Predictors of analgesia use during supervised medical abortion. The Mifepristone Clinical Trials Group

[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.

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.

Women's experiences of self-referral to an abortion service: qualitative study

BACKGROUND

Guidelines from the UK recommend that women should be able to self-refer to abortion services. In 2016, a self-referral system was introduced to the abortion service in Edinburgh, Scotland, as an option for women. Women could telephone a dedicated phone line during office hours and speak to an administrative assistant working in the abortion service who provided them the next available appointment to be seen in the service. This study aimed to evaluate a self-referral service to abortion by investigating its impact on women's experiences of the referral process.

METHODOLOGY

21 semistructured interviews of women attending a specialist abortion service in Edinburgh, Scotland, were conducted. Interviews were transcribed verbatim and thematically analysed. The interviews focused on women's experience of the referral process.

RESULTS

Three main themes arose from the interviews, including reasons for choosing self-referral, experience of self-referral and challenges to using self-referral. Reasons for choosing self-referral were related to convenience, privacy and autonomy. Women found the experience of self-referral to be pleasant, non-judgemental and patient-centred, and self-referral prepared them for the appointment at the specialist abortion service. However, some women felt rushed, and self-referral made them anxious to attend the appointment. Challenges were difficulty with getting through on telephone lines, varying levels of support required for different individuals and awareness about the option of self-referral.

CONCLUSION

Women valued the option of self-referral. Women felt that the service should be expanded to increase availability,and promoted to women more widely within the community .

Auricular acupressure and acupuncture as adjuncts for pain management during first trimester medication abortion: A randomized three-arm trial

OBJECTIVES

To measure pain during first trimester medication abortion using auricular acupressure or auricular acupuncture as an adjunct to pain management. We measured anxiety as a secondary outcome.

STUDY DESIGN

This randomized, double-blinded, 3-arm trial enrolled women seeking medication abortion with mifepristone and misoprostol. Participants received auricular acupressure, auricular acupuncture, or inert auricular placebo patches immediately after receiving mifepristone. In addition, all participants received ibuprofen to use at home as needed. The study started with 1:1:1 randomization, but later overenrolled into the acupressure group after retraining for greater fidelity to that intervention. Participants reported pain and anxiety using numeric rating scales via text message for 4 days, and using a visual analog scale at follow-up. Analyses compared median pain scores of those receiving acupressure, acupuncture, or placebo.

RESULTS

We randomized 136 participants of whom 57 received acupressure, 40 received acupuncture, and 39 received placebo. Groups had similar baseline characteristics. One hundred thirty-two participants (97%) reported outcomes by text message and 120 (88%) completed a follow-up interview. For acupressure, acupuncture and placebo groups the median maximum pain scores reported via text message were 60.0, 75.0, and 55.0 (p = 0.38); median maximum pain scores reported at follow-up were 76.5, 60.0, and 71.0 (p = 0.97), respectively. Acupressure results were similar before and after retraining. Maximum anxiety scores reported via text message were 10.0, 45.0, and 30.0 (p = 0.57). Maximum anxiety scores reported at follow-up were 10.5, 20.0, and 13.0 (p = 0.59).

CONCLUSIONS

Pain and anxiety during medication abortion were similar among women receiving acupressure, acupuncture or placebo.

IMPLICATIONS

We found no benefit in administering auricular acupressure or auricular acupuncture during medication abortion. These modalities are intended to be simple to use, but perhaps the brief provider training for this study was insufficient. These modalities should not be used in clinical practice without further study.

Management of very early medical abortion-An international survey among providers

OBJECTIVE

To record the definition and management of Very Early Medical Abortion (VEMA) in different countries.

STUDY DESIGN

An Internet survey was circulated internationally among providers of medical abortion via a website. The questionnaire focused on reasons for performing or delaying medical abortion at a very early gestational age and the perceived advantages and disadvantages of VEMA.

RESULTS

Out of 220 completed questionnaires, 50 % came from European abortion providers (n = 110). Most respondents (72 %) defined VEMA as abortion performed in the presence of a positive hCG pregnancy test but with an empty uterine cavity or a gestational sac-like structure, and no signs or symptoms of ectopic pregnancy. A total of 74 % of respondents thought it was not necessary to wait for a diagnosis of intrauterine pregnancy before starting medical abortion. Equally, 74 % were aware of the possibility of an ectopic pregnancy.

CONCLUSION

According to European providers of medical abortion, waiting for the diagnosis of an intrauterine pregnancy is not necessary and does not improve treatment of ectopic pregnancy. Providers should know that medical abortion can be performed effectively and safely as soon as the woman has decided. There is no lower gestational age limit.

Assessment of significant factors affecting acceptability of home administration of misoprostol for medical abortion

BACKGROUND

Knowledge on factors affecting acceptability of medical abortion with mifepristone followed by home administration of misoprostol is scarce. The objective of this study was therefore to assess factors affecting acceptability and experience of home use of misoprostol for medical abortion up to 63 days' gestation.

STUDY DESIGN

Prospective observational study with acceptability assessed through questionnaires. Factors affecting acceptability were analyzed using multivariate logistic regression.

RESULTS

A total of 395 women were included. Independent factors for acceptability were having a partner/friend present and having a positive low-sensitivity urine hCG at follow-up, although most of these patients had successful abortions. Age, gestational length and requirement of extra pain medication did not affect acceptability.

CONCLUSION

Home administration of misoprostol is highly acceptable. Increasing the number of complete abortions should be a focus of future research. Women should be encouraged to have a partner/friend present during home administration of misoprostol.

Assessment of women's satisfaction with medical termination of pregnancy

This was a prospective study involving 205 women seeking medical abortion with gestational age<or=63 days. Questionnaires regarding expectations, experience and satisfaction with medical abortion were self-completed at the end of the procedure. Women's satisfaction was assessed using the visual analogue scale from 0 to 10. Satisfaction and acceptability parameters were correlated with socio-demographic and obstetric data. The mean degree of overall satisfaction was 8.3 (range 1-10). Around 90% of women would select the method again and would recommend it to a friend or relative. The degree of satisfaction showed a positive correlation with women's age (P<0.001) and number of children (P<0.05) and a significant negative correlation with gestational age (P<0.005). Marital status, type of financial support and acceptable pain and bleeding experience also showed a correlation with the satisfaction score. On the other hand, acceptability was correlated with husband/partner agreement and support during the procedure and adequate counselling regarding pain and bleeding.

Mid-trimester induced abortion: a review

Mid-trimester abortion constitutes 10-15% of all induced abortion. The aim of this article is to provide a review of the current literature of mid-trimester methods of abortion with respect to efficacy, side effects and acceptability. There have been continuing efforts to improve the abortion technology in terms of effectiveness, technical ease of performance, acceptability and reduction of side effects and complications. During the last decade, medical methods for mid-trimester induced abortion have shown a considerable development and have become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for termination of pregnancy (TOP). Advantages and disadvantages of medical versus surgical methods are discussed. Randomized studies are lacking, and more studies on pain treatment and the safety of any method used in patients with a previous uterine scar are debated, and data are scarce. Pain management in abortion requires special attention. This review highlights the need for randomized studies to set guidelines for mid-trimester abortion methods in terms of safety and acceptability as well as for better analgesic regimens.

Frequently asked questions about medical abortion

The development of methods of inducing abortion medically (nonsurgically) has created alternative options to make abortion available to women in a variety of health-care settings. Medical abortion is induced with a regimen of mifepristone followed by a prostaglandin analogue. Since its first introduction in the late 1980s, the regimen has undergone some modifications based on research evidence, and, in many countries, clinicians are using regimens that may differ from the one that has been licensed. This causes confusion among providers, also because only a few countries have developed national guidelines for the provision of medical abortion. We approached health care personnel providing abortion services in various countries and asked them to send us questions that they, or their colleagues, might have concerning the clinical practice of medical abortion in the early first trimester (up to 63 days since the first day of the last menstrual period). These questions were sent to experts representing the fields of biomedical and clinical research, clinical practice and family planning, who conducted literature reviews so that, whenever possible, the answers could be based on existing evidence. A consensus meeting was held in Bellagio, Italy, between November 1 and 5, 2004, to review the questions and to discuss the answers. The aim of this article is to provide a brief overview of some of the questions asked and the answers discussed.

Treatment of pain during medical abortion

A structured literature review was undertaken to determine, in the context of early medical abortion, the proportion of women who require analgesia, the predictors of analgesia requirement and the most appropriate analgesia regimen. Studies from different centers show wide variations in analgesia use, but, overall, around 75% of women use narcotic analgesics on the day of prostaglandin administration. Differences are likely to be due to differences in policies for offering analgesia rather than differences in patient characteristics. The following characteristics are consistently associated with increased requirement for analgesia: increasing gestation, younger patient age, nulliparity and White race. A regimen comprising 325-500 mg of paracetamol (acetaminophen) with 10 mg of dihydrocodeine or 30 mg of codeine has been used by thousands of women without apparent problems.

The effect of non-steroidal anti-inflammatory drugs on medical abortion with mifepristone and misoprostol at 13–22 weeks gestation

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit the biosynthesis of prostaglandins and concerns have been expressed that they might attenuate the effects of exogenous prostaglandins. This randomized study was conducted to evaluate whether NSAID given during medical abortion with mifepristone/misoprostol in the second trimester has a negative effect on the efficacy of the abortifacient by prolonging the induction-to-abortion interval.

METHODS

Seventy-four women were treated with the anti-progesterone mifepristone, followed by repeated doses of misoprostol 36-48 h later. They were randomized to receive a prophylactic pain treatment of either paracetamol and codeine or diclofenac with the first dose of misoprostol.

RESULTS

Co-treatment of NSAID with misoprostol did not attenuate the efficacy of mifepristone and misoprostol. There was no significant difference between the NSAID and the non-NSAID group in the induction-to-abortion interval (5.4 versus 6.5 h) or the total doses of misoprostol needed (2 versus 3). The frequency of surgical intervention was similar (55.6 versus 52.6%). Women in the group treated with NSAID required significantly less opiates (P = 0.042).

CONCLUSION

Co-treatment with NSAID and misoprostol does not interfere with the action of mifepristone and/or misoprostol to induce uterine contractions and pregnancy expulsion in medical abortion. Prophylactic NSAID administration reduces the need for opiate injections.

Analgesia requirements and predictors of analgesia use for women undergoing medical abortion up to 22 weeks of gestation

OBJECTIVE

To assess analgesia use and the predictors for requiring analgesia in women undergoing medical abortion at all gestations up to 22 weeks.

DESIGN

Retrospective observational study.

SETTING

Aberdeen Royal Infirmary, Scotland.

POPULATION

Consecutive women undergoing medical abortion under the terms of the 1967 Abortion Act.

METHODS

Analgesia requirements and characteristics of women undergoing abortion were analysed using logistic regression.

MAIN OUTCOME MEASURES

The effect of age, gestation, reproductive history, route and dose of misoprostol administration on analgesia requirements.

RESULTS

Of the total 4343 women included in this review, 3139 women (72%) required analgesia. Of these, 3054 women (97%) used oral analgesia, 75 women (2.4%) used opiates while 10 women (0.3%) had diclofenac sodium given rectally. There was no significant difference in analgesia use whether women used the vaginal or sublingual route of misoprostol administration. Logistic regression showed a significant positive association with gestation at termination (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.05-1.12), number of misoprostol doses used (OR 1.31, 95% CI 1.13-1.51) and induction to abortion interval (OR 1.08, 95% CI 1.03-1.12) and a negative association with the age of women undergoing abortion (OR 0.98, 95% CI 0.97-0.99) and previous live birth (OR 0.43, 95% CI 0.33-0.56).

CONCLUSIONS

Analgesia requirement was significantly higher in women of younger age, higher gestation, longer induction to abortion interval and with increased number of misoprostol doses used while women with previous live birth were significantly less likely to use analgesia.

The learning curve is rapid in medical termination of pregnancy--first-year results from the Helsinki area

Medical termination of pregnancy by means of mifepristone and prostaglandin became available in Finland in May 2000. We summarize the first year results of medical abortion in a large tertiary care unit in Helsinki. A regimen of 200 mg of mifepristone followed by 0.4 mg vaginally administered misoprostol 2 days later was used. The maximum duration of pregnancy was 56 days. Four hundred and seventeen women, 47% of those with a pregnancy duration of up to 56 days, chose medical instead of surgical abortion. The monthly percentage of medical abortions varied from 27% to 63%. The percentage of complete terminations increased from 92% among the first quarter of the subjects to 97% among the fourth quarter, the overall success rate being 95%. Subject satisfaction, duration and self-estimated amount of bleeding, as well as analgesia needs were similar to those reported elsewhere. Most subjects (61%) chose combined oral contraceptive (COC) pills for future contraception; 75% of the COCs were started around the day of misoprostol administration. The reported amounts and duration of bleeding were not influenced by the immediate start of oral contraceptives. Intrauterine contraception was planned for 28% of the subjects, and 16% of them chose a levonorgestrel-releasing intrauterine device. We conclude that the learning curve in medical termination of pregnancy is rapid, and results comparable to those in centers with extensive experience with the method can be reached within the first year.

Factors affecting the outcome of early medical abortion: a review of 4132 consecutive cases

OBJECTIVE

To assess the outcome of a regimen of a reduced dose of mifepristone followed by one or two doses of vaginal misoprostol as a non-surgical method for termination of pregnancy.

DESIGN

Prospective observational study.

SETTING

Aberdeen Royal Infirmary, Aberdeen, Scotland.

POPULATION

Women seeking abortion under the 1967 Abortion Act.

METHODS

Factors influencing the outcome in a consecutive series of 4132 women undergoing early medical abortion in one Scottish teaching hospital since 1994.

MAIN OUTCOME MEASURES

Complete abortion rates following one or two doses of misoprostol. The effect of age, gestation, previous pregnancy and previous termination on complete abortion rates following the medical regimen.

RESULTS

Of the 4132 women, 95 (2.3%) aborted within 48 hours of mifepristone and a further 3942 (95.4%) achieved complete abortion following administration of one or two doses of misoprostol. Thus, the overall complete abortion rate was 97.7% (4037/4131). A total of 94 (2.3%) women required surgical intervention of whom 13 (0.3%) had a continuing pregnancy. Following change of the regimen to include the possibility of two doses of misoprostol the continuing pregnancy rates were significantly reduced (OR = 5.88) and gestation ceased to have an effect on overall efficacy. Women who had a previous abortion were more likely to have a failed medical abortion (OR = 2.09), while women with no previous termination, but a previous live birth were more likely to have a failed abortion (OR = 2.03).

CONCLUSION

Mifepristone in combination with one to two doses of vaginal misoprostol is an effective regimen for early medical abortion. The option of administering two doses of misoprostol significantly reduced the ongoing pregnancy rates and abolished the effect of gestation on overall efficacy. Previous termination was the strongest predictor of failed medical abortion.

Parity is a major determinant of success rate in medical abortion: a retrospective analysis of 3161 consecutive cases of early medical abortion treated with reduced doses of mifepristone and vaginal gemeprost

The antiprogesterone mifepristone in combination with a suitable prostaglandin provides an effective method for induction of abortion in early pregnancy up to 63 days of gestation. The combination of 600 mg mifepristone followed by 1 mg of gemeprost vaginal pessary 48 h later is one of the standard regimens in practice, which is registered in several countries in Europe. In 1995, we reduced the doses for both mifepristone and gemeprost to 200 mg and 0.5 mg respectively, as this was shown to decrease significantly the incidence of side effects whilst maintaining a high efficacy. In this article, we report our experience with this regimen in routine clinical practice by analysing 3161 consecutive medical abortions retrospectively. Twelve case notes (0.4%) were not available, and for 310 (9.8%) women, the outcome was not known with certainty as they did not return for their follow up visit. Of the remaining 2839 women, 2732 (96.2%) had a complete abortion following their treatment. One-hundred-two (3.6%) women required an evacuation of the uterus: for incomplete abortion in 63 (2.2%) and ongoing pregnancy in 39 (1.4%). Three women had to undergo surgery for ectopic pregnancies. The surgical intervention rate was significantly higher at gestation of >49 days compared to < or = 49 days (5.7% vs. 2.6%, p = 0.002) and at >56 days than among those at < or = 56 days (6.7% vs. 3.1%; p <0.001). However, for incomplete abortion a significant increase was only seen at gestation >49 days compared to < or = 49 days (3% vs. 1.6%, p = 0.017). The incidence of ongoing pregnancies increased significantly only after 56 days of gestation compared to < or = 56 days (3.8% vs. 0.9%; p <0.001). Parity was related to the outcome with parous women having significantly more incomplete/ongoing abortions compared to nulliparous women (5.4% vs. 2.0%; p <0.001), although parous women did present earlier in pregnancy for termination than nulliparous women (p = 0.01). The incidence of complications was low: 165 (5.8%) women were given antibiotics for presumed genital infection and severe haemorrhage occurred in 11 (0.4%) women, of whom only two required blood transfusion. In summary, the recommended regimen with the reduced doses of mifepristone and gemeprost is highly effective, meeting the anticipated efficacy with a complete abortion rate of >95%. We have concluded from the data that gestation and parity are strong predictors for clinicians to anticipate the probability of a successful medical termination of pregnancy.

Analgesia during at-home use of misoprostol as part of a medical abortion regimen

The objective of this study was to identify predictors of narcotic analgesic use during medical abortion. Two-thousand-seven-hundred-forty-seven women with pregnancies of 63 days gestational age or less received 200 mg mifepristone followed by at-home use of 800 microg vaginal misoprostol in two consecutive clinical trials in the United States, and also reported their use of analgesics. Overall, 79% of these subjects used narcotic analgesics. Women in the 2nd of the two studies were randomized to use misoprostol 24, 48, or 72 h after mifepristone. Those who were randomized to 24 h were more likely to use narcotic analgesics than those who were randomized to 48 or 72 h. In both studies, the use of narcotic analgesia during medical abortion was less prevalent among parous women and Asian women, and among those with a gestational age of 56 days or less. The clinic providing care for the patient was the most important determinant of narcotic analgesia use, even though the analgesia was used at home. Use of narcotic analgesics in these women undergoing medical abortion at home was more prevalent than use reported in previous studies where women underwent medical abortion in a clinical setting.