points) were observed and recorded in patients following discontinuation of propofol. The time and effect-site concentration for BIS reaching 80 in patients following the discontinuation of propofol were observed and recorded. Postoperative observations of adverse reactions, such as nausea, vomiting, and respiratory depression were all made record of. In comparison with patients with UGT1A9 -440C/T CT and TT, those with UGT1A9 -440C/T CC displayed shorter durations of OAA/S by up to 4 points, shorter BIS times reaching 80, as well as higher corresponding effect-site concentrations. No significant differences were detected in the patients with -440C/T, -1818T/C, and -1887T/G in incidence of nausea, vomiting, and respiratory depression. The findings of the study highlighted correlation between UGT1A9 -440C/T gene polymorphisms and positive propofol efficacy in patients undergoing painless induced pregnancy termination procedures.

Retrospective Evaluation of the Procedural Sedation Practices of Expert Nurses During Abortion Care

OBJECTIVE

To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation.

DESIGN

Retrospective chart review.

METHODS

Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge.

SETTING

A single clinical site that employs seven expert nurses.

PARTICIPANTS

A total of 194 medical records were available for this analysis.

RESULTS

All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 μg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038).

CONCLUSION

Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure.

Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework

OBJECTIVES

To develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events.

STUDY DESIGN

As part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework.

RESULTS

The final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions. It further classifies incidents by diagnosis (confirmatory data, etiology, risk factors), management (treatment type and location), timing (immediate or delayed), seriousness (minor or major) and outcome. Empirical validation of the framework using data from 19,673 women receiving aspiration abortions revealed almost an equal proportion of total adverse events (n=205, 1.04%) and total abortion- or pregnancy-related morbidity (n=194, 0.99%). The majority of adverse events were due to retained products of conception (0.37%), failed attempted abortion (0.15%) and postabortion infection (0.17%). Serious or major adverse events were rare (n=11, 0.06%).

CONCLUSIONS

Distinguishing morbidity diagnoses from adverse events using a standardized, empirically tested framework confirms the very low frequency of serious adverse events related to clinic-based abortion care.

IMPLICATIONS

The PAIRS Framework provides a useful set of tools to systematically classify and monitor abortion-related incidents for first-trimester aspiration abortion procedures. Standardization will assist healthcare providers, researchers and policymakers to anticipate morbidity and prevent abortion adverse events, improve care metrics and enhance abortion quality.

Doulas for surgical management of miscarriage and abortion: a randomized controlled trial

BACKGROUND

Women undergoing office-based surgical management of a failed or undesired pregnancy often report fear of pain and anxiety pertaining to the procedure. Doulas are trained to specifically address women's physical and emotional needs in obstetric care, and recently have extended their practice to support women through all pregnancy outcomes.

OBJECTIVE

We sought to evaluate the impact of doulas on patients' physical and emotional responses to surgical management of a first-trimester failed or undesired pregnancy under local anesthesia.

STUDY DESIGN

In this nonblinded, randomized trial, women received doula support or routine care during office uterine aspiration for failed or unwanted pregnancies in the first trimester. The primary outcome was pain measured on a 100-mm visual analog scale. Secondary outcomes included satisfaction, emotional state, sense of personal empowerment, and ability to cope immediately and 1 month after the procedure, as well as medical assistants' assessment of the doula's utility. A sample size of 35 per group (N = 70) was planned to detect a 20% difference in pain score.

RESULTS

From April 2014 through January 2015, 129 women were screened and 70 were randomized. The 2 study groups were similar on all baseline characteristics. The primary outcome was not different between the doula and control groups (pain score 70.7 ± 24.5 mm vs 59.7 ± 32.5 mm, P = .11, respectively), even after controlling for procedure indication (P = .20). While 97% of women who received doula support reported this helped with their experience, there was no statistically significant difference in satisfaction, emotional response, sense of empowerment, or perceived ability to cope between the 2 groups of women immediately following or 1 month after the procedure. Of all study participants, 72% reported that it was important to have someone with them during the procedure, but that the support person did not have to be a doula.

CONCLUSION

Doula support during office uterine aspiration for failed or undesired pregnancies is well received and desired by women undergoing this procedure despite no significant effect on physical comfort or emotional responses related to the procedure. This may suggest an unmet psychosocial need for procedure-related support among such women.

Abortion training in Canadian obstetrics and gynecology residency programs

OBJECTIVE

To evaluate the current state of abortion training in Canadian Obstetrics and Gynecology residency programs.

STUDY DESIGN

Surveys were distributed to all Canadian Obstetrics and Gynecology residents and program directors. Data were collected on inclusion of abortion training in the curriculum, structure of the training and expected competency of residents in various abortion procedures.

RESULTS

We distributed and collected surveys between November 2014 and May 2015. In total, 301 residents and 15 program directors responded, giving response rates of 55% and 94%, respectively. Based on responses by program directors, half of the programs had "opt-in" abortion training, and half of the programs had "opt-out" abortion training. Upon completion of residency, 66% of residents expected to be competent in providing first-trimester surgical abortion in an ambulatory setting, and 35% expected to be competent in second-trimester surgical abortion. Overall, 15% of residents reported that they were not aware of or did not have access to abortion training within their program, and 69% desired more abortion training during residency.

CONCLUSION

Abortion training in Canadian Obstetrics and Gynecology residency programs is inconsistent, and residents desire more training in abortion. This suggests an ongoing unmet need for training in this area. Policies mandating standardized abortion training in obstetrics and gynecology residency programs are necessary to improve delivery of family planning services to Canadian women.

IMPLICATIONS

Abortion training in Canadian Obstetrics and Gynecology residency programs is inconsistent, does not meet resident demand and is unlikely to fulfill the Royal College of Physicians and Surgeons of Canada objectives of training in the specialty.

Postabortion Care: 20 Years of Strong Evidence on Emergency Treatment, Family Planning, and Other Programming Components

Worldwide 75 million women need postabortion care (PAC) services each year following safe or unsafe induced abortions and miscarriages. We reviewed more than 550 studies on PAC published between 1994 and 2013 in the peer-reviewed and gray literature, covering emergency treatment, postabortion family planning, organization of services, and related topics that impact practices and health outcomes, particularly in the Global South. In this article, we present findings from studies with strong evidence that have major implications for programs and practice. For example, vacuum aspiration reduced morbidity, costs, and time in comparison to sharp curettage. Misoprostol 400 mcg sublingually or 600 mcg orally achieved 89% to 99% complete evacuation rates within 2 weeks in multiple studies and was comparable in effectiveness, safety, and acceptability to manual vacuum aspiration. Misoprostol was safely introduced in several PAC programs through mid-level providers, extending services to secondary hospitals and primary health centers. In multiple studies, postabortion family planning uptake before discharge increased by 30-70 percentage points within 1-3 years of strengthening postabortion family planning services; in some cases, increases up to 60 percentage points in 4 months were achieved. Immediate postabortion contraceptive acceptance increased on average from 32% before the interventions to 69% post-intervention. Several studies found that women receiving immediate postabortion intrauterine devices and implants had fewer unintended pregnancies and repeat abortions than those who were offered delayed insertions. Postabortion family planning is endorsed by the professional organizations of obstetricians/gynecologists, midwives, and nurses as a standard of practice; major donors agree, and governments should be encouraged to provide universal access to postabortion family planning. Important program recommendations include offering all postabortion women family planning counseling and services before leaving the facility, especially because fertility returns rapidly (within 2 to 3 weeks); postabortion family planning services can be quickly replicated to multiple sites with high acceptance rates. Voluntary family planning uptake by method should always be monitored to document program and provider performance. In addition, vacuum aspiration and misoprostol should replace sharp curettage to treat incomplete abortion for women who meet eligibility criteria.

Effectiveness of Intrauterine Lignocaine in Addition to Paracervical Block for Pain Relief during Dilatation and Curettage, and Fractional Curettage

PURPOSE OF STUDY

Dilatation and curettage (D&C) and fractional curettage (F/C) are commonly performed gynecological procedures. Randomized controlled trials have concluded that topical anesthesia effectively reduces pain in endometrial sampling and hysteroscopy. Our study was aimed at investigating this modality of pain relief in setting of a developing country where, due to lack of resources, successful completion of these procedures in an outpatient setting is a necessity.

METHODS

This study was a prospective, randomized, placebo-controlled, double-blind study conducted in 84 patients. All patients received either intrauterine 2 % lignocaine or normal saline along with oral NSAID and paracervical block prior to the procedure. The pain was analyzed at three steps: at the time of curette, immediately post-procedure, and 30 min later using 10-cm visual analog score.

RESULTS

The patients in the experimental and control groups were well matched for age, parity, body mass index, menopausal status, and the indications for intervention. At all the three stages, pain perceived in the lignocaine group was significantly less as compared to that in placebo group. As compared to lignocaine group (55 %), significantly higher number of women in placebo group (88 %) perceived severe pain during endometrial curettage (p = 0.001).

CONCLUSIONS

The present study indicates that two percent intrauterine lignocaine significantly decreases the pain perception during intrauterine gynecological procedures such as D&C and F/C. This is a simple, effective, inexpensive, and low-risk intervention which can potentially increase the patient acceptability and compliance with such procedures.

Nonpharmaceutical Pain Control Adjuncts During First-Trimester Aspiration Abortion: A Review

INTRODUCTION

First-trimester aspiration abortion is associated with moderate to severe pain. The effectiveness of adjunctive therapies for pain control is not well understood. This critical review summarizes the existing literature regarding nonpharmacologic interventions to reduce pain during first-trimester office-based abortion.

METHODS

PubMed and Google Scholar were searched using the following search terms in various combinations: "abortion," "pain," "nonpharmaceutical," "nonpharmacologic," "anxiety," "fear," "pain management," "pain reduction," "anxiety reduction," "complementary and alternative medicine," and "integrative medicine." Seven articles meeting inclusion criteria were entered into a matrix for comparison. Findings from each study are summarized describing design, results, and themes. These results are summarized to provide evidence-based clinical guidelines and identify areas for further research.

RESULTS

None of the nonpharmacologic interventions studied were significantly associated with a reduction in pain or anxiety scores. However, women in many studies strongly endorsed future use of these techniques.

DISCUSSION

The data included in this critical review did not demonstrate a relationship between the nonpharmacologic interventions and pain or anxiety scores, yet participants endorsed these as positive and helpful. Women found value in these supportive interventions, and ongoing investigation into these techniques is warranted.

Nalbuphine could decrease the rewarding effect induced by tramadol in mice while enhancing its antinociceptive activity

Nalbuphine, a kappa-opioid agonist and mu-opioid partial agonist, has been used as an analgesic or an adjuvant with morphine to attenuate the development of morphine dependence and rewarding effect. In this study, we investigated the effect of nalbuphine on tramadol rewarding effect and antinociception. Using the conditioned place preference (CPP) paradigm in mice, we demonstrated that co-administration of nalbuphine (7mg/kg, s.c.) with tramadol (70mg/kg, s.c.) during conditioning completely blocked the CPP induced by tramadol. Co-administration of nalbuphine blocked the increase in dopamine level in the nucleus accumbens induced by tramadol. These actions were accompanied by an increase rather than attenuation of the antinociceptive effect of tramadol. These results suggest that nalbuphine could have a great potential as a pharmacotherapy for tramadol abuse.

Doula support during first-trimester surgical abortion: a randomized controlled trial

OBJECTIVE

The objective of the study was to evaluate the impact of doula support on first-trimester abortion care.

STUDY DESIGN

Women were randomized to receive doula support or routine care during first-trimester surgical abortion. We examined the effect of doula support on pain during abortion using a 100 mm visual analog scale. The study had the statistical power to detect a 20% difference in mean pain scores. Secondary measures included satisfaction, procedure duration, and patient recommendations regarding doula support.

RESULTS

Two hundred fourteen women completed the study: 106 received doula support, and 108 received routine care. The groups did not differ regarding demographics, gestational age, or medical history. Pain scores in the doula and control groups did not differ at speculum insertion (38.6 [±26.3 mm] vs 43.6 mm [±25.9 mm], P = .18) or procedure completion (68.2 [±28.0 mm] vs 70.6 mm [±23.5 mm], P = .52). Procedure duration (3.39 [±2.83 min] vs 3.18 min [±2.36 min], P = .55) and patient satisfaction (75.2 [±28.6 mm] vs 74.6 mm [±27.4 mm], P = .89) did not differ between the doula and control groups. Among women who received doula support, 96.2% recommended routine doula support for abortion and 60.4% indicated interest in training as doulas. Among women who did not receive doula support, 71.6% of women would have wanted it. Additional clinical staff was needed to provide support for 2.9% of women in the doula group and 14.7% of controls (P < .01).

CONCLUSION

Although doula support did not have a measurable effect on pain or satisfaction, women overwhelmingly recommended it for routine care. Women receiving doula support were less likely to require additional clinic support resources. Doula support therefore may address patient psychosocial needs.

Intrauterine lidocaine for pain control during laminaria insertion: a randomized controlled trial

OBJECTIVE

To determine if intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block reduces pain during laminaria insertion, when compared with paracervical block and saline placebo.

STUDY DESIGN

This was a randomized, double blind placebo-controlled trial. Women presenting for abortion by dilation and evacuation (D&E) at 14-24 weeks gestational age were randomized to receive an intrauterine instillation of either 5 mL of 2% lidocaine or 5 mL of normal saline, in addition to standard paracervical block with 20 cc of 0.25% bupivacaine. Our primary outcome was self-reported pain scores on a 100mm Visual Analogue Scale (VAS) immediately following laminaria insertion. Secondary outcome was self-reported VAS pain score indicating the maximum level of pain experienced during the 24-48-h interval between laminaria insertion and D&E procedure.

RESULTS

Seventy-two women were enrolled, and data for 67 women were analyzed, only two of whom were more than 21 weeks on gestation. The range of pain scores at both time points was large (1-90 mm at laminaria insertion; 0-100mm in laminaria-D&E interval). Mean pain scores were not different between treatment groups at laminaria insertion, (33 vs. 32, p=.8) or in the laminaria - D&E interval (43 vs. 44, p=.9).

CONCLUSION

Intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block did not reduce pain with laminaria insertion when compared to paracervical block with saline placebo.

IMPLICATIONS

Intrauterine lidocaine combined with paracervical block does not improve pain control at laminaria insertion when compared with paracervical block and saline placebo. Wide variation in pain scores and persistent pain after laminaria insertion suggests patient would benefit from more effective methods of pain control at laminaria insertion and during the post-laminaria interval.

Intrauterine anesthesia for gynecologic procedures: a systematic review

OBJECTIVE

To assess the effectiveness of intrauterine local anesthesia in reducing pain associated with outpatient gynecologic procedures.

DATA SOURCES

We searched online databases PubMed or MEDLINE, Embase, Google Scholar, and Clinicaltrials.gov and hand-searched reference lists from reviews evaluating pain-control methods for gynecologic office procedures. We identified randomized controlled trials using intrauterine local anesthetic in gynecologic procedures.

METHODS

Titles and abstracts were screened for 1,236 articles. We identified 45 potential articles for inclusion. We excluded 22 of these studies because: 1) they were not randomized controlled trials; 2) they did not describe a quantifiable dose of medication used in the study; 3) they did not investigate an intrauterine anesthetic; 4) they did not study a potentially awake, outpatient procedure; and 5) they did not clearly report results or represented duplicate publication. Twenty-three articles were ultimately included for review.

TABULATION, INTEGRATION, AND RESULTS

Two authors independently reviewed full search results and assessed eligibility for inclusion and independently abstracted data from all articles that met criteria for inclusion. Disagreements regarding eligibility or abstraction data were adjudicated by a third independent person. Our primary end point was the reported effect of intrauterine local anesthesia on patient-reported pain scores. As a result of heterogeneity in study methods, outcome measures, and reporting of outcomes, results could not be combined in a meta-analysis. Good evidence supports use of intrauterine anesthesia in endometrial biopsy and curettage, because five good-quality studies reported reduced pain scores, whereas only one good-quality study reported negative results. We found moderate evidence to support intrauterine anesthesia in hysteroscopy, because one good-quality study and two fair or poor quality studies reported reduced pain scores, whereas two good-quality studies had negative results. Good evidence suggests that intrauterine anesthesia is not effective in hysterosalpingography; three good-quality studies reported that pain scores were not reduced, and no good quality studies showed a beneficial effect in that procedure. Evidence was insufficient concerning first-trimester abortion, saline-infusion ultrasonogram, tubal sterilization, and intrauterine device insertion.

CONCLUSION

Intrauterine local anesthesia can reduce pain in several gynecologic procedures including endometrial biopsy, curettage, and hysteroscopy and may be effective in other procedures as well.