Clinical Updates in Reproductive Health

Pain Medication Table

The medications listed in the table below are commonly used for pain management during vacuum aspiration and dilatation and evacuation. Many other options exist. This table does not cover general anesthetic agents.

Both anxiolytics and narcotics may cause respiratory depression, especially when they are used together. Accordingly, lower doses should be used when they are together than when they are used separately. When medications are given intravenously immediately before a procedure they should be given slowly and intermittently by a specially trained provider. Problematic side effects can be avoided by repeated small intravenous doses that are titrated to a woman’s level of pain and sedation. The peak analgesic effect should occur during the procedure to avoid excessive postprocedure sedation.

Even clinicians using lighter sedation analgesia must be able to manage respiratory arrest, in the unlikely event that an unintentional overdose should occur. Providers should be trained in airway management and cardiopulmonary resuscitation. Resuscitative equipment and appropriate antagonist drugs (naloxone and flumazenil) should be available.

Disclaimer: This resource is designed to be a supplemental resource for clinicians and is NOT intended to serve as a replacement for drug label information or clinical judgment that accounts for patients’ and facilities’ unique circumstances.

References

De Oliveira, G. S., Agarwal, D., & Benzon, H. T. (2012). Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials. Anesthesia & Analgesia, 114(2), 424-433.

Roche, N. E., Li, D., James, D., Fechner, A., & Tilak, V. (2011). The effect of perioperative ketorolac on pain control in pregnancy termination. Contraception, 85(3), 299-303.

Local anesthetic

Lidocaine

Dose and timing

20ml of 1% solution or 10mL of 2% solution in a paracervical block not to exceed 4.5mg/kg

Half-life

60-90 minutes

Side effects

Ringing in ears; dizziness; numbness in lips, mouth and tongue; metallic taste

Extremely rare: Seizures

Comments

  • Pull back plunger before injecting to avoid intravascular injection
  • Allergic reaction is very rare. Reactions that do occur may be due to preservatives in multi-dose vials. Preservative-free lidocaine allergy is extremely rare.
Nonsteroidal anti-inflammatory drug (NSAID)

Ibuprofen

Dose and timing

Oral: 400-800mg 1 hour before the procedure/p>

Half-life

2 hours

Side effects

Possible gastrointestinal upset

Comments

Do not use in women with active peptic ulcer disease or renal failure

Nonsteroidal anti-inflammatory drug (NSAID)

Naproxen

Dose and timing

Oral: 500mg 1 hour before the procedure

Half-life

12-17 hours

Side effects

Possible gastrointestinal upset

Comments

Do not use in women with active peptic ulcer disease or renal failure

Nonsteroidal anti-inflammatory drug (NSAID)

Ketorolac

Dose and timing

Oral: 20mg 1 hour before procedure IV: 30mg over at least 15 seconds 30-60 minutes before procedure
IM: 60mg 30-60 minutes before procedure For women less than 50kg, all doses should be halved

Half-life

4-6 hours

Side effects

Possible gastrointestinal upset

Comments

  • Single dose IM ketorolac prior to surgery may reduce opioid use and postoperative pain (de Oliveira, 2012; Roche, 2011)
  • Do not use in women with active peptic ulcer disease, renal failure, breastfeeding or sensitivity to other NSAIDs
  • Breakthrough pain should be managed with narcotics rather than increasing ketorolac beyond the recommended doses

Analgesic

Acetaminophen

Dose and timing

Oral: 500-1,000mg 30-60 minutes before procedure

Half-life

2-4 hours

Comments

  • Not a first-line pain medication for vacuum aspiration or medical abortion. May be used as an antipyretic
  • Liver toxicity from overdose (maximum dose = 4,000mg/day) is a risk
Narcotic/analgesic combination

Acetaminophen 300mg + codeine 30mg

Dose and timing

Oral: 1-2 tablets 1 hour before procedure

Half-life

2-4 hours

Side effects

Drowsiness; light-headedness; nausea and vomiting

Comments

Be aware of combining with other acetaminophen-containing products. Liver toxicity from overdose of acetaminophen (maximum dose=4,000 mg/day) is a risk.

Narcotic/analgesic combination

Acetaminophen 500mg + hydrocodone 5mg

Dose and timing

Oral: 1-2 tablets 1 hour before procedure

Half-life

4-6 hours

Side effects

Drowsiness; light-headedness; nausea and vomiting

Comments

Be aware of combining with other acetaminophen-containing products. Liver toxicity from overdose of acetaminophen (maximum dose=4,000 mg/day) is a risk.

Narcotic

Meperidine

Dose and timing

  • Oral: 100-150mg 30-60 minutes before procedure
  • IV: 25-50mg 5-15 minutes prior to procedure
  • IM/SC: 50-100mg 30-90 minutes prior to procedure

Half-life

2-4 hours

Side effects

Drowsiness; light-headedness; nausea and vomiting; decreased breathing rate; loss of consciousness; hypotension; seizures

Comments

  • IM or SC administration preferred over IV
  • If respiration is compromised, assist with breathing (airway management, oxygen and ambu bag) and reverse with naloxone (see Reversal agent for narcotic, below)
  • More rapid onset and shorter duration of action than morphine
  • Meperidine 300mg PO=Meperidine 75mg IV=morphine 10mg IV
Narcotic

Fentanyl

Dose and timing

  • IV: 50-100mcg immediately before procedure (may repeat every 5-10 minutes, not to exceed 250mcg)
  • IM: 50-100mcg 30-60 minutes before procedure

Half-life

4 hours

Side effects

Drowsiness; light-headedness; weakness; bradycardia; decreased breathing rate; loss of consciousness; hypotension; seizures

Comments

  • If respiration is compromised, assist with breathing (airway management, oxygen and ambu bag) and reverse with naloxone (see end of chart)
  • More rapid onset and shorter duration of action than meperidine
  • Fentanyl 100mcg IV = morphine 10mg IV
  • Onset of action is 2-7 minutes when given IV

Narcotic

Tramadol

Dose and timing

  • IV/IM: 50-100mg 15-30 minutes before the procedure
  • Oral/suppository: 50-100mg 60-90 minutes prior to the procedure

Half-life

6-8 hours

Side effects

Drowsiness; light-headedness; sweating; weakness; fatigue; seizures

Comments

  • If respiration is compromised, assist with breathing (airway management, oxygen and ambu bag) and reverse with naloxone (see Reversal agent for narcotic, below)
  • If using IV, inject slowly over 2-3 minutes
  • Less respiratory depression than morphine or meperidine
Anxiolytic (Benzodiazepine)

Diazepam

Dose and timing

  • Oral: 5-10mg 1 hour before procedure
  • IV: 2-5mg 20 minutes before procedure

Half-life

30-60 hours

Side effects

Blurred vision; dizziness; disorientation; pain and redness on injection; decreased breathing rate; loss of consciousness

Comments

  • If respiration is compromised, assist with breathing (airway management, oxygen and ambu bag) and reverse with flumazenil (see Reversal agent for narcotic, below)
  • Has a mild amnestic effect
  • Onset of action is 1-22 minutes when given IV
Anxiolytic (Benzodiazepine)

Midazolam

Dose and timing

  • IV: 1-2mg immediately before the procedure, then 0.5-1mg IV every 5 minutes as needed, not to exceed 5mg
  • IM: 0.07-0.08mg/kg or about 5mg up to 1 hour before procedure

Half-life

2.5 hours

Side effects

Blurred vision; dizziness; disorientation; CNS and respiratory depression

Comments

  • If respiration is compromised, assist with breathing (airway management, oxygen and ambu bag) and reverse with flumazenil (see end of chart)
  • Midazolam 2.5mg=diazepam 10mg
  • Stronger amnestic effect than diazepam
  • Onset of action is 1-5 minutes when given IV and 15-30 minutes when given IM
Anxiolytic (Benzodiazepine)

Lorazepam

Dose and timing

  • Oral: 1-2mg 30-60 minutes before procedure
  • IV: 2mg given over 1 minute 15-20 minutes before the procedure
  • IM: 0.05mg/kg up to a maximum of 4mg within 2 hours before the procedure

Half-life

14 hours

Side effects

Blurred vision; dizziness; disorientation; decreased breathing rate; loss of consciousness

Comments

  • If respiration is compromised, assist with breathing (airway management, oxygen and ambu bag) and reverse with flumazenil (see Reversal agent for narcotic, below)
  • Amnestic effect
Reversal agent for narcotic

Naloxone

Dose and timing

  • IV/IM/SC: 0.4mg every 2 minutes until reversal is seen

Half-life

1-1.5 hours

Comments

  • Naloxone’s duration of action is 1 hour and may wear off before the narcotic. Therefore, patients treated with naloxone must be monitored closely for several hours.
  • Maintain airway and respirations while giving naloxone
Reversal agent for benzodiazepine

Flumazenil

Dose and timing

  • IV: 0.2mg every minute until respirations return. Do not exceed 1mg

Half-life

1 hour

Comments

  • Flumazenil’s duration of action is 1 hour and may wear off before the benzodiazepine. Therefore, patients treated with flumazenil must be monitored closely for several hours. In the event of overdose with narcotic and benzodiazepine, reverse the narcotic first with naloxone and use flumazenil subsequently if needed.
  • Maintain airway and respirations while giving flumazenil
Treatment for hypersensitivity reaction/anaphylaxis

Epinephrine

Dose and timing

  • IM/SC: 0.2-0.5mg every 5 to 15 minutes
  • IV: 0.1mg diluted with 10mL of saline administered over 5 to 10 minutes

Half-life

1 minute

Side-effects

Tachycardia; palpitations; nausea; diaphoresis; dizziness; anxiety

Comments

  • There are no contraindications to epinephrine in the setting of anaphylaxis
  • IM administration preferred
  • Consider giving methylprednisolone 125mg IV
  • Support respiration. If wheezing is present, inhaler may be helpful
  • Immediate intubation if evidence of impending airway obstruction