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Renner RM, Ennis M, McKercher AE, Henderson JT, Edelman A. Local anaesthesia for pain control in first trimester surgical abortion. Cochrane Database Syst Rev 2024; 2:CD006712. [PMID: 38348912 PMCID: PMC10862555 DOI: 10.1002/14651858.cd006712.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
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.
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Affiliation(s)
- Regina-Maria Renner
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Madeleine Ennis
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Adrienne E McKercher
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Jillian T Henderson
- Fertility Regulation Group, Oregon Health & Science University, Portland, Oregon, USA
| | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
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Effect of Paracervical Block Volume on Pain Control for Dilation and Aspiration. Obstet Gynecol 2022; 140:234-242. [DOI: 10.1097/aog.0000000000004862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
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Bercu C, Moseson H, McReynolds-Pérez J, Wilkinson Salamea E, Grosso B, Trpin M, Zurbriggen R, Cisternas C, Meza M, Díaz V, Kimport K. In-person later abortion accompaniment: a feminist collective-facilitated self-care practice in Latin America. Sex Reprod Health Matters 2021; 29:2009103. [PMID: 34928196 PMCID: PMC8725943 DOI: 10.1080/26410397.2021.2009103] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In Argentina, Chile and Ecuador, abortion at later durations of pregnancy is legally restricted. Feminist collectives in these contexts support people through self-managed medical abortion outside the healthcare system. The model of in-person abortion accompaniment represents an opportunity to examine a self-care practice that challenges and reimagines abortion provision. We formed a collaborative partnership built on a commitment to shared power and decision-making between researchers and partners. We conducted 28 key informant interviews with accompaniers in Argentina, Chile and Ecuador in 2019 about their model of in-person abortion accompaniment at later durations of pregnancy. We iteratively coded transcripts using a thematic analysis approach. Accompaniers premised their work in a feminist activist framework that understands accompaniment as addressing inequalities and expanding rights, especially for the historically marginalised. Through a detailed description of the process of in-person accompaniment, we show that the model, including the logistical considerations and security mechanisms put in place to ensure favourable abortion outcomes, emphasises peer-to-peer provision of supportive physical and emotional care of the accompanied person. In this way, it represents supported self-care through which individuals are centred as the protagonists of their own abortion, while being accompanied by feminist peers. This model of supported self-care challenges the idea that “self-care” necessarily means “solo care”, or care that happens alone. The model’s focus on peer-to-peer transfer of knowledge, providing emotional support, and centring the accompanied person not only expands access to abortion, but represents person-centred practices that could be scaled and replicated across contexts.
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Affiliation(s)
- Chiara Bercu
- Senior Project Manager, Ibis Reproductive Health, Oakland, CA, USA. Correspondence:
| | - Heidi Moseson
- Senior Research Scientist, Ibis Reproductive Health, Oakland, CA, USA
| | | | | | - Belén Grosso
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | - María Trpin
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | - Ruth Zurbriggen
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | | | - Milena Meza
- Activist and Researcher, Con las Amigas y en la Casa, Santiago, Chile
| | - Viviana Díaz
- Activist and Researcher, Con las Amigas y en la Casa, Santiago, Chile
| | - Katrina Kimport
- Associate Professor, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, CA, USA
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Gabapentin as an adjunct to paracervical block for perioperative pain management for first-trimester uterine aspiration: a randomized controlled trial. Am J Obstet Gynecol 2020; 223:884.e1-884.e10. [PMID: 32534843 DOI: 10.1016/j.ajog.2020.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 05/10/2020] [Accepted: 06/05/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pain management approaches during uterine aspiration vary, which include local anesthetic, oral analgesics, moderate sedation, deep sedation, or a combination of approaches. For local anesthetic approaches specifically, we continue to have suboptimal pain control. Gabapentin as an adjunct to pain management has proven to be beneficial in gynecologic surgery. We sought to evaluate the impact of gabapentin on perioperative pain during surgical management of first-trimester abortion or early pregnancy loss with uterine aspiration under local anesthesia. OBJECTIVE We hypothesized that adding gabapentin to local anesthesia will reduce perioperative and postoperative pain associated with uterine aspiration. Secondary outcomes included tolerability of gabapentin and postoperative pain, nausea, vomiting, and anxiety. STUDY DESIGN We conducted a randomized double-blinded placebo-controlled trial of gabapentin 600 mg given 1 to 2 hours preoperatively among subjects receiving a first-trimester uterine aspiration under paracervical block in an outpatient ambulatory surgery center. There were 111 subjects randomized. The primary outcome was pain at time of uterine aspiration as measured on a 100-mm visual analog scale. Secondary outcomes included pain at other perioperative time points. To assess changes in pain measures, an intention to treat mixed effects model was fit with treatment groups (gabapentin vs control) as a between-subjects factor and time point as a within-subjects factor plus their interaction term. Because of a non-normal distribution of pain scores, the area under the curve was calculated for secondary outcomes with comparison of groups utilizing Mann-Whitney U tests. RESULTS Among the 111 randomized, most subjects were Black or African American (69.4%), mean age was 26 years (±5.5), and mean gestational age was 61.3 days (standard deviation, 14.10). Mean pain scores at time of uterine aspiration were 66.77 (gabapentin) vs 71.06 (placebo), with a mean difference of -3.38 (P=.51). There were no significant changes in pain score preoperatively or intraoperatively. Subjects who received gabapentin had significantly lower levels of pain at 10 minutes after surgery (mean difference [standard error (SE)]=-13.0 [-5.0]; P=.01) and 30 minutes after surgery (mean difference [SE]=-10.8 [-5.1]; P=.03) compared with subjects who received placebo. Median nausea scores and incidence of emesis pre- and postoperatively did not differ between groups. Similarly, anxiety scores did not differ between groups, before or after the procedure. At 10 and 30 minutes after the procedure, most participants reported no side effects or mild side effects, and this did not differ between groups. CONCLUSION Preoperative gabapentin did not reduce pain during uterine aspiration. However, it did reduce postoperative pain, which may prove to be a desired attribute of its use, particularly in cases where postoperative pain may be a greater challenge.
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Tschann M, Salcedo J, Soon R, Kaneshiro B. Patient choice of adjunctive nonpharmacologic pain management during first-trimester abortion: a randomized controlled trial. Contraception 2018; 98:205-209. [DOI: 10.1016/j.contraception.2018.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/02/2018] [Accepted: 05/05/2018] [Indexed: 11/16/2022]
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Retrospective Evaluation of the Procedural Sedation Practices of Expert Nurses During Abortion Care. J Obstet Gynecol Neonatal Nurs 2017; 46:755-763. [PMID: 28727994 DOI: 10.1016/j.jogn.2017.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation. DESIGN Retrospective chart review. METHODS Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge. SETTING A single clinical site that employs seven expert nurses. PARTICIPANTS A total of 194 medical records were available for this analysis. RESULTS All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 μg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038). CONCLUSION Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure.
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Tschann M, Salcedo J, Kaneshiro B. Nonpharmaceutical Pain Control Adjuncts During First-Trimester Aspiration Abortion: A Review. J Midwifery Womens Health 2016; 61:331-8. [PMID: 26990781 DOI: 10.1111/jmwh.12445] [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] [Indexed: 11/29/2022]
Abstract
INTRODUCTION First-trimester aspiration abortion is associated with moderate to severe pain. The effectiveness of adjunctive therapies for pain control is not well understood. This critical review summarizes the existing literature regarding nonpharmacologic interventions to reduce pain during first-trimester office-based abortion. METHODS PubMed and Google Scholar were searched using the following search terms in various combinations: "abortion," "pain," "nonpharmaceutical," "nonpharmacologic," "anxiety," "fear," "pain management," "pain reduction," "anxiety reduction," "complementary and alternative medicine," and "integrative medicine." Seven articles meeting inclusion criteria were entered into a matrix for comparison. Findings from each study are summarized describing design, results, and themes. These results are summarized to provide evidence-based clinical guidelines and identify areas for further research. RESULTS None of the nonpharmacologic interventions studied were significantly associated with a reduction in pain or anxiety scores. However, women in many studies strongly endorsed future use of these techniques. DISCUSSION The data included in this critical review did not demonstrate a relationship between the nonpharmacologic interventions and pain or anxiety scores, yet participants endorsed these as positive and helpful. Women found value in these supportive interventions, and ongoing investigation into these techniques is warranted.
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Aksoy H, Aksoy U, Ozyurt S, Ozoglu N, Acmaz G, Aydın T, İdem Karadağ Ö, Tayyar AT. Comparison of lidocaine spray and paracervical block application for pain relief during first-trimester surgical abortion: A randomised, double-blind, placebo-controlled trial. J OBSTET GYNAECOL 2016; 36:649-53. [PMID: 26926158 DOI: 10.3109/01443615.2016.1148681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Huseyin Aksoy
- a Department of Obstetrics and Gynaecology , Kayseri Military Hospital , Kayseri , Turkey
| | - Ulku Aksoy
- b Department of Obstetrics and Gynaecology , Kayseri Memorial Hospital , Kayseri , Turkey
| | - Sezin Ozyurt
- c Department of Obstetrics and Gynaecology , Kayseri Education and Research Hospital of Medicine , Kayseri , Turkey
| | - Nil Ozoglu
- d Department of Family Planning , Kayseri Education and Research Hospital of Medicine , Kayseri , Turkey
| | - Gokhan Acmaz
- c Department of Obstetrics and Gynaecology , Kayseri Education and Research Hospital of Medicine , Kayseri , Turkey
| | - Turgut Aydın
- e Department of Obstetrics and Gynaecology , Kayseri Acıbadem Hospital , Kayseri , Turkey , and
| | - Özge İdem Karadağ
- e Department of Obstetrics and Gynaecology , Kayseri Acıbadem Hospital , Kayseri , Turkey , and
| | - Ahter Tanay Tayyar
- f Department of Obstetrics and Gynaecology , Private Erciyes Hospital , Kayseri , Turkey
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Women Know Best—Findings from a Thematic Analysis of 5,214 Surveys of Abortion Care Experience. Womens Health Issues 2014; 24:594-9. [DOI: 10.1016/j.whi.2014.07.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 07/01/2014] [Accepted: 07/03/2014] [Indexed: 11/20/2022]
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Freedman L, Levi A. How clinicians develop confidence in their competence in performing aspiration abortion. QUALITATIVE HEALTH RESEARCH 2014; 24:78-89. [PMID: 24265103 DOI: 10.1177/1049732313514483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
In this article we explore how nurse practitioners, physician assistants, and nurse midwives in California (collectively referred to as clinicians) developed confidence while learning to provide vacuum aspiration abortion. We interviewed clinicians (n = 30) who worked in reproductive health care settings and had participated in a large abortion-training study. Although the training had moral and political significance for the trainees, in this article we focus on their experience of skill development and how they gained confidence and competence in aspiration abortion, a procedure typically performed by physicians. We argue that confidence is not one dimensional. Understanding the diverse ways in which clinicians arrive at confidence might inform health care training and education generally. By examining attained competency from the clinicians' perspectives, we continue the discussion within the social science of health care and medicine about how clinicians know what they know and what expertise feels like to them.
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Affiliation(s)
- Lori Freedman
- 1University of California, San Francisco, California, USA
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Anestesia intracervical para la realización del legrado uterino instrumental. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2013. [DOI: 10.1016/j.gine.2012.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Karasahin KE, Alanbay I, Ercan CM, Mesten Z, Simsek C, Başer I. Lidocaine spray in addition to paracervical block reduces pain during first-trimester surgical abortion: a placebo-controlled clinical trial. Contraception 2011; 83:362-6. [DOI: 10.1016/j.contraception.2010.07.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 07/23/2010] [Accepted: 07/23/2010] [Indexed: 11/29/2022]
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A Review of Physician Anaesthesia Prescribing Practices in an Abortion Clinic in British Columbia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:41-44. [DOI: 10.1016/s1701-2163(16)34402-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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