Four Percent Intrauterine Lidocaine Infusion for Pain Management in First-Trimester Abortions

Local anaesthesia for pain control in first trimester surgical abortion

BACKGROUND

Abortions prior to 14 weeks are among the most common outpatient surgical procedures performed on people capable of becoming pregnant. Various methods have been used to control pain; however, many people still experience pain with the procedure.

OBJECTIVES

To evaluate the benefits and harms of local anaesthesia given for pain control during surgical abortion at less than 14 weeks' gestation.

SEARCH METHODS

We searched CENTRAL (Ovid EBM Reviews), MEDLINE (Ovid), Embase, POPLINE, and Google Scholar to December 2022 for randomized controlled trials of pain control in surgical abortion at less than 14 weeks' gestation using suction aspiration. We searched the reference lists of related reviews and articles.

SELECTION CRITERIA

We selected effectiveness and comparative effectiveness randomized controlled trials that studied local anaesthesia with common local anaesthetics and administration routes given for pain control in surgical abortion at less than 14 weeks' gestation using uterine aspiration. Outcomes included intraoperative pain, patient satisfaction, and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We computed mean differences (MD) with 95% confidence intervals (CI) for continuous variables reporting a mean. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

Thirteen studies with 1992 participants met the inclusion criteria. Due to heterogeneity of interventions, we could not pool more than two studies for any outcome. We used 13 mm improvement on a visual/verbal analogue scale to indicate a clinically meaningful difference in pain with surgical abortion (pain with dilation, aspiration, or during procedure). Based on type of pain control, we divided studies into three groups. Paracervical block (PCB) effectiveness trials A 20 mL 1% lidocaine PCB reduced pain with dilation (MD -37.00, 95% CI -45.64 to -28.36), and aspiration (MD -26.00, 95% CI -33.48 to -18.52) compared to a sham PCB (1 RCT, 120 participants; high-certainty evidence). A PCB with 14 mL of 1% chloroprocaine resulted in a slight reduction in pain with aspiration compared to a PCB with normal saline injected at two or four sites (MD -1.50, 95% CI -2.45 to -0.55; 1 RCT, 79 participants; high-certainty evidence). PCB comparative effectiveness trials An ultracaine PCB probably results in little to no clinically meaningful difference in pain during procedure compared to topical cervical lidocaine spray (median 1 point higher, interquartile range (IQR) 0 to 3; P < 0.001; 1 RCT, 48 participants; moderate-certainty evidence). A 1000 mg dose of intravenous paracetamol probably does not decrease pain as much as ultracaine PCB during procedure (median 2 points higher, IQR 1 to 3; P < 0.001; 1 RCT, 46 participants; moderate-certainty evidence). Various local anaesthetics in PCB comparative effectiveness trials A 10 mL buffered 2% lidocaine PCB probably does not result in a clinically meaningful difference in pain with dilation compared to a plain lidocaine PCB (MD -0.80, 95% CI -0.89 to -0.71; 1 RCT, 167 participants; moderate-certainty evidence). A buffered lidocaine PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to plain lidocaine PCB (MD -0.57, 95% CI -1.01 to -0.06; 2 RCTs, 291 participants; moderate-certainty evidence). Non-PCB local anaesthesia or PCB technique effectiveness trials PCB: waiting versus no waiting Waiting three to five minutes between 1% lidocaine PCB injection and dilation probably does not result in a clinically meaningful difference in pain with dilation compared to not waiting (MD -0.70, 95% CI -1.23 to -0.17; 2 RCTs, 357 participants; moderate-certainty evidence). Topical cervical analgesia Topical 10 mL 2% lignocaine gel probably does not result in a clinically meaningful difference in pain with aspiration compared to KY Jelly (MD -0.87, 95% CI -1.60 to -0.14; 1 RCT, 131 participants; moderate-certainty evidence). In participants who also received a PCB, 20 mg topical cervical lidocaine spray probably does not result in a clinically meaningful difference in pain during the procedure compared to two pumps of normal saline spray (median -1 point, IQR -2 to -1; P < 0.001; 1 RCT, 55 participants; moderate-certainty evidence). Intravenous paracetamol 1000 mg compared to two pumps of cervical lidocaine spray probably does not results in a clinically meaningful difference in pain procedure (median 1 point, IQR -2 to 2; P < 0.001; 1 RCT, 48 participants; low-certainty evidence). Non-PCB local anaesthesia or PCB technique comparative effectiveness trials Depth of PCB The evidence suggests that a 3-cm deep PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to a 1.5-cm deep PCB (MD -1.00, 95% CI -1.09 to -0.91; 2 RCTs, 229 participants; low-certainty evidence). PCB: four sites versus two sites A two-site (4-8 o'clock) 20 mL 1% lidocaine PCB does not result in a clinically meaningful difference in pain with dilation compared to a four-site (2-4-8-10 o'clock) PCB (MD 8.60, 95% CI 0.69 to 16.51; 1 RCT, 163 participants; high-certainty evidence). Overall, participants reported moderately high satisfaction with pain control and studies reported few adverse events.

AUTHORS' CONCLUSIONS

Evidence from this updated review indicates that a 20 mL 1% plain lidocaine PCB decreases pain during an abortion procedure. Evidence supports forgoing buffering lidocaine and a wait time between PCB injection and cervical dilation. A 1.5-cm deep injection as opposed to a 3-cm deep injection is sufficient. A two-site PCB injection as opposed to a four-site injection has similar effectiveness. Topical cervical anaesthesia (10 mL 2% lignocaine gel or 20 mg topical cervical lidocaine spray) as compared to placebo did not decrease pain based on moderate-certainty evidence, but then when compared to PCB, pain control was similar. Due to this inconsistency in evidence regarding the effectiveness of topical anaesthesia, its routine use is presently not supported. This review did not include studies of pain management with conscious sedation but, based on the results of our prior Cochrane review and the 2022 WHO guidelines, we recommend that the option of combination of pain management using conscious sedation plus PCB and non-steroidal anti-inflammatory drugs should be offered where conscious sedation is available as it further decreases pain.

Intranasal Fentanyl for First-Trimester Uterine Aspiration Pain:A Randomized Controlled Trial

OBJECTIVE

To evaluate whether administration of intranasal fentanyl reduces reported pain during first-trimester uterine aspiration.

STUDY DESIGN

We conducted a multicenter, randomized, double-blind, placebo-controlled trial of patients with pregnancies less than or equal to 14 weeks gestation seeking uterine aspiration for induced abortion, early pregnancy loss, or failed medication abortion. We randomized participants 1:1 to either intranasal fentanyl 100 mcg or intranasal placebo. All participants received ibuprofen and a standardized paracervical block. The primary outcome was pain indicated at the time of uterine aspiration on a 100 mm visual analog scale (VAS). We designed the study to detect a 15 mm difference in mean pain scores, which required 53 people in each arm for a total of 106 participants. Secondary outcomes included post-procedure pain and patient satisfaction with pain control.

RESULTS

From March 2017 through June 2018, we screened 355 people for eligibility and enrolled 107 participants. Those who received intranasal fentanyl reported similar uterine aspiration pain to participants receiving placebo (58.4±28.0 fentanyl vs 58.6±24.5 placebo, p=0.97). Participants receiving intranasal fentanyl also reported similar post-procedure pain scores compared to participants receiving placebo (19.1±19.4 fentanyl vs 17.2±19 placebo, p=0.63), and were equally satisfied with procedure pain control (66.8±31.2 fentanyl vs 63.3±29.2 placebo, p=0.57).

CONCLUSION

Intranasal fentanyl did not decrease reported pain with first-trimester uterine aspiration, nor did it decrease post-procedure pain compared to placebo. As an adjunct to ibuprofen and paracervical block, intranasal fentanyl did not improve patient satisfaction with pain control.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

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

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS

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

Nitrous oxide for pain management of first trimester surgical abortion -- a randomized controlled pilot study

OBJECTIVE

The objective was to determine feasibility of a study comparing mean pain scores between women randomized to nitrous oxide/oxygen (NO) versus oxygen+oral analgesics for trimester surgical abortion.

STUDY DESIGN

Pilot randomized controlled trial comparing NO (n=10) versus oxygen+oral analgesics (n=10). Feasibility of subject recruitment, and pain and satisfaction scores on a visual analog scale were evaluated.

RESULTS

Fifty-seven percent of eligible women participated. Mean pain scores were similar between groups, and mean satisfaction scores were higher for the NO group (77.5 vs. 46.7, P=.048).

CONCLUSIONS

The majority of eligible women agreed to participate in this study evaluating an uncommon pain control intervention.

Introduction of a manual vacuum aspiration service: a model of service within a NHS Sexual Health Service

BACKGROUND

We assessed the applicability, acceptability and cost implications of introducing the manual vacuum aspiration (MVA) technique with local anaesthesia for fully conscious first-trimester termination of pregnancy within our service and for our population.

SETTING

The outpatient setting of a Pregnancy Advisory Service within a NHS Sexual Health Service.

METHODS

Self-administered misoprostol and diclofenac, extra-amniotic local anaesthetic gel and paracervical mepivicaine prior to MVA. Routinely collected data were used to provide information on uptake, demographic details, timing, pain score, complications, contraceptive uptake, and economic implications for our service.

RESULTS

MVA was chosen by 305/1681 potentially eligible women. Forty percent had the procedure on the day they attended for assessment. Seventy-nine percent gave a pain score of 3 or less out of 10. Complications occurred in six cases (2%); these included cervical rigidity, a false passage, retained products of conception, bleeding (more than 200 ml) and one allergic reaction. Eighty percent of women chose to commence a long-acting reversible contraception (LARC) method at the time of MVA. Operating theatre utilisation was reduced by one termination list per week and cost savings of around £60,000 per annum were realised.

CONCLUSIONS

The technique for fully conscious MVA was very suitable for our outpatient setting. It was associated with very low levels of pain and bleeding. The uptake of LARC was high, and particularly the ability to provide intrauterine contraception at MVA was associated with a very high uptake.

Intrauterine anesthesia for gynecologic procedures: a systematic review

OBJECTIVE

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

DATA SOURCES

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

METHODS

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

TABULATION, INTEGRATION, AND RESULTS

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

CONCLUSION

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

Systematic review reveals heterogeneity in definition of a clinically relevant difference in pain

OBJECTIVE

To describe the pain decrease considered as clinically relevant when designing a trial and reporting its results.

METHODS

A systematic review of the literature in MEDLINE was conducted to select randomized controlled trials (RCTs) with pain as a primary outcome. Data extracted included the definition (terms and values) of a clinically relevant difference in pain, the type of pain studied (acute or chronic), the level of application (group or individual) of the clinically relevant difference, and the reference justifying the choice of value for clinically relevant difference.

STUDY DESIGN AND SETTING

Seventy-four trials were included, and only 16 articles justified the choice of a value for clinically relevant difference with a reference citation. The values chosen for the clinically relevant relative decrease in pain varied from 4 to 40 mm or from 15% to 55% at the group level and from 20 to 50 mm at the individual level. In seven articles, the authors confused the application of the reference value at the individual or group level.

CONCLUSION

Our review revealed a great heterogeneity in definition, format, and values of what is considered a clinically relevant difference in pain in RCTs of analgesics, and standardizations are advisable.

Assessment of pain after elective abortion relating to the use of misoprostol for dilatation of the cervix

OBJECTIVE

Our objective was to compare the use of misoprostol to that of laminaria tents for dilatation of the cervix before a surgical elective abortion (EAB) during the first trimester, with regard to the pain caused (1) during insertion, for both methods, (2) immediately before the EAB, and (3) one hour after the procedure.

METHODS

One hundred two women were recruited at Clinique de planification des naissances du Centre hospitalier universitaire de Québec, CHUL pavilion, between March 1, 2006 and March 1, 2007, for a tracking study. Fifty-three women were given 400 microg of misoprostol intravaginally, three to four hours before the EAB, and a laminaria tent was inserted in 49 women, 16 to 24 hours before the EAB. A visual analog scale was used to determine the pain score.

RESULTS

One hour after EAB, severe pain was reported in 6% of the participants who were given misoprostol. The pain score post-EAB was 3.8 times higher in women who were given misoprostol than in those who had a laminaria tent inserted (P = 0.004). The pain score during insertion of the dilatation method was 33 times higher with the laminaria tent than with misoprostol (P < 0. 001), and 30% of women who had a laminaria tent inserted felt severe pain.

CONCLUSION

While misoprostol may increase pain after EAB in a small percentage of women, it remains an efficient, easy to use, low-cost method for dilating the cervix before an EAB. It is one of the options that may be offered to women when a pre-EAB dilatation of the cervix is required, after discussing its benefits and disadvantages with them.

Comparison of the efficacy of intrauterine lidocaine, paracervical block and oral etodolac for decreasing pain in endometrial biopsy

OBJECTIVE

To compare the effectiveness of paracervical block, intrauterine lidocaine and oral etodolac in decreasing the pain caused by pipelle endometrial sampling. A secondary goal of this study was to determine the adverse effects and compare possible effects of these methods on pulse and blood pressure.

MATERIAL AND METHODS

The study was performed between April 2006 and October 2006 in the Obstetrics and Gynecology Department of Van Yüzüncü Yıl University Research Hospital. One-hundred twenty patients were randomized into four groups: 1. Group: Paracervical block was performed with 3 ml 2% prilocaine solution. 2. Group: Five ml of 2% lidocaine solution was instilled through the endocervix into the uterine cavity. 3. Group: Subjects received 400 mg oral etodolac tablet 1-1.5 hour before the procedure. 4. Group: No method of anesthesia was used in the control group. Endometrial sampling was performed with pipelle. Severity of pain during the procedure was scored by the subjects according to the "6-point Verbal Rating Scale (VRS)". Blood pressure and pulse rate were measured before, during and 30 minutes after the procedure.

RESULTS

Pain scores in intrauterine lidocaine group (2(nd) group) were found statistically significantly lower than the other three groups (p<0.05).

CONCLUSION

Intrauterine lidocaine anesthesia technique decreases pain in endometrial sampling with pipelle more efficiently than paracervical block or oral etodolac. While indication of menorrhagia and endometrial thickness more than 5 mm increased pain scores, intrauterine lidocaine application or paracervical block decreased the scores significantly (p<0.05).

Comparison of lidocaine 1% and normal saline in paracervical anesthesia for decreasing of pain in curettage

The objective of this study was to compare the efficiency oflidocaine with that of plain saline for paracervical pain relief during fractional curettage. The double-blind randomized clinical trial was performed on 150 patients presenting from 2004 to 2005 for curettage. The patients were assigned randomly in two groups to receive lidocaine 1% or normal saline. Number of patients at each group was 75 women. The pain intensity was assessed in four stages: (1) after speculum insertion, (2) during cervical dilatation, (3) during curettage and (4) 30 min after curettage completion. The pain intensity was graded as 0 to 100 according to the Likert Scale. The Mean +/- SD of pain intensity after speculum insertion, during dilatation, during curettage and 30 min after curettage in lidocaine group were 11.33 +/- 9.70, 24.93 +/- 15.36, 37.00 +/- 17.35, 6.47 +/- 6.42 and in normal saline group were 11.73 +/- 9.81, 28.20 +/- 13.19, 49.47 +/- 21.55 and 7.33 +/- 6.22, respectively. There was no significant difference between pain intensity after speculum insertion, during dilatation and during 30 min after curettage but there was a significant difference in pain intensity during curettage between lidocaine 1% group and normal saline group (p < 0.05). Normal saline is as effective as lidocaine 1% in low pain in curettage (distention of nerve capsule) but when increase pain in curettage (third time point), lidocaine 1% is more effective than normal saline. Nerve capsule distention is not the only factor for pain control in paracervical block and analgesic agent is still an important factor.

Pain control in first trimester surgical abortion

BACKGROUND

First trimester abortions especially cervical dilation and suction aspiration are associated with pain, despite various methods of pain control.

OBJECTIVES

Compare different methods of pain control during first trimester surgical abortion.

SEARCH STRATEGY

We searched multiple electronic databases with the appropriate key words, as well as reference lists of articles, and contacted professionals to seek other trials.

SELECTION CRITERIA

Randomized controlled trials comparing methods of pain control in first trimester surgical abortion at less than 14 weeks gestational age using electric or manual suction aspiration. Outcomes included intra- and postoperative pain, side effects, recovery measures and satisfaction.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data. Meta-analysis results are expressed as weighted mean difference (WMD) or Peto Odds ratio with 95% confidence interval (CI).

MAIN RESULTS

We included forty studies with 5131 participants. Due to heterogeneity we divided studies into 7 groups:Local anesthesia: Data was insufficient to show a clear benefit of a paracervical block (PCB) compared to no PCB or a PCB with bacteriostatic saline. Pain scores during dilation and aspiration were improved with deep injection (WMD -1.64 95% CI -3.21 to -0.08; WMD 1.00 95% CI 1.09 to 0.91), and with adding a 4% intrauterine lidocaine infusion (WMD -2.0 95% CI -3.29 to -0.71, WMD -2.8 95% CI -3.95 to -1.65 with dilation and aspiration respectively).PCB with premedication: Ibuprofen and naproxen resulted in small reduction of intra- and post-operative pain.Analgesia: Diclofenac-sodium did not reduce pain.Conscious sedation: The addition of conscious intravenous sedation using diazepam and fentanyl to PCB decreased procedural pain.General anesthesia (GA): Conscious sedation increased intraoperative but decreased postoperative pain compared to GA (Peto OR 14.77 95% CI 4.91 to 44.38, and Peto OR 7.47 95% CI 2.2 to 25.36 for dilation and aspiration respectively, and WMD 1.00 95% CI 1.77 to 0.23 postoperatively). Inhalation anesthetics are associated with increased blood loss (p<0.001).GA with premedication: The COX 2 inhibitor etoricoxib, the non-selective COX inhibitors lornoxicam, diclofenac and ketorolac IM, and the opioid nalbuphine were improved postoperative pain.Non-pharmacological intervention: Listening to music decreased procedural pain.No major complication was observed.

AUTHORS' CONCLUSIONS

Conscious sedation, GA and some non-pharmacological interventions decreased procedural and postoperative pain, while being safe and satisfactory to patients. Data on the widely used PCB is inadequate to support its use, and it needs to be further studied to determine any benefit.

Pain experienced during transvaginal ultrasound, saline contrast sonohysterography, hysteroscopy and office sampling: a comparative study

OBJECTIVE

To evaluate and compare the pain experienced by women during transvaginal ultrasound, saline contrast sonohysterography (SCSH), diagnostic hysteroscopy and office sampling.

METHODS

This was a descriptive study of 402 consecutive patients presenting at a 'one-stop' Bleeding Clinic between October 2004 and November 2006. Thirty-nine percent of the patients were postmenopausal. The patients underwent the following examinations transvaginally: first ultrasound with color Doppler, second SCSH, third diagnostic hysteroscopy and fourth endometrial biopsy. After completion of the examinations the patients were asked to complete a questionnaire including a visual analog scale (VAS) about their subjective appreciation of all four examinations. Two-hundred and ninety-three (72%) patients returned the questionnaire.

RESULTS

The median (range) VAS scores for transvaginal ultrasound, SCSH, diagnostic hysteroscopy and endometrial sampling were 1.0 (0-8.1), 2.2 (0-10), 2.7 (0-10) and 5.1 (0-10), respectively (P < 0.0001). The patients' answers to the other questions about the pain experienced, including comparison with other minor procedures such as venous blood sampling, were all concordant with the VAS scores.

CONCLUSIONS

Transvaginal ultrasound was the procedure best accepted, followed by SCSH, hysteroscopy and endometrial sampling. These results suggest that patients would prefer SCSH over hysteroscopy as an initial diagnostic approach in the evaluation of abnormal uterine bleeding.

Intrauterine lidocaine infusion for pain relief during saline solution infusion sonohysterography: a randomized, controlled trial

STUDY OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine instillation in reducing patient discomfort during saline solution infusion sonohysterography (SIS).

DESIGN

A double-blinded, randomized, controlled trial (Canadian Task Force classification I).

SETTING

Suleyman Demirel University School of Medicine, Department of Obstetrics and Gynecology, Isparta.

PATIENTS

One hundred-six women who underwent SIS.

INTERVENTIONS

Fifty-three patients were allocated to the lidocaine group and 53 to the saline solution group.

MEASUREMENTS AND MAIN RESULTS

The main outcome measures were the intensity of pain during, immediately after, and 20 minutes after the procedure, assessed by a visual analog scale and the patients' distress evaluated by the physician with a 3-point observer scale. There were no statistically significant differences between the study group and the control group in mean age, parity, past cervical surgery, history of chronic pelvic pain and dysmenorrhea, history of curettage, education, socioeconomic status, menopausal status, volume of saline solution infused (mL), tenaculum use, and indication for SIS. Pain scores demonstrated a statistically significant difference between groups during the procedure (placebo 5.09 +/- 1.25 [95% CI 4.74-5.43], lidocaine 3.90 +/- 1.02 [95% CI 3.61-4.18], p <.001); immediately after procedure (placebo 4.03 +/- 0.89 [95% CI 3.78-4.27], lidocaine 3.16 +/- 0.67 [95% CI 2.97-3.34], p <.001); and 20 minutes after procedure (placebo 3.32 +/- 0.54 [95% CI 3.17-3.46], lidocaine 2.43 +/- 0.72 [95% CI 2.23-2.62], p <.001). No significant pain relief in nulliparous patients was obtained by the use of lidocaine (4.88 +/- 1.01 [95% CI 4.60-5.15], 3.88 +/- 0.86 [95% CI 3.64-4.11], 3.22 +/- 0.55 [95% CI 3.06-3.37], respectively; p >.05). Pain rated by the physician during, immediately after, and 20 minutes after the procedure was significantly different between the groups (p <.001), and a significant correlation was noted between the visual analog pain score and the patients' distress recorded by the physician (r = 0.816, r = 0.697, r = 0.676; p <.001, respectively).

CONCLUSION

Intrauterine lidocaine seems to be effective in decreasing pain in parous women undergoing SIS.

Intrauterine lidocaine plus buccal misoprostol in the endometrial biopsy

OBJECTIVE

To evaluate the efficacy of intrauterine lidocaine plus buccal misoprostol in reducing the discomfort caused by endometrial biopsy with a suction curette.

METHODS

In this double-blind, randomized, placebo-controlled trial 126 women undergoing endometrial biopsy were administered a 200-microg tablet of misoprostol buccally, followed by a 5-mL uterine instillation of either of 2% lidocaine or a saline solution. The main outcome measures were the intensity of pain during, immediately following, and 20 min following the biopsy, as assessed on a 10-cm visual analog scale. Statistical analysis was performed using the Friedman test with the Bonferroni correction, the t test, and the chi(2) test.

RESULTS

There were no statistically significant differences between the study and control groups in mean age, parity, or relevant medical history. A statistically significant difference in pain scores was noted in premenopausal women during the procedure (lidocaine, 4.93+/-1.67; placebo, 6.17+/-1.26; P<0.001) as well as immediately later (lidocaine, 4.12+/-1.14 vs. placebo, 5.42+/-1.08; P<0.001) and 20 min later (lidocaine, 3.60+/-1.10; placebo, 4.22+/-1.46; P<0.001). No significant differences in pain scores were observed in postmenopausal women for any of the 3 time points (6.72+/-2.01, 5.18+/-1.22, and 4.56+/-0.80, respectively; P>0.05). The number needed to treat was 2.6 (95% confidence interval, 1.9-4.8).

CONCLUSION

Intrauterine lidocaine plus buccal misoprostol appears to be effective in decreasing pain in premenopausal women undergoing endometrial biopsy with a suction curette.