First-trimester Surgical Abortion Research Articles

Patient Preferences and Expectations in Analgesia for First Trimester Surgical Abortion

<i>A central component of a patient’s abortion experience is pain perception and optimization of pain management choices. Yet, data on patients’ experience of pain and their preferences regarding pain strategies are limited and tend to utilize solely quantitative data. This study utilized a qualitative thematic analysis to identify patient priorities, preferences, and expectations for pain management during first-trimester surgical abortion with nitrous oxide or oral sedation. Thirty-one patients seeking a first-trimester surgical abortion, self-selecting inhaled nitrous oxide (NO) (16 patients), or oral sedation (PO) with oxycodone and Ativan (15 patients) enrolled in this prospective cohort study. Participants provided demographic data, rated procedure pain on a 10 cm visual analog scale (VAS), and participated in semi-structured interviews. We analyzed qualitative data using a content analysis approach. Pre-procedure participants wanted a positive experience. Participants endorsed an ideal analgesic as having a quick onset of action, minimal side effects, no addiction potential, and being effective at reducing pain. After the procedure, there we start differences between priorities in NO and PO participants. NO participants valued the resumption of everyday activities, while PO participants desired ongoing anxiolysis. Anticipatory counseling often mitigated higher procedure pain and more medication side effects than anticipated. Participants emphasized that positive interactions with providers/staff significantly improved their abortion experience. Preemptive comprehensive counseling about procedure and analgesic effectiveness, along with providing options for analgesia, will facilitate an affirmative and patient-centered abortion experience.</i>

A survey of obstetric and gynaecology doctors at an Australian metropolitan tertiary hospital to understand their views, training and confidence in abortion care.

The barriers to comprehensive abortion care in Australian metropolitan tertiary hospitals are under-researched. Previous work has suggested that negative practitioner attitudes and lack of training may play a large role; however, this remains poorly understood. The aim was to survey doctors practicing obstetrics and gynaecology to better understand their views, training experience and confidence in abortion care. The method involved a cross-sectional study via an anonymous survey at a single metropolitan tertiary hospital not providing substantive abortion services in Melbourne, Australia. Inclusion criterion was obstetric and gynaecology medical staff working at that hospital. Data were collected regarding views, training experiences and confidence in first-trimester medical and surgical abortion, and second-trimester surgical abortion. Data were analysed according to levels of training, categorised as RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) Fellows, prevocational/vocational trainees and general practitioner specialists. Sixty-one valid responses were received from 90 eligible participants (response rate 68%). An overwhelming majority (96%) supported abortion services. The majority of RANZCOG Fellows felt confident performing first-trimester surgical abortion (89%) and first-trimester medical abortion (71%); however, only half felt confident performing second-trimester surgical abortion (50%). Prevocational/vocational trainees were overall less confident but overwhelmingly expressed interest in gaining further experience in abortion. Doctors are generally confident in providing first-trimester abortion services (medical or surgical) in the metropolitan tertiary setting. However, further work is required to understand ongoing barriers to comprehensive abortion care. There may also be a skills shortage for second-trimester surgical abortion, requiring significant improvements in abortion training.

Comparison of the efficacy of paracervical block in first-trimester surgical abortion to endometrial sampling and its relation to anxiety

Psychological support, premedication with analgesics, and local anesthesia are the most widely used methods for pain management during gynecological surgeries. The World Health Organization's (WHO) Safe Abortion Technical and Policy Guidance for Health Systems Guideline recommends the use of manual vacuum aspiration for first-trimester induced abortions for pain management. We aimed to compare the efficacy of lidocaine used for pain management in first-trimester voluntary termination to endometrial sampling and its relation to anxiety.

Intravenous Ketamine for Pain Control in First-Trimester Surgical Abortion: Interim Analysis of a Randomized Controlled Trial

ObjectivesSurgical abortion is common, with most completed in the first trimester. Gold standard pain control is intravenous (IV) fentanyl and midazolam, requiring continuous cardio-respiratory monitoring, a potential challenge where this monitoring is unavailable. Ketamine is a sedative and analgesic without the cardio-respiratory depression risk associated with IV opioids, representing a potential alternative. Investigating non-opiate pain control methods is imperative given the context of the opioid crisis. This is an interim analysis of 45 participants from a randomized controlled trial comparing IV ketamine, oral morphine, and IV fentanyl for pain control in first-trimester surgical abortion. We hypothesize that ketamine will provide better pain control than morphine. MethodsThis is a double-blind, single-centre superiority trial of 3 parallel groups. Participants were ≥18 years old with confirmed intrauterine pregnancy of gestational age <12 weeks. Pain was assessed using the Visual Analogue Scale and the Wong-Baker Faces Pain Rating Scale. ResultsIn total, 2 participants were excluded post-randomization for 43 treated. Findings indicate that ketamine (n = 14; M = 0.7; 95% CI 0.1–1.3) provides better intra-operative pain control than morphine (n = 15, M = 4.4, 95% CI 2.9–5.9) and fentanyl (n = 14; M = 4.3; 95% CI 3.0–5.6; P < 0.001). The ketamine group was more satisfied with the anaesthetic method than the morphine group (P = 0.017). No group experienced serious adverse events. ConclusionsFindings support continuation of the randomized controlled trial and highlight ketamine as a compelling non-opiate pain control option in first-trimester surgical abortion. Ketamine use may represent more optimal pain control in settings where continuous cardio-respiratory monitoring is unavailable.

Comparing Early COVID-19 Abortion Care Innovations in Hospital Versus Nonhospital Clinics: Data From a Nationwide Survey of Abortion Providers [ID: 1370918

INTRODUCTION: We examined differences between hospital-affiliated clinics and non-hospital-affiliated (independent of Planned Parenthood) clinics regarding abortion service innovation in response to the early COVID-19 pandemic. METHODS: We analyzed data from the third phase of a longitudinal nationwide survey of abortion providers conducted by the Society of Family Planning (collected August to October 2020). We analyzed adoption of abortion service innovation, comparing hospital-affiliated clinics to non-hospital-affiliated clinics that included adoption of no- or low-test or low-touch practices for medication abortion and first-trimester surgical abortion. RESULTS: Sixty-one clinics completed the survey (30 hospital affiliated, 31 non-hospital affiliated). We found hospital-affiliated clinics were more likely to be in the Northeast and West (P&lt;.01). We found evidence of adoption, but no significant difference between clinic type in changes in gestational limit, changes in Rh testing policy, or adoption or expansion of telehealth services for pre-abortion counseling. Hospital-affiliated clinics were more likely to have reported making any change to abortion services in response to the pandemic (100% versus 87%, P&lt;.04). Hospital-affiliated clinics were also significantly more likely to start/expand telemedicine visits for follow-up visits for medication abortion (odds ratio [OR] 6.63, 95% CI 1.6–26.8) and first-trimester surgical abortion (OR 12.75, 95% CI 3.1–51.9). CONCLUSION: Abortion care changed quickly, regardless of setting, when the stresses of COVID-19 hit the U.S. health care system. System-wide abortion care changes suggest successful information sharing regarding best practices and recommendations in abortion provision, which should continue to be promoted as the pandemic continues.

First-trimester surgical abortion practice in Canada in 2012

To evaluate practices among first-trimester surgical abortion facilities and providers in Canada in 2012 and examine the characteristics of the surgical abortion work force. Self-administered paper or electronic survey adapted from a survey previously fielded in the United States. Canada. Facility administrators and physicians. Descriptive statistics on reported first-trimester surgical abortion practice and provider demographic characteristics. Eighty-three percent of identified facilities (78 of 94) and 178 physicians responded. Of the respondents, 99% of facilities and 96% of physicians provided first-trimester surgical abortions. Responding facilities provided 68,154 first-trimester surgical abortions in 2012. This represented 96% of their reported total (combined medical and surgical) first-trimester abortions. More than half (55%) of responding facilities were community based, while 45% were hospital affiliated. Most physician providers were female (68%) and were family doctors (59%). Preoperatively, 96% of physicians routinely used ultrasound and 89% gave perioperative antibiotics. Almost half (48%) used manual vacuum aspiration, but less than 35% did so beyond 9 weeks after the last menstrual period. At most facilities, most procedures were performed under combined local anesthesia and intravenous sedation (73%); only 7% indicated deep sedation or general anesthesia were used exclusively. Postoperatively, 81% of physicians performed immediate tissue examination and 96% offered postabortion contraception on the same day as the abortion. Other assessed outcomes included medication regimens and cervical preparation, with a high degree of consistency among facilities and physicians. First-trimester surgical abortion providers are mostly family physicians and most are female. Practices across Canada were mostly uniform and followed evidence-based guidelines. Uptake of the most recent Canadian practice guidelines may help further standardize patient care and improve routine perioperative antibiotic use and immediate tissue examination.

P038Ketamine versus fentanyl for surgical abortions: A randomized noninferiority trial

<h3>Objectives</h3> To compare patient satisfaction with anesthesia after first-trimester surgical abortions among patients receiving intravenous ketamine vs. IV fentanyl for procedural sedation. <h3>Methods</h3> This was a randomized noninferiority trial comparing IV ketamine to IV fentanyl for surgical abortions up to 13 6/7 weeks' gestation. Patients were randomized to receive midazolam 2 mg IV and either ketamine 200–500 mcg/kg IV over two minutes, repeated every five minutes until appropriate analgesia was achieved, or fentanyl 0.5–1 mcg/kg IV over two minutes, repeated every five minutes until appropriate analgesia was achieved. The primary outcome, patient satisfaction, was measured using the Iowa Satisfaction with Anesthesia Scale (ISAS) immediately post-procedure. Secondary outcomes included postoperative pain and additional pain medication given. We calculated a sample size of 84 with a noninferiority margin of 0.6 on the ISAS scale with 80% power, one-sided type 1 error of 0.025, and further increased this number to 110 to account for potential dropout. <h3>Results</h3> From April to October 2021, 184 patients were screened and 110 were randomized (57 to ketamine and 53 to fentanyl). Demographics were similar between groups. The primary outcome, patient satisfaction with anesthesia, was noninferior in the ketamine group (mean score, 2.4; SD, 0.8) compared with the fentanyl group (mean score, 2.2; SD, 0.9) with a risk difference of 0.20 (95% CI, 0.11–0.52). Secondary outcomes were similar between the groups. <h3>Conclusions</h3> Compared with IV fentanyl, IV ketamine is noninferior for patient satisfaction with anesthesia when used for procedural sedation for first-trimester surgical abortions.

Abortion services and providers in Canada in 2019: results of a national survey.

Background:Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion.Methods:We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics.Results:Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (n = 2334) of all abortions in rural areas, as opposed to 25.6% (n = 11 067) in urban areas.Interpretation:The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.

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Comparison of Analgesic Effects between Nalbuphine and Sufentanil in First-Trimester Surgical Abortion: A Randomized, Double-Blind, Controlled Trial.

IntroductionSurgical abortion is one of the commonly conducted procedures worldwide. Nevertheless, pregnant women still complain of procedural and postoperative pain despite the use of advanced anesthesia. It is vital to women’s reproductive healthcare to improve postsurgical pain management to achieve the lowest level of pain.MethodsThis randomized, double-blind, parallel-controlled clinical trial compared the analgesic effects between nalbuphine and sufentanil in patients who underwent first-trimester surgical abortion. In total, 224 patients were allocated randomly into (a) the sufentanil group that received sufentanil (0.1 ug/kg) combined propofol, and (b) the nalbuphine group that received nalbuphine (0.1 mg/kg) combined propofol. Postoperative pain scores, propofol injection pain, intraoperative analgesic effect, adverse events, and degree of satisfaction were recorded as outcome measures.ResultsThe pain scores in the nalbuphine group were lower than those in the sufentanil group at 15 min, 30 min, 1 h, and 6 h after surgical abortion. In addition, the incidence and intensity of propofol injection pain were lower in the nalbuphine group. The degree of satisfaction of the patients in the nalbuphine group was higher than that in the sufentanil group. The intraoperative analgesic effect, hemodynamic fluctuation, and adverse events were comparable between the two groups.ConclusionsNalbuphine combined with propofol is superior to sufentanil combined with propofol for first-trimester abortion surgeries.Clinical Trial RegistrationThe trial was registered at www.chictr.org.cn, identifier ChiCTR2000040243.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-021-00334-0.

Pain Associated With Cervical Priming for First-Trimester Surgical Abortion: A Randomized Controlled Trial.

Pain Associated With Cervical Priming for First-Trimester Surgical Abortion: A Randomized Controlled Trial.

Fear of childbirth after medical vs surgical abortion. Population-based register study from Finland.

To evaluate the effect of method of induced abortion and other abortion-associated variables on the incidence of fear of childbirth in subsequent pregnancy. This population-based register study cohort includes all nulliparous women with their first pregnancy ending in an induced abortion in 2000-2015 and subsequent pregnancy with live singleton delivery between 2000 and 2017 (n=21479). Data were derived from three national registers maintained by the Finnish Institute for Health and Welfare. We divided the study population in three cohorts: (a) medical and (b) surgical abortion during first trimester (≤84days of gestation), and (c) medical abortion during second trimester (85-168days of gestation). Primary outcome measures were the incidence of registry-identified fear of childbirth and cesarean delivery related to it. The overall incidence of fear of childbirth was 5.6% (n=1209). Altogether, 19.2% (n=4121) of women underwent cesarean delivery. The odds were elevated especially for elective cesarean delivery (odds ratio [OR] 9.30, 95% CI 7.95-10.88, P<.001) in women with fear of childbirth. In multivariable analysis, the odds for fear of childbirth (adjusted OR [aOR] 0.80, 95% CI 0.68-0.94) and cesarean delivery (aOR 0.66, 95% CI 0.84-0.90) were decreased in women with a history of first-trimester medical abortion compared with those with first-trimester surgical abortion. Second-trimester medical abortion had no effect on the odds for fear of childbirth (aOR 1.04, 95% CI 0.71-1.50). Maternal age of 30-39years and interpregnancy interval over 2years were additional risk factors for both fear of childbirth and cesarean delivery, but surgical evacuation of uterus after the abortion was not. One first- or second-trimester medical abortion does not increase the odds for fear of childbirth, and cesarean delivery related to it in subsequent pregnancy when compared with first-trimester surgical abortion. Older maternal age and longer interpregnancy interval emerged as risk factors for fear of childbirth.

Complications Associated with First-trimester Surgical Abortion at Ain-Shams Maternity Hospital over the period from January 1, 2016 to December 31, 2017

Background: First trimester surgical abortion is a common obstetric procedure with some known complications.Objective: The aim of this study was to examine the incidence of major complications of first trimester surgical abortion in Ain-Shams Maternity Hospital.Patients and Methods: Retrospective record-based case series in which records of patients who underwent first trimester surgical abortion in the period from January 1st, 2016 till December 31st, 2017 were examined.Results: A total of 1003 patients underwent first trimester surgical abortion. The overall major complication rate was 18.2%. There was a higher incidence of one or major complications in patients with previous abortions (P-value <0.002), valve replacement (P- value 0.001), missed and septic abortions, those requiring cervical dilatation, less hemoglobin, higher total leucocytic count, higher PTT.Conclusion: First trimester surgical abortion is a relatively safe procedure with hemorrhage being the most common complication.

Transcutaneous electrical nerve stimulation (TENS) for pain control during first-trimester abortion: A single-blinded randomized controlled trial

Introduction High-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS), pulsating electrical currents that activate underlying nerves, is an inexpensive and non-invasive pain control approach. We sought to compare TENS to intravenous sedation (IV) for pain control in first-trimester surgical abortion. Method We conducted a non-inferiority, single-blinded, randomized controlled trial of participants undergoing surgical abortion up to 11 weeks’ gestation. Participants received TENS (electrodes parallel to the spinal cord at the T10-L1 and S2-S4 levels) or IV (100mcg fentanyl and 1mg versed). Providers administered the IV sedation and research staff administered the TENS and were therefore not blinded. The primary outcome was self-reported pain with aspiration (visual analogue scale, VAS 100mm, 0 “no pain” and 100 “worst pain imaginable”). Non-inferiority limit was defined as 15mm. We also assessed participant demographics and blinding. Results A total of 109 participants were enrolled (55 TENS, 54 IV) between January 2018 and October 2019. Participants had a mean gestational age of 56-days across groups (p = 0.88); groups were similar with regard to age, race and ethnicity, parity, and BMI. Nine (16%) in the TENS group were given IV sedation and excluded from the per-protocol analysis. 100 participants were included in the per-protocol analysis (46 TENS, 54 IV). Mean reported VAS for aspiration was 64.78 mm (SD24.16) and 60.35mm (SD26.06) in the TENS and IV groups, respectively, with a mean difference of 4.43mm (95% CI −5.6 to 14.47). One IV group participant received additional IV medications (2%). Post-procedure, in both groups the majority of participants identified their correct assignment (p = 0.96); one in five in both groups incorrectly identified their assignment (21.7%, n = 10 TENS; 22.2%, n = 12 IV). Intention-to-treat analysis (n = 109) yielded non-inferior results for the primary outcome. Conclusions TENS for pain control during first-trimester surgical abortion is non-inferior to IV sedation with respect to the primary outcome of pain with aspiration. TENS could be a pain control option for patients without access to IV sedation or for those who are ineligible to receive IV sedation due to additional cost, lack of sedation provider or restrictions, including the need for a designated driver. Expanding pain control options improves quality of care and access to abortion.

Immersive Virtual Reality Intervention for Anxiety Reduction During In-Office Dilation and Curettage [4B

INTRODUCTION: Progress in virtual reality (VR) has generated interest in using VR as a method for managing patient anxiety and subsequently decreasing pain. We assessed the practicality and effects of VR use among patients presenting for first-trimester surgical abortion at our academic center. METHODS: In this prospective pilot study, we consented women presenting for first trimester surgical abortion in office under local anesthesia. We enrolled a convenient sample of 30 participants (15 experimental and 15 control). Experimental participants were given a commercially available VR device to wear during the procedure. Anxiety scores using Modified Amsterdam Preoperative Anxiety and Information Survey (MAPAIS) and the Visual Analog Scale (VAS) were recorded before, during, and after the procedure in both groups. RESULTS: The two groups showed no significant differences in anxiety prior to procedure (P=0.29). On average the experimental group demonstrated lower anxiety during and after the procedure though results were not statistically significant in the pilot phase. Among participants in the experimental group, those who used the VR device for over 5 minutes (n=11) had statistically significant decrease in anxiety compared to those who used the device for a shorter period of time (n=4) (P=0.018). CONCLUSION: Our results suggest that VR can be used during in-office dilation and curettage and may have an impact on decreasing procedure-related anxiety. Based on our findings, we determine that a sampling size of 156 total participants would be sufficient for a target power of 0.80.

Comparative study between paracervical block and general anesthesia for pain control in first-trimester surgical abortion

Introduction Pain perception is a complex phenomenon that impacts the selection of analgesia. The majority of first-trimester surgical abortions in United States are performed with a paracervical block (PCB). Satisfactory pain control for women undergoing surgical abortion is important for patient comfort and satisfaction. Aim of the work The aim of this study was to estimate the pain related to first-trimester abortion under local or general anesthesia. Patients and methods A hundred female patients (American Society of Anesthesiologists)(ASA) I-II undergoing dilatation and curettage were randomly allocated into two equal groups. Group A (n=50): they received a PCB with 5 ml of 2% lidocaine injected into each side of cervix at the 3 and 9 o'clock positions. Group B (n=50): they received general anesthesia with intravenous bolus of 2.5 to 4 mg/kg propofol and 1 µg/kg fentanyl, and maintained anesthesia by 1 mac isoflorine in oxygen as inhalational anesthesia by face mask. Results The study showed that the most commonly prevalent type of pain by the visual analog scale is in group A during aspiration, curettage, and immediately postoperatively as 41; 27 and 48 patients felt mild pain, respectively; while during dilatation increase incidence of moderate pain as 26 (52%) patients felt moderate pain. Conclusion The PCB is more preferred than general anesthesia under condition that we wait a few minutes before beginning the procedure as it insures the satisfaction of the patient while avoiding the side effects of general anesthesia and is also not as expensive.

Factors Shaping Women's Pre-abortion Communication with Members of Their Social Network.

To understand women's pre-abortion conversations with members of their social network about their abortion decision. Semi-structured interviews were conducted with women presenting for first-trimester surgical abortion at a high volume, hospital-based abortion clinic. Women were asked their reasons for discussing or not discussing abortion and responses received after disclosing their abortion decision. Interviews were transcribed and computer-assisted content analysis was performed. Salient themes are presented. Thirty women who obtained an abortion were interviewed. All but three spoke to at least one member of their social network about their abortion decision making. However, women were very selective about whom they spoke to regarding this decision. Reasons not to discuss their abortion decision included: concerns about judgment, desiring to maintain privacy, and certainty about their decision. Reasons to discuss their abortion decision included: seeking information about the procedure, needing guidance about their decision, wanting support for their decision to proceed with abortion. While many were concerned about being judged, most women who spoke about their decision experienced a positive response. Though most women in this study had at least one person to turn to for assistance with abortion decision making, many participants avoided confiding in some or all members of their social network about their abortion decision due to concerns of judgment and stigma.

Factors associated with anesthesia choice in outpatient first-trimester surgical abortion

Factors associated with anesthesia choice in outpatient first-trimester surgical abortion

A randomized controlled trial of three prophylactic antibiotic regimens for first-trimester surgical abortion

Objectives: We aimed to assess side effects of prophylactic oral metronidazole, doxycycline and azithromycin vs. placebo among women undergoing surgical abortion. A substudy assessed serum drug levels and utility of endometrial cultures to examine bacterial burden after surgical abortion.

What is the most effective method of preprocedural cervical dilation for first-trimester surgical abortion?

EVIDENCE-BASED ANSWER Misoprostol 400 μg, administered vaginally 3 hours before or sublingually 1 hour before first-trimester surgical abortion, is effective for preprocedural cervical dilation but causes more nausea than placebo, especially the sublingual route. Mifepristone may have a greater effect on cervical dilation than misoprostol, but requires dosing 24 hours before the procedure. Vaginal laminaria and vaginal misoprostol are equivalent in terms of need for additional mechanical dilation and average difference in duration of procedure (SOR: C, meta-analysis of RCTs and a noninferiority RCT with disease-oriented outcomes). The Society for Family Planning recommends limiting use of preprocedural cervical ripening medications to patients at increased risk for complications from cervical dilation (SOR: C, expert opinion).