Evaluation of Pain Management During First Trimester Surgical Abortions Using Moderate Sedation [3A

Abstract

INTRODUCTION: The Green Journal has emphasized that abortions continue to be painful and has called for research into improving the comfort of therapeutic abortions (TABs). Anesthesia literature defines >4 out of 10 on the Pasero Pain Intensity Scale as unacceptable, which we refer to as “significant pain”. METHODS: We performed a retrospective observational study evaluating pain scores, moderate sedation dosages, and incidence of anesthetic reversal agents among all patients undergoing TAB aspiration procedures by all sixteen providers at an outpatient procedure center from 2012-2014. RESULTS: Of 539 patients, 16% experienced significant pain just before TAB from misoprostol placed pre-procedure, 28% experienced significant pain during the TAB procedure, and 18% experienced pain beyond their stated comfort threshold. Half of procedures started with low doses of ≤1mg midazolam and ≤100mcg fentanyl. Additional doses of fentanyl and/or midazolam were received intraoperatively by 54% of patients; these patients were more likely to report significant pain (P < .0001). Reversal agents were never needed. CONCLUSION: Over one quarter of patients experienced unacceptable levels of pain in this study of first trimester surgical TABs. Obstetrician-gynecologists administering conscious sedation may not be aware of under-medicating their patients. In over half of TAB cases, the provider recognized part-way through the short procedure that the patient required additional sedation. Obstetrician-gynecologists performing TABs and similar procedures such as diagnostic hysteroscopy may consider administering higher initial sedative doses, with minimal risk of oversedation. Future study of preoperative analgesia, such as ibuprofen administration concomitant with miso placement, is warranted to evaluate improvement in intra-procedural pain.