Pain management for up to 9 weeks medical abortion – An international survey among abortion providers

Opt-in versus universal codeine provision for medical abortion up to 10 weeks of gestation at British Pregnancy Advisory Service: a cross-sectional evaluation

OBJECTIVE

To assess patient experiences of pain management during medical abortion up to 10 weeks' gestation with opt-in versus universal codeine provision.

METHODS

We invited patients who underwent medical abortion up to 10 weeks of gestation to participate in an online, anonymous, English-language survey from November 2021 to March 2022. We performed ordinal regression analyses to compare satisfaction with pain management (5-point Likert scale) and maximum abortion pain score (11-point numerical rating scale) in the opt-in versus universal codeine provision groups.

RESULTS

Of 11 906 patients invited to participate, 1625 (13.6%) completed the survey. Participants reported a mean maximum pain score of 6.8±2.2. A total of 1149 participants (70.7%) reported using codeine for pain management during their abortion. Participants in the opt-in codeine provision group were significantly more likely to be satisfied with their pain management than those in the universal group (aOR 1.48, 95% CI 1.12 to 1.96, p<0.01). Maximum abortion pain scores were lower on average among the opt-in codeine provision group (OR 0.80, 95% CI 0.66 to 0.96, p=0.02); however, this association was not statistically significant in the model adjusted for covariates (aOR 0.85, 95% CI 0.70 to 1.03, p=0.09).

CONCLUSION

Our findings suggest that patients have a better experience with pain management during medical abortion when able to opt-in to codeine provision following counselling versus receiving this medication routinely.

[Pain assessment during medical abortion up to 14 weeks: A 1-year prospective comparative study]

OBJECTIVES

Pain assessment of patients requesting a medical abortion according to the term, up to 14 weeks, by a numerical rating scale (NRS).

METHODS

This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020.

RESULTS

There was no significant difference in pain assessed by the NRS for medical abortion performed between 7-9 weeks and those performed between 9-14 weeks (6.5±2.5 vs. 6.6±2.2, P=0.85). Regardless of the term (before 7 weeks, between 7-9 weeks and between 9-14 weeks), patients felt relieved by taking painkillers in the case of medical abortion in 88.9%, 80.3% and 87.3% of cases respectively (P=0.18). The use of analgesics allowed a decrease of 3 points of the NRS in the 3 groups (P=0.67). Patients were more painful in case of medical protocol vs. surgical (maximum pain at 6.0±2.6 vs. 1.4±2.0, P<0.01), but declared to be relieved by analgesics in 85.1 and 94.3% of cases (P=0.24).

CONCLUSIONS

As pain is similar whatever the term in the case of medical abortion, and its management by analgesics seems to be effective, this criterion should not guide the professional in the choice of method, particularly between 9 and 14 weeks. This choice must be made by the patient.

A comparison of misoprostol with and without methylergometrine and oxytocin in outpatient medical abortion: a phase III randomized controlled trial

OBJECTIVE

The complications associated with miscarriages have surfaced as a major concern in maintaining women's physical and mental health. The present study evaluated the efficacy of three medication regimes for the complete expulsion of retained intrauterine tissues in patients who underwent a miscarriage.

METHODS

In this randomized clinical trial, 90 patients participated with their gestational age below 12 weeks, each having undergone a recent miscarriage. After being screened for underlying diseases and coagulative blood disorders, they were randomly allocated into three groups. For the first group, labeled as the control group, misoprostol was administered alone. In contrast, the combination of misoprostol plus methylergometrine and misoprostol plus oxytocin was prescribed for the second and third groups, respectively. Further, the data obtained were analyzed by descriptive and inferential statistics using Stata software version 14.

RESULTS

The mean age of participants and gestational age were 29.76 ± 5.53 years and 8.23 ± 2.29 weeks, respectively. There was no significant difference between the three treatment groups regarding the amount of bleeding after the abortion(P = 0.627). Regarding pain severity, the group that received Misoprostol plus Methylergometrine had less pain intensity than the other two groups(p = 0.004). The mean rate of RPOC expulsion was in the Misoprostol plus Oxytocin (9.68 ± 10.36) group, Misoprostol plus Methylergometrine (11.73 ± 12.86), and Misoprostol groups (19.07 ± 14.31)(p = 0.013). The success rate in outpatient medical abortion in the misoprostol plus oxytocin and misoprostol plus methylergonovine group was 93.33%, but in patients treated by misoprostol alone was 83.33%.

CONCLUSION

The effectiveness of the drugs in the two drug groups combined with oxytocin and methylergometrine is higher than the misoprostol group alone. An outpatient approach was deemed more satisfactory against surgical maneuvers and hospitalizations by patients since family support influenced their pain coping mechanism.

TRIAL REGISTRATION

The trial was registered in the Iranian registry of clinical trials on 04/10/2019. ( https://fa.irct.ir/trial/34519 ; registration number: IRCT20150407021653N19).

How much will it hurt? Factors associated with pain experience in women undergoing medication abortion during the first trimester

OBJECTIVES

Few studies have investigated the features associated with pain levels during abortion. We aimed to investigate the risk factors for experiencing pain during medication abortion, focusing on women's psychological distress and anxiety levels.

STUDY DESIGN

We carried out this observational study at two centers in Bologna, Italy. We included women aged 18 years or more with a viable intrauterine pregnancy of up to 63 days of amenorrhea, who chose medication abortion. Women received 600 mg of Mifepristone orally and after 48 hours 400 mcg of buccal misoprostol, repeated after 3 hours according to local and regional medication abortion guidelines, as well as prophylactic analgesia. We evaluated the clinical characteristics which may represent risk factors for severe pain (Visual Analogue Scale ≥ 70) through a multivariate model.

RESULTS

Two hundred forty-two patients were included in our analysis; 92 (38.0%) reported severe pain during medication abortion. Women with higher baseline anxiety levels (General Health Questionnaire 12 score ≥ 6 and General Anxiety Disorder 7 score ≥ 10) had a higher probability of experiencing pain with a Visual Analogue Scale ≥70 (OR = 3.33, 95% CI 1.43-7.76), as well as those who reported dysmenorrhea in the past year (OR = 6.30, 95% CI 2.66-14.91). Previous vaginal deliveries were inversely correlated with pain intensity (OR 0.26, 95% CI 0.14 - 0.50).

CONCLUSIONS

Increased baseline anxiety levels, dysmenorrhea and no previous vaginal deliveries are associated with severe pain in women undergoing medication abortion.

IMPLICATIONS

The identification of women at risk for severe pain based on clinical and historical factors as well as the definition of an adequate analgesic regimen may help to improve women's care and pain management during medication abortion.

Satisfaction with medication abortion and marijuana use: A prospective cohort study

OBJECTIVES

This exploratory study compared self-reported satisfaction rates and pain scores between patients who used marijuana during their medication abortion versus non-users.

STUDY DESIGN

We recruited medication abortion patients at a University-affiliated abortion clinic in Denver, Colorado. Participants completed a pre-abortion questionnaire, pain diary, and follow-up survey that assessed satisfaction with pain control, symptoms, and abortion experience. Using medians test, we compared the sums of median satisfaction scores between patients who used marijuana versus non-users. Based on diary entries, we also compared reported pain over 24 h after misoprostol (area under the curve [AUC]) between cohorts.

RESULTS

We enrolled 51 participants; 16 marijuana users and 35 non-marijuana users. Marijuana users and non-users had similar sums of median satisfaction scores (22 vs. 20 out of 30, p = 0.90) and median question-specific satisfaction scores (range 7-8 vs. 6.5-8, p = 0.6-1.0). Sixteen marijuana users (100%) and 20 (57%) non-users completed their pain diary; median AUCs for pain were similar (65.0 vs. 59.5, p = 0.73). Thirteen (81%) patients subjectively correlated marijuana use with pain reduction, seven (44%) with anxiety reduction, and six (38%) with nausea/vomiting improvement.

CONCLUSIONS

We found no significant difference in measures of medication abortion satisfaction and pain when comparing marijuana users to non-users. However, marijuana users often attributed symptom improvement during their medication abortion to marijuana use.

IMPLICATIONS

Until randomized studies are available, clinicians can counsel patients that marijuana use may not necessarily affect satisfaction or pain with medication abortion. It remains unknown whether marijuana has potential benefits in a marijuana-naïve population undergoing medication abortion. Future studies should explore the role that marijuana and its derivatives may play for pain and side effect management during medication abortion among marijuana-naïve patients.

Opioid Analgesia for Medical Abortion: A Randomized Controlled Trial

OBJECTIVE

To estimate the effect of oral opioids on patient pain during first-trimester medical abortion.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial where patients up to 10 0/7 weeks of gestation undergoing a medical abortion with mifepristone and misoprostol took 10 mg oral oxycodone or placebo at onset of painful cramping. Additionally, all patients received 800-mg ibuprofen tablets, 4-mg ondansetron oral dissolving tablets, and a written prescription for adjunctive pain medication (six tablets oxycodone 5 mg). Participants used a text-messaging service to report pain scores on a numerical rating scale from 0 to 10 (0 being no pain, 10 being worst pain) for 24 hours at start of misoprostol dosing. The primary outcome was maximum pain experienced within 24 hours postmisoprostol. Our secondary outcomes were maximum pain stratified by gestational age (less than 7 weeks of gestation, 7-10 weeks of gestation), duration of maximum pain, use of adjunctive medication, presence of nausea or vomiting, and satisfaction. We needed at least 76 participants per group to differentiate a clinically important pain difference of 2 points on the numerical rating scale.

RESULTS

From May 2017 to May 2018, we randomized 172 participants (placebo group with 86, oxycodone group with 86). The study groups had comparable baseline characteristics. We found no difference between groups in median maximum pain scores (placebo 8 [range 1-10], oxycodone 8 [range 2-10], P=.92) and the median duration of maximum pain (placebo 0.75 hours range 0.01-15 vs oxycodone 1 hour range 0.02-10, P=.39). Groups were also similar in the proportion obtaining (placebo 62%, oxycodone 49%, P=.09) and using (placebo 48%, oxycodone 40%, P=.28) adjunctive medication, experiencing nausea or vomiting (placebo 59%, oxycodone 65%, P=.43) and reported satisfaction with pain medications (placebo 62%, oxycodone 65%, P=.63).

CONCLUSION

Oxycodone does not reduce the maximum level of pain experienced by women undergoing medical abortion up to 10 0/7 weeks of gestation or improve satisfaction.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03139240.

Experiences with pain of early medical abortion: qualitative results from Nepal, South Africa, and Vietnam

Background

Medical abortion (MA) has become an increasingly popular choice for women even where surgical abortion services are available. Pain is often cited by women as one of the worst aspects of the MA experience, yet we know little about women’s experience with pain management during the process, particularly in low resource settings. The aim of this study is to better understand women’s experiences of pain with MA and strategies for improving quality of care.

Methods

This qualitative study was conducted as part of a three-arm randomized, controlled trial in Nepal, Vietnam, and South Africa to investigate the effect of prophylactic pain management on pain during MA through 63 days’ gestation. We purposively sampled seven parous and seven nulliparous women with a range of reported maximum pain levels from each country, totaling 42 participants. Thematic content analysis focused on MA pain experiences and management of pain compared to menstruation, labor, and previous abortions.

Results

MA is relatively less painful compared to giving birth and relatively more painful than menstruation, based on four factors: pain intensity, duration, associated symptoms and side effects, and response to pain medications. We identified four types of pain trajectories: minimal overall pain, brief intense pain, intermittent pain, and constant pain. Compared to previous abortion experiences, MA pain was less extreme (but sometimes longer in duration), more private, and less frightening. There were no distinct trends in pain trajectories by treatment group, parity, or country. Methods of coping with pain in MA and menstruation are similar in each respective country context, and use of analgesics was relatively uncommon. The majority of respondents reported that counseling about pain management before the abortion and support during the abortion process helped ease their pain and emotional stress.

Conclusions

Pain management during MA is increasingly essential to ensuring quality abortion care in light of the growing proportion of abortions completed with medication around the world. Incorporating a discussion about pain expectations and pain management strategies into pre-MA counseling and providing access to information and support during the MA process could improve the quality of care and experiences of MA patients.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12613000017729, registered January 8, 2013.