Pain management for medical abortion at or after 13 weeks gestation

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Last reviewed: September 19, 2022

Recommendation:

• Offer pain medication to everyone undergoing medical abortion.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended and should be initiated with misoprostol.
• Narcotic analgesics and anxiolytics should be offered in addition to NSAIDs.
• Regional anesthesia and patient-controlled anesthesia may be offered where available.

Strength of recommendation: Strong

Quality of evidence: Very Low

Pain during medical abortion at or after 13 weeks gestation

In multiple cohort studies of medical abortion using prostaglandin E1 analogues (misoprostol, gemeprost) at or after 13 weeks gestation, most people required pain medication (Ashok et al., 2004; Gemzell-Danielsson & Östlund, 2000; Hamoda et al., 2004; Rose, Shand, & Simmons, 2006). Advanced gestational age, higher number of misoprostol doses and longer induction-to-abortion interval are associated with increased pain during medical abortion (Hamoda et al., 2004; Louie et al., 2017). Pain rarely starts after taking mifepristone; cramping pain generally starts after initiating  misoprostol and typically peaks with expulsion (Mentula, Kalso, & Heikinheimo, 2014).

Medications for pain management

Limited evidence exists regarding the optimal pain medication regimen for medical abortion at or after 13 weeks gestation (Jackson & Kapp, 2020). One randomized trial of 74 women at or after 13 weeks gestation undergoing abortion with mifepristone and misoprostol prophylactically treated patients with either an NSAID (diclofenac) or with paracetamol plus codeine at the time of misoprostol administration. There was no difference in reported pain between the two groups, but NSAID pretreatment reduced the need for subsequent intravenous opiates (Fiala et al., 2005). A second trial randomized 54 women undergoing abortion between 14-24 weeks gestation to receive the NSAID celecoxib or a placebo at the time of misoprostol administration. Those in the NSAID group had significantly lower pain scores at the time of abortion; however, nearly half of participants in both groups reported severe pain and there was no difference in use of additional analgesia between the two groups (Tintara, Voradithi, & Choobun, 2018).

In the largest available cohort study, 1,002 women at or after 13 weeks gestation undergoing abortion with mifepristone and misoprostol were offered a combination of oral and parenteral narcotic analgesics and NSAIDs to manage pain (Ashok et al., 2004). Study authors reported the proportion of women who used no analgesia (18%), and those who used paracetamol plus dihydrocodone (70%), parenteral morphine (7%) or NSAIDs (5%) for pain relief; women’s pain or satisfaction with pain management was not reported. Ipas recommends a combination regimen involving prophylactic NSAIDs given at the time of misoprostol, plus oral and/or parenteral narcotic analgesics (Edelman & Mark, 2017). Regional (epidural) and patient-controlled anesthesia are safe and effective methods of pain management. They may be offered if the requisite personnel, monitoring and equipment are available, (Maggiore et al., 2016; Smith et al., 2016; World Health Organization [WHO], 2022).

Two small studies examining use of paracervical block during medical abortion at or after 13 weeks gestation found no improvement in women’s pain with this modality (Andersson et al., 2016; Winkler et al., 1997).

Non-pharmacologic pain management

There are no comparative trials evaluating the benefit of non-pharmacologic pain management strategies for medical abortion at or after 13 weeks gestation. However, experts recommend adjunctive non-pharmacologic measures to improve women’s comfort during a medical abortion, including thorough education about expected pain and bleeding, a supportive environment and application of a heating pad or hot water bottle to the lower abdomen (Akin et al., 2001). These modalities are to be employed in addition to—not as substitutes for—pain medications.

Resources

Pain Medication Table

Continuum of depth of sedation: Definition of general anesthesia and levels of sedation/analgesis

References

Akin, M. D., Weingard, K. W., Hengehold, D. A., Goodale, M. B., Hinkle, R. T., & Smith, R. P. (2001). Continuous low-level topical heat in the treatment of dysmenorrhea. Obstetrics & Gynecology, 97, 343-349.

Andersson, I. M., Benson, L., Christensson, K., & Gemzell-Danielsson, K. (2016). Paracervical block as pain treatment during second-trimester medical termination of pregnancy: An RCT with bupivacaine versus sodium chloride. Human Reproduction, 31(1), 67-74.

Ashok, P., Templeton, A., Wagaarachchi, P., & Flett, G. (2004). Midtrimester medical termination of pregnancy: A review of 1002 consecutive cases. Contraception, 69(1), 51-58.

Edelman, A., & Mark, A. (2017). Medical abortion reference guide: Induced abortion and postabortion care at or after 13 weeks gestation. Chapel Hill, NC: Ipas.

Fiala, C., Swahn, M., Stephansson, O., & Gemzell-Danielsson, K. (2005). The effect of non-steroidal anti-inflammatory drugs on medical abortion with mifepristone and misoprostol at 13–22 weeks gestation. Human Reproduction, 20(11), 3072-3077.

Gemzell-Danielsson, K., & Östlund, E. (2000). Termination of second trimester pregnancy with mifepristone and gemeprost. Acta Obstetricia et Gynecologica Scandinavica, 79(8), 702-706.

Hamoda, H., Ashok, P., Flett, G., & Templeton, A. (2004). Analgesia requirements and predictors of analgesia use for women undergoing medical abortion up to 22 weeks of gestation. BJOG: An International Journal of Obstetrics & Gynaecology, 111(9), 996-1000.

Jackson, E., & Kapp, N. (2020). Pain management for medical and surgical termination of pregnancy between 13 and 24 weeks of gestation: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology , 127, 1348-1357.

Louie, K. S., Chong, E., Tsereteli, T., Avagyan, G., Abrahamyan, R., & Winikoff, B. (2017). Second trimester medical abortion with mifepristone followed by unlimited dosing of buccal misoprostol in Armenia. European Journal of Contraception & Reproductive Health Care, 22(1), 76-80.

Maggiore, U. L. R., Silanos, R., Carlevaro, S., Gratarola, A., Venturini, P.L., Ferrero, S., & Pelosi, P. (2016). Programmed intermittent epidural bolus versus continuous epidural infusion for pain relief during termination of pregnancy: A prospective, double-blind, randomized trial. International Journal of Obstetric Anesthesia, 25, 37-44.

Mentula, M., Kalso, E., & Heikinheimo, O. (2014). Same-day and delayed reports of pain intensity in second-trimester medical termination of pregnancy: A brief report. Contraception, 90(6), 609-11.

Rose, S. B., Shand, C., & Simmons, A. (2006). Mifepristone- and misoprostol-induced mid-trimester termination of pregnancy: A review of 272 cases. Australian and New Zealand Journal of Obstetrics and Gynaecology, 46(6), 479-485.

Smith, R. L., Siddiqui, N., Henderson, T., Teresi, J., Downey, K., & Carvalho, J. C. (2016). Analgesia for medically induced second trimester termination of pregnancy: A randomized trial. Journal of Obstetrics and Gynaecology Canada, 38(2), 147-153.Tintara, H., Voradithi, P., & Choobun, T. (2018). Effectiveness of celecoxib for pain relief and antipyresis in second trimester medical abortions with misoprostol: a randomized controlled trial. Archives of Gynecology and Obstetrics, 297(3), 709-715.

Winkler, M., Wolters, S., Funk, A., & Rath, W. (1997). Second trimester abortion with vaginal gemeprost-improvement by paracervical anesthesia? Zentralblatt fur Gynakologie, 119, 621-624.

World Health Organization. (2022). Abortion care guideline. Geneva: World Health Organization.