Clinical Updates in Reproductive Health

Pain management for vacuum aspiration

Last reviewed: December 6, 2019

Recommendation:

  • A combination of paracervical block and preprocedure nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management is recommended for all women.
  • Additional measures such as narcotic analgesics, anxiolytics and non-pharmacologic pain management measures may be helpful.
  • Intravenous sedation, where available, may be offered.
  • Paracetamol is not effective for vacuum aspiration pain management.
  • General anesthesia is not routinely recommended for vacuum aspiration pain management.

Strength of recommendation: Strong

Quality of evidence: Moderate

Pain during vacuum aspiration

Most women undergoing vacuum aspiration will experience pain (Borgatta & Nickinovich, 1997). Preprocedure depression or emotional distress, or gestational age beyond 10 weeks, are associated with more pain during uterine aspiration (Allen, Kumar, Fitzmaurice, Lifford, & Goldberg, 2006; Belanger, Melzack, & Lauzon, 1989; Duros et al., 2018), while having a prior vaginal delivery is associated with less pain (Borgatta & Nickinovich, 1997). Clinicians consistently underestimate the amount of pain women experience during abortion (Oviedo, Ohly, Guerrero, & Castano, 2018; Singh et al., 2008; Tschann, Salcedo, Soon, & Kaneshiro, 2018).

Methods of pain management

For vacuum aspiration before 13 weeks gestation, a combination of paracervical block with local anesthesia, analgesics, and non-pharmacologic measures typically provides pain relief for most women (World Health Organization, 2014; Renner, Jensen, Nichols, & Edelman, 2010). Intravenous sedation may also be offered.

Local anesthesia

A paracervical block given before dilating the cervix has been shown to decrease pain with dilation and uterine aspiration (Acmaz, Aksoy, Ozoglu, Aksoy, & Albayrak, 2013; Renner, Nichols, Jensen, Li, & Edelman, 2012; Renner et al., 2016). Paracervical block is a low-risk procedure that can be safely performed by physicians and midlevel providers (Warriner et al., 2006). For further information, see “Pain Management: Paracervical block.”

Medications

Two small studies examining use of oral NSAIDs alone for vacuum aspiration pain found no benefit (Acmaz et al., 2013; Li, Wong, Chan, & Ho, 2003). However, pre-procedure treatment with NSAIDs was found to decrease pain during and after the procedure in studies where women also received paracervical block for pain relief (Renner et al., 2010; Romero, Turok, & Gilliam, 2008; Suprapto & Reed, 1984; Wiebe & Rawling, 1995); both oral and intramuscular NSAIDs are effective (Braaten, Hurwitz, Fortin & Goldberg, 2013). There are no studies assessing the additional benefit of NSAIDs when moderate intravenous sedation is used for pain relief; based on findings from three small randomized trials, it is unclear if NSAIDs provide additional benefit when deeper levels of intravenous sedation are used (Khazin et al., 2011; Lowenstein et al., 2006; Roche, Li, James, Fechner, & Tilak, 2012).

The benefit of narcotic analgesics in alleviating vacuum aspiration pain is unclear. In one randomized controlled trial, the addition of oral hydrocodone-acetaminophen to a pain management regimen of paracervical block, ibuprofen and lorazepam did not improve pain during uterine aspiration when compared to placebo (Micks et al., 2012). In another randomized trial, the addition of intravenous fentanyl to the same pain management regimen significantly improved procedural pain (Rawling & Weibe, 2001). Two randomized trials showed that oral and rectal NSAIDs are more effective than tramadol in alleviating postprocedure pain (Lowenstein et al., 2006; Romero et al., 2008); however, a third randomized trial showed that rectal tramadol was more effective than NSAIDs (Khazin et al., 2011).

Anxiolytics such as lorazepam or midazolam decrease anxiety related to the procedure and cause amnesia for some women, but do not affect pain scores (Allen, et al., 2006; Bayer et al., 2015; Wiebe, Podhradsky, & Dijak, 2003).

Only one study has assessed effectiveness of pretreatment with paracetamol on pain during uterine aspiration performed without paracervical block, finding no difference between the paracetamol group and control group (Acmaz et al., 2013). In two studies where women also received deep sedation or general anesthesia, paracetamol did not improve post-procedure pain (Cade & Ashley, 1993; Lowenstein et al., 2006).

One randomized trial compared the effect of preprocedure gabapentin to placebo in women who also received oral lorazepam, ibuprofen, oxycodone and acetaminophen and found no difference in pain scores between the two groups (Gray et al., 2019).

Intravenous sedation

Intravenous sedation using a combination of narcotics and anxiolytics is an effective means of pain control and improves satisfaction with the abortion procedure (Allen, Fitzmaurice, Lifford, Lasic, & Goldberg, 2009; Allen et al., 2006; Wells, 1992; Wong, Ng, Ngai, & Ho, 2002). Intravenous administration of narcotics and anxiolytics is more effective than oral administration for pain during uterine aspiration (Allen et al., 2009). In women who receive sedation for pain management, it is unclear if there is additional benefit in administering a paracervical block (Kan, Ng, & Ho, 2004; Renner et al., 2010; Wong et al., 2002). When delivered by trained staff and with appropriate monitoring, intravenous sedation is safe. A 2017 retrospective cohort study which included more than 20,000 normal weight, overweight and obese women who received intravenous sedation for vacuum aspiration found that the rate of any anesthesia-related adverse event was very low (0.2%) (Horwitz et al., 2018). However, providing intravenous sedation increases the expense, complexity and potential risks of an abortion procedure and requires a trained provider with equipment for patient monitoring. The increased monitoring necessary to deliver intravenous sedation safely requires facility investments in training and equipment.

General anesthesia

Although effective for pain control, general anesthesia increases the expense, complexity and potential risks associated with abortion and is not recommended for routine procedures (Atrash, Cheek, & Hogue, 1988; Bartlett et al., 2004; Royal College of Obstetricians and Gynaecologists, 2015). When using general anesthesia it is unclear whether preprocedure administration of pain medication affects postprocedure pain (Ali, Shamim, & Chughtai, 2015; Liu et al., 2005; Mustafa-Mikhail et al., 2017), and there is no additional benefit to using a paracervical block (Hall, Ekblom, Persson, & Irestedt, 1997; Renner et al., 2010).

Non-pharmacologic pain management

A 2018 randomized controlled trial examining the use of auricular acupuncture in combination with paracervical block and preprocedure NSAIDs found that women in the intervention group reported significantly less pain and anxiety when compared to women receiving a placebo or usual care (Ndubisi, Danvers, Gold, Morrow, & Westhoff, 2019). The use of transcutaneous acupoint electrical stimulation as a means to modulate abortion pain is an area of active research, but no recommendations can be drawn from existing  studies (Feng et al., 2016; Wang et al., 2018).

Medications and paracervical block should be supplemented with supportive techniques to decrease pain and anxiety (Allen & Singh, 2018). Helpful approaches include educating the patient about what to expect during the procedure; conducting the procedure in a clean and private setting with supportive staff; providing verbal support; using gentle and efficient technique; and applying a heating pad or hot water bottle to the lower abdomen in the recovery room  (Akin et al., 2001). A 2016 systematic review of non-pharmacological adjunctive therapies to manage pain included studies of hypnosis, aromatherapy, music, relaxation and imagery exercises and use of doulas. While the review found that none of the interventions showed a statistically significant reduction in pain or anxiety, women rated non-pharmacological interventions highly and recommend their use, particularly those that include dedicated support people (Tschann, Salcedo, & Kaneshiro, 2016; Wilson, Gurney, Sammel, & Schreiber, 2016). A later randomized trial found no difference in reported pain between women receiving an adjunctive nonpharmacologic pain management strategy of their choosing (ambient music, guided imagery meditation or focused breathing, among others) and women receiving standard care (Tschann et al, 2018).

Resources

Pain Medication Table

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

References

Acmaz, G., Aksoy, H., Ozoglu, N., Aksoy, U., & Albayrak, E. (2013). Effect of paracetamol, dexketoprofen trometamol, lidocaine spray, and paracervical block application for pain relief during suction termination of first-trimester pregnancy. BioMed Research International, 2013, 869275.

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.

Allen, R. H., & Singh, R. (2018). Society of Family Planning clinical guidelines pain control in surgical abortion part 1 – local anesthesia and minimal sedation. Contraception, 97(6), 471-477.

Allen, R.H., Fitzmaurice, G., Lifford, K. L., Lasic, M., & Goldberg, A. (2009). Oral compared with intravenous sedation for first-trimester surgical abortion: A randomized controlled trial. Obstetrics & Gynecology, 113(2Pt1), 276-283.

Allen, R. H., Kumar, D., Fitzmaurice, G., Lifford, K. L., & Goldberg, A. B. (2006). Pain management of first-trimester surgical abortion: Effects of selection of local anesthesia with and without lorazepam or intravenous sedation. Contraception74(5), 407-413.

Ali, M. A., Shamim, F., & Chughtai, S. (2015). Comparison between intravenous paracetamol and fentanyl for intraoperative and postoperative pain relief in dilatation and evacuation: Prospective, randomized interventional trial. Journal of Anaesthesiology and Clincal Pharmacology, 31(1), 54-58.

Atrash, H. K., Cheek, T. G., & Hogue, C. J. (1988). Legal abortion mortality and general anesthesia. American Journal of Obstetrics & Gynecology158(2), 420-424.

Bartlett, L. A., Berg, C. J., Shulman, H. B., Zane, S. B., Green, C. A., Whitehead, S., & Atrash, H. K. (2004). Risk factors for legal induced abortion-related mortality in the United States. Obstetrics & Gynecology, 103, 729-739.

Bayer, L. L., Edelman, A. B., Fu, R., Lambert, W. E., Nichols, M. D., Bednarek, P. H., … Jensen, J. T. (2015). An evaluation of oral midazolam for anxiety and pain in first-trimester surgical abortion: A randomized controlled trial. Obstetrics & Gynecology, 126(1), 37-46.

Belanger, E., Melzack, R., & Lauzon, P. (1989). Pain of first-trimester abortion: A study of psychosocial and medical predictors. Pain36(3), 339-350.

Borgatta, L., & Nickinovich, D. (1997). Pain during early abortion. Journal of Reproductive Medicine, 42(5), 287-293.

Braaten, K.P., Hurwitz, S., Fortin, J., & Goldberg, A.B. (2014). Intramuscular ketorolac versus oral ibuprofen for pain relief in first-trimester surgical abortion: A randomized clinical trial. Contraception89(2), 116-121.

Cade, L., & Ashley, J. (1993). Prophylactic paracetamol for analgesia after vaginal termination of pregnancy. Anaesthesia and Intensive Care21(1), 93.

Duros, S., Joueidi, Y., Nyangoh Timoh, K., Boyer, L., Lemeut, P., Tavenard, A., . . . Lavoue, V. (2018). A prospective study of the frequency of severe pain and predictive factors in women undergoing first-trimester surgical abortion under local anaesthesia. European Journal of Obstetrics, Gynecology and Reproductive Biology, 221, 123-128.

Feng, X., Ye, T., Wang, Z., Chen, X., Cong, W., Chen, Y., … Xie, W. (2016). Transcutaneous acupoint electrical stimulation pain management after surgical abortion: a cohort studyInternational Journal of Surgery, 30, 104-108.

Gray, B. A., Hagey, J. M., Crabtree, D., Wynn, C., Weber, J. M., Pieper, C. F., & Haddad, L. B. (2019). Gabapentin for perioperative pain management for uterine aspiration: A randomized controlled trial. Obstetrics and Gynecology, 134(3), 611-619.

Hall, G., Ekblom, A., Persson, E., & Irestedt, L. (1997). Effects of prostaglandin treatment and paracervical blockade on postoperative pain in patients undergoing first trimester abortion in general anesthesia. Acta Obstetricia et Gynecologica Scandinavica, 76, 868-872.

Horwitz, G., Roncari, D., Braaten, K. P., Maurer, R., Fortin, J., & Goldberg, A. (2018). Moderate intravenous sedation for first trimester surgical abortion: A comparison of adverse outcomes between obese and normal-weight women. Contraception, 97(1), 48-53.

Kan, A. S. Y., Ng, E. H. Y., & Ho, P. C. (2004). The role and comparison of two techniques of paracervical block for pain relief during suction evacuation for first-trimester pregnancy termination. Contraception, 70, 159-163.

Khazin, V., Weitzman, S., Rozenzvit-Podles, E., Ezri, T., Debby, A., Golan, A., & Evron, S. (2011). Postoperative analgesia with tramadol and indomethacin for diagnostic curettage and early termination of pregnancy. International Journal of Obstetric Anesthesia, 20(3), 236-239.

Li, C. F. I., Wong, C. Y. G., Chan, C. P. B., & Ho, P. C. (2003). A study of co-treatment of nonsteroidal anti-inflammatory drugs (NSAIDs) with misoprostol for cervical priming before suction termination of first trimester pregnancy. Contraception, 67, 101-105.

Liu, W., Loo, C. C., Chiu, J. W., Tan, H. M., Ren, H. Z., & Lim, Y. (2005). Analgesic efficacy of pre-operative etoricoxib for termination of pregnancy in an ambulatory centre. Singapore Medical Journal, 46(8), 397-400.

Lowenstein, L., Granot, M., Tamir, A., Glik, A., Deutsch, M., Jakobi, P., & Zimmer, E. Z. (2006). Efficacy of suppository analgesia in postabortion pain reduction. Contraception74(4), 345-348.

Oviedo, J. D., Ohly, N. T., Guerrero, J. M., & Castano, P. M. (2018). Factors associated with participant and provider pain rating during office-based first-trimester vacuum aspiration. Contraception, 97(6), 497-499.

Micks, E. A., Edelman, A. B., Renner, R. M., Fu, R., Lambert, W. E., Bednarek, P. H., … Jensen, J. T. (2012). Hydrocodone-acetaminophen for pain control in first-trimester surgical abortion: A randomized controlled trial. Obstetrics & Gynecology120(5), 1060-1069.

Ndubisi, C., Danvers, A., Gold, M. A., Morrow, L., & Westhoff, C. L. (2018). Auricular acupuncture as an adjunct for pain management during first trimester abortion: A randomized, double-blinded, three arm trial. Contraception, 99(3), 143-147.

Rawling, M. J., & Wiebe, E. R. (2001). A randomized controlled trial of fentanyl for abortion pain. American Journal of Obstetrics & Gynecology, 185, 103-107.

Renner, R. M., Edelman, A. B., Nichols, M. D., Jensen, J. T., Lim J. Y., & Bednarek, P. H. (2016). Refining paracervical block techniques for pain control in first trimester surgical abortion: A randomized controlled noninferiority trial. Contraception94(5), 461-466.

Renner, R.M., Jensen, J.T., Nichols, M.D., & Edelman, A.B. (2010). Pain control in first-trimester surgical abortion: A systematic review of randomized controlled trials. Contraception81, 372-388.

Renner, R. M., Nichols, M. D., Jensen, J. T., Li, H., & Edelman, A. B. (2012). Paracervical block for pain control in first-trimester surgical abortion: A randomized controlled trial. Obstetrics & Gynecology119(5), 1030-1037.

Roche, N. E., Li, D., James, D., Fechner, A., & Tilak, V. (2012). The effect of perioperative ketorolac on pain control in pregnancy termination. Contraception85(3), 299-303.

Romero, I., Turok, D., & Gilliam, M. (2008). A randomized trial of tramadol versus ibuprofen as an adjunct to pain control during vacuum aspiration abortion. Contraception77(1), 56-59.

Royal College of Obstetricians and Gynaecologists. (2015). Best Practice Paper No. 2: Best practice in comprehensive abortion care. London: Royal College of Obstetricians and Gynaecologists.

Singh, R. H., Ghanem, K. G., Burke, A. E., Nichols, M. D., Rogers, K., & Blumenthal, P. D. (2008). Predictors and perception of pain in women undergoing first trimester surgical abortion. Contraception78(2), 155-161.

Suprapto, K., & Reed, S. (1984). Naproxen sodium for pain relief in first-trimester abortion. American Journal of Obstetrics & Gynecology150(8), 1000-1001.

Tschann, M., Salcedo, J., & Kaneshiro, B. (2016). Nonpharmacological pain control adjuncts during first-trimester aspiration abortion: A review. Journal of Midwifery Women’s Health61(3), 331-338.

Tschann, M., Salcedo, J., Soon, R., & Kaneshiro, B. (2018). Patient choice of adjunctive nonpharmacologic pain management during first-trimester abortion: A randomized controlled trial. Contraception, 98(3), 205-209.

Wang, Z., Chen, Y., Chen, C., Zhao, L., Chen, P., Zeng, L., & Xie, W. (2018). Pain management of surgical abortion using transcutaneous acupoint electrical stimulation: An orthogonal prospective study. Journal of Obstetrics and Gynaecology Research, 44(7), 1235-1242.

Warriner, I. K., Meirik, O., Hoffman, M., Morroni, C., Harries, J., My Huong, N. T., & Seuc, A. H. (2006). Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and midlevel providers in South Africa and Vietnam: A randomised controlled equivalence trial. The Lancet368(9551), 1965-1972.

Wells, N. (1992). Reducing distress during abortion: A test of sensory information. Journal of Advanced Nursing, 17, 1050-1056.

Wiebe, E., Podhradsky, L., & Dijak, V. (2003). The effect of lorazepam on pain and anxiety in abortion. Contraception67(3), 219-221.

Wiebe, E. R., & Rawling, M. (1995). Pain control in abortion. International Journal of Gynecology & Obstetrics50(1), 41-46.

Wilson, S. F., Gurney, E. P., Sammel, M. D., & Schreiber, C. A. (2016). Doulas for surgical management of miscarriage and abortion: a randomized controlled trial. American Journal of Obstetrics & Gynecology, 216(1), 44.e1-44.e6.

Wong, C. Y., Ng, E. H., Ngai, S. W., & Ho, P. C. (2002). A randomized, double blind, placebo-controlled study to investigate the use of conscious sedation in conjunction with paracervical block for reducing pain in termination of first trimester pregnancy by suction evacuation. Human Reproduction17(5), 1222-1225.

World Health Organization. (2014). Clinical practice handbook for safe abortion. Geneva: World Health Organization Press.