Last reviewed: October 12, 2022
- A combination of paracervical block and preprocedure nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management is recommended for all people.
- 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 recommended for pain management for routine vacuum aspiration procedures .
- General anesthesia is not recommended for vacuum aspiration pain managementClinicians consistently underestimate the amount of pain people experience during vacuum aspiration.
- Pain management is recommended for all vacuum aspiration procedures, whether they are performed to induce abortion or for postabortion care.
Strength of recommendation: Strong
Quality of evidence: High
Pain during vacuum aspiration
Most people undergoing vacuum aspiration-whether for induced abortion (Borgatta & Nickinovich, 1997) or for postabortion care (Crouthamel et al., 2022; Gomez et al., 2004)-will experience pain. Preprocedure depression or emotional distress, or gestational age beyond 10 weeks, are associated with more pain during uterine aspiration (Allen et al., 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 people experience during abortion (Oviedo et al., 2018; Singh et al., 2008; Tschann et al., 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 people (Renner et al., 2010; Royal College of Obstetricians and Gynaecologists [RCOG], 2022; World Health Organization [WHO], 2022). Intravenous sedation may also be offered (RCOG, 2022; WHO, 2022).
A paracervical block given before dilating the cervix has been shown to decrease pain with dilation and uterine aspiration (Acmaz et al., 2013; Renner et al., 2012; Renner et al., 2016). Paracervical block is a low-risk procedure that can be safely performed by many types of healthcare workers, including physicians, associate/advanced associate clinicians, nurses, traditional and complementary medicine professionals, and health workers who provide basic emergency obstetric care (Warriner et al., 2006; WHO, 2022). For further information, see section 2.5 Paracervical block.
Two small studies examining use of oral NSAIDs alone for vacuum aspiration pain found no benefit (Acmaz et al., 2013; Li et al., 2003). However, pre-procedure treatment with NSAIDs was found to decrease pain during and after the procedure in studies where participants 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 et al., 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 et al., 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), while in another randomized trial, the addition of intravenous fentanyl to the same pain management regimen significantly improved procedural pain (Rawling & Weibe, 2001). Intranasal fentanyl, however, when added to ibuprofen and paracervical block, did not improve pain when compared to placebo (Moayedi et al., 2022). 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, 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). A subsequent trial compared preprocedure gabapentin to placebo amongst women having uterine aspiration under local anesthesia with paracervical block and oral ibuprofen and found no differences in intra-operative or postoperative pain scores (Hailstorks et al., 2020).
Intravenous sedation using a combination of narcotics and anxiolytics is an effective means of pain control and improves satisfaction with the abortion procedure (Allen et al., 2009; Allen et al., 2006; Cansino et al., 2021; Wells, 1992; Wong et al., 2002). Intravenous administration of narcotics and anxiolytics is more effective than oral administration for pain during uterine aspiration (Allen et al., 2009). In people 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 (Cansino et al., 2021). The increased monitoring necessary to deliver intravenous sedation safely requires facility investments in training and equipment. For further information regarding the definition of levels of sedation, including general anesthesia, see Appendix B: Continuum of depth of sedation: Definition of general anesthesia and levels of sedation/analgesia.
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; RCOG, 2022; WHO, 2022). 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 et al. 1997; Renner et al., 2010). For further information regarding the definition of levels of sedation, including general anesthesia, see Appendix B: Continuum of depth of sedation: Definition of general anesthesia and levels of sedation/analgesia.
Non-pharmacologic pain management
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 et al., 2016). Two subsequent randomized trials found no difference in reported pain between those receiving preprocedure music therapy (Belloeil et al., 2020), or 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). Two studies examining the use of auricular acupuncture, in combination with paracervical block and preprocedure NSAIDs, had conflicting results (Ndubisi et al., 2019; Oviedo et al., 2021). Additionally, a third trial combining auricular acupuncture with deep sedation did not find a clinically meaningful improvement in postprocedure pain in the intervention group (Zhu et al., 2022). The use of transcutaneous acupoint electrical stimulation (TEAS) 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). A single well designed randomized controlled trial examined high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) as an alternative to intravenous sedation for aspiration pain relief up to 12 weeks gestation, finding TENS to be non-inferior to sedation (Lerma et al., 2021).
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