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Lambert SJ, Lunde B, Porsch L, Stoffels G, MacIsaac L, Dayananda I, Dragoman MV. Adjuvant misoprostol or mifepristone for cervical preparation with osmotic dilators before dilation and evacuation. Contraception 2024; 132:110364. [PMID: 38218312 DOI: 10.1016/j.contraception.2024.110364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVES This study aimed to compare effectiveness and safety of cervical preparation with osmotic dilators plus same-day misoprostol or overnight mifepristone prior to dilation and evacuation (D&E). STUDY DESIGN We conducted a retrospective cohort analysis of 664 patients initiating abortion between 18 and 22 weeks at an ambulatory health center. We abstracted medical record data from two consecutive 12-month periods in 2017 to 2019. All patients received overnight dilators plus: 600 mcg buccal misoprostol 90 minutes before D&E (period 1); 200 mg oral mifepristone at time of dilators (period 2). Our primary outcome was procedure time. We report frequency of patients experiencing any acute complication, defined as unplanned procedure (i.e., reaspiration, cervical laceration repair, uterine balloon tamponade) or hospital transfer and bleeding complications. RESULTS We observed higher mean procedure time in the mifepristone group (9.7 ± 5.3 minutes vs 7.9 ± 4.4, p = 0.004). After adjusting for race, ethnicity, insurance, body mass index, parity, prior cesarean, prior uterine surgery, gestational age, provider, trainee participation, and long-acting reversible contraception initiation, the difference remained statistically significant (relative change 1.09, 95% CI 1.01, 1.17) but failed to reach our threshold for clinical significance. The use of additional misoprostol was more common in the mifepristone group, but the use of an additional set of dilators was not different between groups. Acute complications occurred at a frequency of 4.1% in misoprostol group and 4.3% in mifepristone group (p = 0.90). CONCLUSIONS We found procedure time to be longer with adjunctive mifepristone compared to misoprostol; however, this difference is unlikely to be clinically meaningful. Furthermore, the frequency of acute complications was similar between groups. IMPLICATIONS Overnight mifepristone at the time of cervical dilator placement is a safe and effective alternative to adjuvant same-day misoprostol for cervical preparation prior to D&E and may offer benefits for clinic flow and patient experience.
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Affiliation(s)
- Stephanie J Lambert
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Britt Lunde
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lauren Porsch
- Planned Parenthood of Greater New York, New York, NY, USA
| | - Guillaume Stoffels
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura MacIsaac
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ila Dayananda
- Planned Parenthood of Greater New York, New York, NY, USA
| | - Monica V Dragoman
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Fraz F, Liu SM, Shaw KA. Cervical preparation for second-trimester procedural abortion. Curr Opin Obstet Gynecol 2023; 35:470-475. [PMID: 37678155 DOI: 10.1097/gco.0000000000000912] [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: 09/09/2023]
Abstract
PURPOSE OF REVIEW To review the evidence-informed options for cervical preparation prior to second-trimester dilation and evacuation (D&E). RECENT FINDINGS As abortion restrictions increase and the number of abortion clinics and providers decreases, pregnant people are facing more barriers to abortion access. Those in need are now often required to travel for second-trimester abortion care, only to be faced with additional restrictions, such as mandatory waiting periods. Cervical preparation is recommended prior to D&E and takes time for effect. Given the increasing time required to obtain an abortion, patients and providers may prefer same-day cervical preparation to decrease the total time required. Options for same-day cervical preparation include misoprostol alone with single or serial doses, and misoprostol combined with osmotic dilators or transcervical balloon (Foley catheter). Same-day preparation may require additional clinical space to accommodate people after initiation of cervical preparation to manage side-effects and timing of the abortion. Overnight options are also used and more frequently later in the second trimester. Overnight options include mifepristone, osmotic dilators, and transcervical balloon and are often combined with same-day misoprostol. Medication alone preparation is well tolerated and effective in the second trimester, with the addition of mechanical methods with advancing gestation. With many options and combinations being safe and effective, providers can be dynamic and alter approach with supply shortages, adjust to different clinical settings, consider patient medical and surgical factors, and accommodate provider and patient preferences. SUMMARY Multiple pharmacologic and mechanical options have been shown to be safe and effective for cervical preparation prior to D&E. Consideration for multiple factors should influence the method of cervical preparation and methods may vary by patient, provider and setting.
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Affiliation(s)
- Farsam Fraz
- Division of Gynecology and Gynecologic Specialities, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
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Dzuba IG, Chandrasekaran S, Fix L, Blanchard K, King E. Pain, Side Effects, and Abortion Experience Among People Seeking Abortion Care in the Second Trimester. WOMEN'S HEALTH REPORTS 2022; 3:533-542. [PMID: 35651992 PMCID: PMC9148646 DOI: 10.1089/whr.2021.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/04/2022]
Abstract
Background: There is limited documentation about pain and side effects associated with dilation and evacuation (D&E) abortion, yet, pain and side effects are important factors that can affect a client's abortion experience. In 2016, Hope Clinic for Women, an independent abortion clinic in Illinois, altered its cervical preparation protocols before D&E to reduce the total time of the abortion process and improve the client experience. This analysis addresses the gap in data on client experience of abortion in the later second trimester by evaluating pain, side effects, and acceptability by gestational age. Methods: Abortion clients obtaining services at the clinic between March 2017 and June 2018 were eligible to participate if they had viable singleton pregnancies of 16–23.6 weeks' gestation, spoke English, and were at least 18 years old. Eligible participants completed a two-part survey about their abortion experience. Results: We found that respondents seeking abortion care at later gestations in the second trimester were more likely to report pain during their abortions. We did not find any association between side effects and gestational age. Conclusion: Although most respondents were prepared for the pain they experienced, some reported experiencing more pain than they expected, and more effective pain relief was commonly reported as a way to improve the service. More research on patient experiences of later abortion is needed, particularly on experiences of pain and options for pain management.
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Affiliation(s)
| | | | - Laura Fix
- Ibis Reproductive Health, Cambridge, Massachusetts, USA
| | | | - Erin King
- Hope Clinic for Women, Granite City, Illinois, USA
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Uhm S, Mastey N, Baker CC, Chen MJ, Matulich MC, Hou MY, Melo J, Wilson SF, Creinin MD. Mifepristone prior to osmotic dilators for dilation and evacuation cervical preparation: A randomized, double-blind, placebo-controlled pilot study. Contraception 2021; 107:23-28. [PMID: 34464634 DOI: 10.1016/j.contraception.2021.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/20/2021] [Accepted: 08/20/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To evaluate mifepristone impact on osmotic dilator placement and procedural outcomes when given 18 to 24 hours before dilator placement for dilation and evacuation (D&E) at 18 weeks 0 days to 23 weeks 6 days gestation. STUDY DESIGN We performed a randomized, double-blind, placebo-controlled trial from April 2019 through February 2021, enrolling participants undergoing osmotic dilator (Dilapan) placement for a planned, next-day D&E. Participants took mifepristone 200 mg or placebo orally 18 to 24 hours before dilator placement. We used a gestational age-based protocol for minimum number of dilators. Our primary outcome was the proportion of participants for whom 2 or more additional dilators could be placed compared to the minimum gestational age-based standard. We secondarily evaluated cervical dilation after dilator removal in the operating room, subjective procedure ease, and complication rates (cervical laceration, uterine perforation, blood transfusion, infection, hospitalization, or extramural delivery). RESULTS Of the planned 66 participants, we enrolled 44 (stopped due to coronavirus disease 2019-related obstacles), and 41 (19 mifepristone; 22 placebo) completed the study. We placed 2 or more additional dilators compared to standard in 7 (36.8%) and 3 (13.6%) participants after mifepristone and placebo, respectively (p = 0.14). We measured greater median initial cervical dilation in the mifepristone (3.2 cm[2.6-3.6]) compared to placebo (2.6 cm[2.2-3.0]) group, p = 0.03. Surgeon's perception of procedure being "easy" (8/19[42.1] vs 9/22[40.9], respectively, p = 1.00) and complication rate (3/19[15.8%] vs 3/22[13.6], respectively, p = 1.00) did not differ. CONCLUSION Our underpowered study did not demonstrate a difference in cervical dilator placement, but mifepristone 18 to 24 hours prior to dilators increases cervical dilation without increasing complications. IMPLICATIONS Mifepristone 18 to 24 hours prior to cervical dilator placement may be a useful adjunct to cervical dilators based on increased cervical dilation at time of procedure; however, logistical barriers, such as an additional visit, may preclude routine adoption without definite clinical benefit.
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Affiliation(s)
- Suji Uhm
- Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine; Pittsburgh, PA, United States.
| | - Namrata Mastey
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Courtney C Baker
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Melissa C Matulich
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Melody Y Hou
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Juliana Melo
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | | | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
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Liu SM, Flink-Bochacki R. A single-blinded randomized controlled trial evaluating pain and opioid use after dilator placement for second-trimester abortion. Contraception 2021; 103:171-177. [PMID: 33285100 DOI: 10.1016/j.contraception.2020.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/19/2020] [Accepted: 11/25/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To compare pain levels and medication needs after placement of laminaria vs Dilapan-S, and after dilation and evacuation (D&E). STUDY DESIGN We conducted a single-blinded randomized control trial of patients undergoing D&E at 15 0/7 to 23 6/7 weeks gestation, randomizing to cervical preparation with laminaria or Dilapan-S. We compared pain levels and medication usage following dilator placement (5 minutes; 2, 4, and 8 hours; the following morning) and D&E (1, 4, 24, and 48 hours). Our primary outcome was median change from baseline pain, and secondary outcomes included maximum pain timing and overall narcotic use. We compared baseline characteristics, median pain increases and quantities of narcotics used. RESULTS We analyzed 67 participants with laminaria (n = 34) and Dilapan-S (n = 33). More Dilapan-S users had a prior vaginal delivery (n = 20, 60.6%) than laminaria users (n = 11, 32.4%), p = 0.02. Maximum median pain was not statistically different (Laminaria: +3.5 (interquartile range [IQR] +0.5, +6.5); Dilapan-S: +3 (IQR +1, +5); p = 0.42. Thirty-seven (63.8%) participants reported higher levels of pain following dilator placement than D&E. Overall, 26 (42.6%) participants used narcotics during their abortion episode, with no difference in median number of tablets between laminaria (2, range 1-8) and Dilapan-S (4.5, range 1-15) participants (p = 0.34). CONCLUSIONS Median pain increase did not differ in participants receiving laminaria or Dilapan-S for cervical preparation prior to D&E. The majority of patients will use a small amount of narcotics if available. IMPLICATIONS The lack of difference in pain between laminaria and Dilapan-S enhances the applicability of pain intervention research across dilator types. With over half of participants using a small amount of narcotics during their D&E episode, pain management should be individualized to patient needs.
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Affiliation(s)
- Serena M Liu
- Albany Medical Center, Department of Obstetrics & Gynecology, 391 Myrtle Ave. MC-74, Albany, NY 12208, United States
| | - Rachel Flink-Bochacki
- Albany Medical Center, Department of Obstetrics & Gynecology, 391 Myrtle Ave. MC-74, Albany, NY 12208, United States.
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Cervical priming before surgical abortion between 14 and 24 weeks: a systematic review and meta-analyses for the National Institute for Health and Care Excellence-new clinical guidelines for England. Am J Obstet Gynecol MFM 2020; 3:100283. [PMID: 33451604 DOI: 10.1016/j.ajogmf.2020.100283] [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: 09/20/2020] [Revised: 11/11/2020] [Accepted: 11/18/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study aimed to determine the optimal cervical priming regimen before surgical abortion between 14+0 and 24+0 weeks' gestation. DATA SOURCES Embase, MEDLINE, and the Cochrane Library were searched for publications up to February 2020. Experts were consulted for any ongoing or missed trials. STUDY ELIGIBILITY CRITERIA Randomized controlled trials, published in English after 1985, that compared (1) mifepristone, misoprostol, and osmotic dilators against each other, alone or in combination; (2) different doses of mifepristone and misoprostol; (3) different intervals between priming and abortion; or (4) different routes of administration of misoprostol were included. METHODS Risk of bias was assessed using the Cochrane Collaboration checklist for randomized controlled trials, and data were meta-analyzed in Review Manager 5.3. Dichotomous outcomes were analyzed as risk ratios using the Mantel-Haenszel method, and continuous outcomes were analyzed as mean differences using the inverse variance method. Fixed effects models were used when there was no significant heterogeneity (I2<50%), random effects models were used for moderate heterogeneity (I2≤50% and <80%), and evidence was not pooled when there was high heterogeneity (I2≥80%). Subgroup analyses were undertaken based on parity where available. The overall quality of the evidence was assessed using Grades of Recommendation Assessment, Development, and Evaluation. RESULTS A total of 15 randomized controlled trials (N=2454) were included and showed decreased difficulty of procedure and/or increased cervical dilation and decreased patient acceptability with regimens that included dilators compared with those that did not include dilators; increased preoperative expulsion of the pregnancy with sublingual misoprostol and mifepristone compared with sublingual misoprostol alone; increased difficulty of procedure with dilators and misoprostol compared with dilators and mifepristone; decreased difficulty of procedure with dilators and mifepristone compared with dilators alone; and increased cervical dilation when dilators were placed the day before abortion compared with the same day. CONCLUSION Considered alongside clinical expertise, the published data support the use of osmotic dilators, misoprostol, or mifepristone before abortion for pregnancies at 14+0 to 16+0 weeks' gestation; osmotic dilators or misoprostol for pregnancies at 16+1 to 19+0 weeks' gestation; and osmotic dilators alone or with mifepristone for pregnancies at 19+1 to 24+0 weeks' gestation. The effectiveness of pharmacologic agents alone beyond 16+0 weeks' gestation and the optimal timing of dilator placement remain important questions for future research.
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Diedrich JT, Drey EA, Newmann SJ. Society of Family Planning clinical recommendations: Cervical preparation for dilation and evacuation at 20-24 weeks' gestation. Contraception 2020; 101:286-292. [PMID: 32007418 DOI: 10.1016/j.contraception.2020.01.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 11/18/2022]
Abstract
Although only 1.3% of abortions in the United States are between 20 and 24 weeks' gestation, these procedures are associated with elevated risks of morbidity and mortality. Adequate cervical preparation before dilation and evacuation (D&E) at 20-24 weeks' gestation reduces procedural risk. For this gestational range, at least one day of cervical preparation with osmotic dilators is recommended before D&E. The use of overnight osmotic dilators alone is sufficient for most D&Es at 20-24 weeks' gestation. Dilapan-S® dilators require a shorter time to achieve maximum dilation, may be more effective than laminaria and may increase the likelihood of success on the first D&E attempt. The use of adjunctive mifepristone administered one-day pre-operatively at the time of osmotic dilator placement, should be considered because evidence demonstrates that it makes D&E subjectively easier at 20-24 weeks without increasing side effects. While older studies suggest that two-days of serial osmotic dilators provide greater dilation than one day of dilators, adjunctive mifepristone may be comparable to a second day of dilators. Adjunctive misoprostol administered on the day of D&E does not appear to affect initial cervical dilation and procedure time and compared with mifepristone is associated with more side effects, such as pain and nausea. Using overnight mifepristone and same-day misoprostol without osmotic dilators at 20-24 weeks' gestation lengthens D&E procedure time and appears to increase immediate complications, at least among less experienced providers. Some evidence shows the feasibility of same-day cervical preparation before D&E at 20-24 weeks using Dilapan-S® with adjunctive misoprostol or serial repeat dosing of misoprostol, but same-day preparation should be limited to providers with significant experience with these regimens. The Society of Family Planning recommends preoperative cervical preparation before D&E at 20-24 weeks' gestation. Further studies are needed to clarify the best means of preparing the cervix in order to minimize abortion complications and improve outcomes in this gestational range.
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Affiliation(s)
- Justin T Diedrich
- Department of Obstetrics & Gynecology, University of California, Irvine, United States.
| | - Eleanor A Drey
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, United States
| | - Sara J Newmann
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, United States
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Creinin MD, Schimmoeller NR, Matulich MC, Hou MY, Melo J, Chen MJ. Gabapentin for pain management after osmotic dilator insertion and prior to dilation and evacuation: A randomized controlled trial. Contraception 2020; 101:167-173. [DOI: 10.1016/j.contraception.2019.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
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Cahill EP, Henkel A, Shaw JG, Shaw KA. Misoprostol as an adjunct to overnight osmotic dilators prior to second trimester dilation and evacuation: A systematic review and meta-analysis,. Contraception 2020; 101:74-78. [DOI: 10.1016/j.contraception.2019.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/26/2019] [Accepted: 09/15/2019] [Indexed: 10/25/2022]
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Costescu D, Guilbert É. No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:750-783. [PMID: 29861084 DOI: 10.1016/j.jogc.2017.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care. INTENDED USERS Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs. TARGET POPULATION Women with an unintended or abnormal first or second trimester pregnancy. EVIDENCE PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched. VALUES The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request. BENEFITS, HARMS, AND/OR COSTS IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.
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Shakir-Reese JM, Ye PP, Perritt JB, Lotke PS, Reeves MF. A factorial-design randomized controlled trial comparing misoprostol alone to Dilapan with misoprostol and comparing buccal to vaginal misoprostol for same-day cervical preparation prior to dilation & evacuation at 14 weeks 0 days-19 weeks 6 days gestation .. Contraception 2019; 100:445-450. [PMID: 31520608 DOI: 10.1016/j.contraception.2019.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 09/04/2019] [Accepted: 09/04/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare procedure times following same-day cervical preparation using misoprostol 400 mcg alone or misoprostol 400 mcg plus hygroscopic dilators for dilation and evacuation (D&E) before 20 weeks gestation and to compare side effects of buccal and vaginal misoprostol administration. STUDY DESIGN We randomized women undergoing D&E at 14 weeks 0 days-19 weeks 6 days gestation to receive (1) hygroscopic dilators or not and (2) buccal or vaginal misoprostol using a 2 × 2 factorial design. We assessed two primary outcomes: (1) total procedure time, defined as time to insert hygroscopic dilators plus D&E time, and (2) side effects of misoprostol 4-6 h after initiation of cervical preparation using a 5-point Likert scale assessing nausea, emesis, diarrhea, chills and cramps. RESULTS We randomized 163 women and 161 completed the study. We completed all procedures in one day. Mean total procedure time was 14.0 and 10.8 min. with and without hygroscopic dilators (difference 3.2 minutes, 95% CI 1.7, 4.6). Mean D&E procedure time was 0.7 (95% CI -0.8, 2.1) min longer without hygroscopic dilators. Initial cervical dilation was 15.6 and 11.7 mm with and without hygroscopic dilators (difference 3.9 mm, 95% CI 3.1, 4.8). Participants receiving buccal misoprostol reported less chills (1.9) than women receiving vaginal misoprostol (2.3), p = 0.04. CONCLUSIONS Hygroscopic dilators with misoprostol requires more time and increases cervical dilation without shortening D&E time when used for cervical preparation 4-6 h prior to D&E before 20 weeks. Women receiving vaginal misoprostol may have more chills compared to buccal misoprostol. IMPLICATIONS Adding hygroscopic dilators to misoprostol for same day D&E procedures at less than 20 weeks gestation increases total intervention time without reducing D&E time and is less favored by patients. Clinical judgment requires balancing relative effectiveness with patient preference. Further studies should evaluate the side effect profile of vaginal misoprostol.
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Affiliation(s)
- Jamilah M Shakir-Reese
- MedStar Washington Hospital Center, 106 Irving St., Suite 4700, Washington, DC 20010, USA.
| | - Peggy P Ye
- MedStar Washington Hospital Center, 106 Irving St., Suite 4700, Washington, DC 20010, USA
| | - Jamila B Perritt
- Planned Parenthood of Metropolitan Washington, DC, 1225 4th. St., NE, Washington, DC 20002, USA
| | - Pamela S Lotke
- MedStar Washington Hospital Center, 106 Irving St., Suite 4700, Washington, DC 20010, USA; Georgetown University School of Medicine, 4000 Reservoir Rd NW, 120 Building D, Washington, DC 20007, USA
| | - Matthew F Reeves
- MedStar Washington Hospital Center, 106 Irving St., Suite 4700, Washington, DC 20010, USA; DuPont Clinic, 1120 19th St. NW, Suite 316, Washington, DC 20036, USA; Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St. Baltimore, MD 21205, USA
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Adjunctive Agents for Cervical Preparation in Second Trimester Surgical Abortion. Adv Ther 2019; 36:1246-1251. [PMID: 31004327 PMCID: PMC6822869 DOI: 10.1007/s12325-019-00953-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Indexed: 11/26/2022]
Abstract
Late second trimester dilation and evacuation is a challenging subset of surgical abortion. Among the reasons for this is the degree of cervical dilation required to safely extricate fetal parts. Cervical dilation is traditionally achieved by placing multiple sets of osmotic dilators over two or more days prior to the evacuation procedure; however, there is interest in shortening cervical preparation time. The use of adjuvant mifepristone and misoprostol in conjunction with osmotic dilators has been studied for this purpose, and their use demonstrates that adequate cervical dilation can be achieved in less time than with dilators alone. We present a review of the current evidence surrounding adjunctive agents for cervical preparation, and contend that for women presenting for surgical abortion care above 19 weeks gestation, the use of adjunctive mifepristone and/or misoprostol should be strongly considered along with osmotic dilator insertion when cervical preparation in less than 24 h is needed.
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Lerma K, Blumenthal PD. Current and potential methods for second trimester abortion. Best Pract Res Clin Obstet Gynaecol 2019; 63:24-36. [PMID: 31281014 DOI: 10.1016/j.bpobgyn.2019.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/26/2022]
Abstract
Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.
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Affiliation(s)
- Klaira Lerma
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA.
| | - Paul D Blumenthal
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA
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No 360 - Avortement provoqué : avortement chirurgical et méthodes médicales au deuxième trimestre. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:784-821. [DOI: 10.1016/j.jogc.2018.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Whitehouse K, Fontanilla T, Kim L, Tschann M, Soon R, Salcedo J, Kaneshiro B. Use of medications to decrease bleeding during surgical abortion: a survey of abortion providers' practices in the United States. Contraception 2018; 97:500-503. [PMID: 29490288 DOI: 10.1016/j.contraception.2018.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Our objective was to document current practices of abortion providers on the use of medications to decrease bleeding during surgical abortion. STUDY DESIGN We emailed surveys to 336 abortion providers through a professional listserv to elicit information on their use of medications to prevent and treat bleeding during first- and second-trimester surgical abortion. RESULTS One hundred sixty-eight (50%) providers responded to our survey. The majority were obstetrician-gynecologists (83%) working in an academic practice (66%). Most completed a fellowship in family planning (87%) and currently perform abortions up to 22 or 24weeks of gestation (63%). Seventy-two percent routinely used prophylactic medications for bleeding. Providers who routinely used medications to prevent bleeding most commonly chose vasopressin (83%). Providers preferred methylergonovine as a treatment for excessive bleeding in the second trimester, followed by misoprostol. CONCLUSION We found that most providers routinely use medications to prevent bleeding and use several different regimens to treat bleeding during abortion. IMPLICATIONS We found that surgical abortion providers use a range of medications to prevent and treat hemorrhage at the time of surgical abortion. Scant evidence is available to guide abortion providers on the use of medications to decrease hemorrhage during surgical abortion. To provide evidence-based recommendations for the prevention and treatment of clinically significant bleeding, researchers should target the most commonly used interventions.
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Affiliation(s)
- Katherine Whitehouse
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA.
| | - Tiana Fontanilla
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
| | - Leslie Kim
- University of Hawaii, John A. Burns School of Medicine, 651 Ilalo St., Honolulu, HI 96813, USA
| | - Mary Tschann
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
| | - Reni Soon
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
| | - Jennifer Salcedo
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
| | - Bliss Kaneshiro
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
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Shaw KA, Lerma K, Shaw JG, Scrivner KJ, Hugin M, Hopkins FW, Blumenthal PD. Preoperative effects of mifepristone for dilation and evacuation after 19 weeks of gestation: a randomised controlled trial. BJOG 2017; 124:1973-1981. [DOI: 10.1111/1471-0528.14900] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2017] [Indexed: 11/30/2022]
Affiliation(s)
- KA Shaw
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
| | - K Lerma
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
| | - JG Shaw
- Division of Primary Care and Population Health; Department of Medicine; Stanford University School of Medicine; Stanford CA USA
| | - KJ Scrivner
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
| | - M Hugin
- Department of Obstetrics & Gynecology; Santa Clara Valley Medical Center; San Jose CA USA
| | - FW Hopkins
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
- Department of Obstetrics & Gynecology; Santa Clara Valley Medical Center; San Jose CA USA
| | - PD Blumenthal
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
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Fink G, Gerber S, Dean G. Misoprostol in Abortion Care: Review and Update. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0202-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Khooshideh M, Yarmohammadi N, Shahriari A, Sheikh M. Sublingual misoprostol plus laminaria for cervical preparation before surgical management of late first trimester missed abortions, a randomized controlled trial. J Matern Fetal Neonatal Med 2017; 30:317-322. [PMID: 27020489 DOI: 10.3109/14767058.2016.1171838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 03/24/2016] [Accepted: 03/24/2016] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Comparing the efficacy of low-dose sublingual misoprostol plus laminaria to medium-dose sublingual misoprostol alone for cervical dilation before surgical management of late first trimester missed abortions. METHODS Randomized, controlled trial evaluated 70 women with missed abortion, admitted for surgical termination of pregnancy. The patients were randomly assigned to receive 200 μg sublingual misoprostol with cervical laminaria (intervention group) or 400 μg sublingual misoprostol without laminaria (control group), four hours before surgical process. The study is registered at www.irct.ir (IRCT2014070711020N4). RESULTS More patients in the intervention group achieved the desired cervical dilation (≥Hegar7) before surgical process than the control group (91.4% versus 17.1%, p < 0.001). Patients in the intervention group experienced less pain during the waiting period (mean Visual Analog Scale scores: 30.8 ± 3.7 versus 43.7 ± 5.9, p < 0.001), and had higher satisfaction level (highly satisfied: 97.1% versus 77.1%, p = 0.02). Four patients in the intervention group and none in the control group had spontaneous expulsion of pregnancy products (p = 0.11). CONCLUSIONS Compared to medium-dose sublingual misoprostol alone, using a combination of cervical laminaria plus low-dose sublingual misoprostol before surgical process is associated with significantly more effective and rapid cervical dilation, lower requirement for mechanical dilation, lower abdominal pain and discomfort during the waiting period and higher patients' satisfaction.
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Affiliation(s)
- Maryam Khooshideh
- a Department of Obstetrics and Gynecology , Arash Women's Hospital, Tehran University of Medical Sciences , Tehran , Iran
| | - Nasim Yarmohammadi
- a Department of Obstetrics and Gynecology , Arash Women's Hospital, Tehran University of Medical Sciences , Tehran , Iran
| | - Ali Shahriari
- b Department of Anesthesiology , Roozbeh Hospital, Tehran University of Medical Sciences , Tehran , Iran , and
| | - Mahdi Sheikh
- c Maternal, Fetal and Neonatal Research Center, Vali-Asr Hospital, Tehran University of Medical Sciences , Tehran , Iran
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Guo Q, Qian Z, Huang L. Two cervical preparation regimens prior to surgical abortion at 10-14 weeks of gestation: A randomized clinical trial. J Matern Fetal Neonatal Med 2016; 30:2686-2689. [PMID: 27903087 DOI: 10.1080/14767058.2016.1261282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The aim of the study was to determine whether same-day cervical preparation with an osmotic dilator and misoprostol was as effective and safe as overnight cervical preparation for surgical abortions at 10-14 weeks. METHODS Seventy women seeking surgical abortion at 10-14 weeks were allocated to receive one osmotic dilator 16-17 h or 6-7 h prior to an abortion. All women received misoprostol 400 μg orally 2 h before the abortion. RESULTS The abortion time of the same-day group was 7.42 ± 1.73 min, and that of the overnight group was 8.00 ± 2.19 min (p = 0.23). The blood loss volume of the same-day group was 20.6 ± 10.6 mL, and that of the overnight group was 16.3 ± 7.0 mL (p = 0.55). The degree of cervical dilation for the same-day group was inferior to the overnight group (p = 0.02). CONCLUSIONS Same-day cervical preparation with misoprostol and an osmotic dilator shortens the hospitalization days, suggesting same-day cervical preparation is safe, effective, and feasible for surgical abortion at 10-14 weeks of gestation.
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Affiliation(s)
- Qingyun Guo
- a Department of Obstetrics and Gynecology , Women's Hospital School of Medicine, Zhejiang University , Hangzhou , China
| | - Zhida Qian
- a Department of Obstetrics and Gynecology , Women's Hospital School of Medicine, Zhejiang University , Hangzhou , China
| | - Lili Huang
- a Department of Obstetrics and Gynecology , Women's Hospital School of Medicine, Zhejiang University , Hangzhou , China
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Abstract
PURPOSE OF REVIEW To review the recent literature on surgical second-trimester abortion, with specific attention to cervical preparation techniques. RECENT FINDINGS Confirming previous studies, a recent retrospective observational cohort study, including 54 911 abortions, estimated the total abortion-related complication rate to be 0.41% for second-trimester or later procedures. Cervical preparation is known to reduce risks associated with second-trimester dilation and evacuation (D&E). When considering adjuncts to osmotic dilators for cervical preparation prior to D&E after 16 weeks, both misoprostol and mifepristone are effective alone and in combination or as adjuncts to osmotic dilators. Misoprostol consistently has been shown to cause more pain and cramping than placebo, but is an effective adjunct to osmotic dilators after 16 weeks. Although mifepristone has fewer side-effects, at its current price, it may not be as cost-effective as misoprostol. SUMMARY Second-trimester abortion is safe. The use of mifepristone and misoprostol for second-trimester abortion has improved safety and efficacy of medical and surgical methods when used alone or in combination and as adjuncts to osmotic dilators. An important aspect of D&E, cervical preparation, is not a one-size-fits-all practice; the approach and methods are contingent on patient, provider and setting and should consider all the evidence-based options.
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Synthetic osmotic dilators with adjunctive misoprostol for same-day dilation and evacuation: a randomized controlled trial. Contraception 2016; 94:467-472. [DOI: 10.1016/j.contraception.2016.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 05/09/2016] [Accepted: 05/24/2016] [Indexed: 11/22/2022]
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Cervical Preparation Before Dilation and Evacuation Using Adjunctive Misoprostol or Mifepristone Compared With Overnight Osmotic Dilators Alone. Obstet Gynecol 2015. [DOI: 10.1097/aog.0000000000000977] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ramesh S, Roston A, Zimmerman L, Patel A, Lichtenberg ES, Chor J. Misoprostol 1 to 3 h preprocedure vs. overnight osmotic dilators prior to early second-trimester surgical abortion. Contraception 2015; 92:234-40. [PMID: 25891258 DOI: 10.1016/j.contraception.2015.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 04/09/2015] [Accepted: 04/09/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We sought to compare the effectiveness of at least 1 h of 400 mcg of buccal misoprostol to overnight osmotic dilators for early second-trimester surgical abortion cervical preparation. DESIGN We conducted a retrospective cohort study, reviewing 145 consecutive charts to compare procedure duration for women who received 400 mcg of buccal misoprostol at least 1 h preprocedure vs. overnight osmotic dilators before dilation and evacuation between 14 weeks, 0 days and 15 weeks, 6 days' gestation. Primary outcome was procedure duration and secondary outcomes included maximum mechanical dilator size, estimated blood loss and side effects. RESULTS Sixty-four women (44.1%) received buccal misoprostol (mean 1.6 h), and 81 women (55.9%) received overnight osmotic dilators. Groups did not differ regarding mean gestational age or gynecologic history. All procedures in both groups were completed. Procedure duration was not significantly different between the misoprostol and osmotic dilator groups (median 11.0 min vs. 10.0 min, p=.22), even after multivariable linear regression (p=.17). The mean total cervical preparation duration was 1.6 h for women in the misoprostol group compared to 20.3 h in the osmotic dilator group (p<.001). Secondary outcomes did not differ between groups. CONCLUSIONS We found that at least 1 h of preprocedure misoprostol decreased the duration of cervical preparation for early second-trimester procedures performed by an experienced surgeon. IMPLICATIONS In this small, retrospective review, at least 1 h of preprocedure buccal misoprostol decreased the duration from cervical preparation initiation to procedure completion in early second-trimester procedures performed by an experienced surgeon. These results should be considered as a pilot evaluation, and further prospective study is needed to further clarify whether this short interval could be applied in general practice.
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Affiliation(s)
- Shanthi Ramesh
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alicia Roston
- Department of Obstetrics and Gynecology, The John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Lindsay Zimmerman
- Department of Obstetrics and Gynecology, The John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Ashlesha Patel
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Obstetrics and Gynecology, The John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - E Steve Lichtenberg
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Family Planning Associates Medical Group, Limited, Chicago, IL, USA
| | - Julie Chor
- Department of Obstetrics and Gynecology, The John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA.
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Micks E, Edelman A, Botha R, Bednarek P, Nichols M, Jensen JT. The effect of sevoflurane on interventions for blood loss during dilation and evacuation procedures at 18–24 weeks of gestation: a randomized controlled trial. Contraception 2015; 91:488-94. [DOI: 10.1016/j.contraception.2015.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 02/17/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
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Ben-Ami I, Stern S, Vaknin Z, Smorgick N, Schneider D, Halperin R. Prevalence and risk factors of inadequate cervical dilation following laminaria insertion in second-trimester abortion--case control study. Contraception 2015; 91:308-12. [PMID: 25575873 DOI: 10.1016/j.contraception.2014.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 12/24/2014] [Accepted: 12/30/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective was to explore the prevalence of and risk factors for inadequate cervical dilation following insertion of a single set of laminaria in women scheduled for dilation & evacuation (D&E) at 14-24 weeks' gestation. STUDY DESIGN We retrospectively reviewed all cases of women who underwent pregnancy termination by D&E at 14-24 weeks' gestation between January 2003 and December 2013. All cases in which the surgical procedure was cancelled due to failure to achieve adequate cervical dilation after a single set of laminaria inadequate cervical dilation were included. The control group was women who underwent D&E following adequate cervical dilation after a single set of laminaria, and were matched according to gestational week in a ratio of 1:3. RESULTS The overall dilation failure rate was 3.2%, with 4.0% among the induced-abortion patients and 1.5% among the patients with fetal demise (p=.002). Patients who had inadequate cervical dilation had lower rates of gravidity (p=.002) and previous spontaneous vaginal delivery (p<.001), along with higher rates of primigravidity, nulliparity (p<.001), previous cesarean section/s (p=.041), previous abdominal surgeries (p=.001) and previous cervical procedures (p=.003), compared to controls. A multivariable logistic regression analysis revealed two risk factors for inadequate cervical dilation following laminaria insertion, namely, previous cesarean section (p=.002) and previous cervical procedure (p<.001), whereas increased gravidity was found to protect against inadequate cervical dilation (p=.002). CONCLUSIONS Previous cesarean section/s, cervical procedures and primigravidity were found to be risk factors for failure to achieve adequate cervical dilation after a single set of laminaria. Women who are scheduled for D&E, and in whom one of these risk factors exists, might benefit from additional interventions to achieve better cervical preparation.
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Affiliation(s)
- Ido Ben-Ami
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University.
| | - Sharon Stern
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
| | - Zvi Vaknin
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
| | - Noam Smorgick
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
| | - David Schneider
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
| | - Reuvit Halperin
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel-Aviv University
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Mercier RJ, Liberty A. Intrauterine lidocaine for pain control during laminaria insertion: a randomized controlled trial. Contraception 2014; 90:594-600. [PMID: 25139724 DOI: 10.1016/j.contraception.2014.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 07/13/2014] [Accepted: 07/16/2014] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Rebecca J Mercier
- Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
| | - Abigail Liberty
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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