Anesthesia for Abortion Procedures

Abstract

Abortion procedures are associated with some degree of pain, and managing pain is an essential goal in caring for patients who undergo this procedure. Patients seeking abortion should be counseled on all pain-management options, which include nonpharmacologic methods, local cervical anesthetic injection, oral medication, intravenous sedation, and general anesthesia. Organizations, including the American Society of Anesthesiologists, the National Abortion Federation, and the Planned Parenthood Federation of America have published evidence-based guidelines for anesthesia administration to patients receiving abortion care. Abortion-care practices should have pertinent anesthesia and procedural policies consistent with the care setting, whether they are hospital-based or freestanding sites. These policies should follow guidelines set by national medical institutions and not include additional targeted regulation of clinics or providers of abortion care. (J GYNECOL SURG 38:324)

Introduction

Abortion procedures are associated with some degree of pain, and managing pain is an essential goal in caring for patients undergoing these procedures. There are several management options for pain, including verbal support, nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthesia, intravenous (IV) sedation, and general anesthesia. The pain-management plan depends on several factors, including patient preference, procedural considerations, and clinical resources. Patients' ability to access specific types of anesthesia may also be limited by state regulations or hospital policies.¹ Organizations including the American Society of Anesthesiologists (ASA), the National Abortion Federation (NAF), and the Planned Parenthood Federation of America (PPFA), have published evidence-based guidelines for anesthesia administration to patients receiving abortion care.^1–3

Surgical-Pain Physiology and Factors Influencing Abortion-Procedure–Related Pain

Pain related to abortion procedures stems from stimulation of sensory fibers that innervate the uterus and cervix. The upper vagina, cervix, and lower uterine segment are innervated by parasympathetic fibers from S-2 to S-4, which enter along the uterine blood vessels at the 3 and 9 o'clock positions of the cervix. The uterine fundus is innervated by sympathetic fibers from T-10 to L-1 via the inferior hypogastric nerve, which enters at the uterosacral ligament and ovarian plexus at the uterine cornua.

Pain experienced during an abortion procedure is influenced by several factors. Self-reports of depression, anxiety, and fear of procedural pain are predictors of perceived procedural pain.⁴ Other patient factors that may be associated with increased pain perception include younger age, a retroverted uterus, a history of dysmenorrhea, and gestational age.^4,5 Clinician recognition of these factors may help anticipate the patient's analgesic needs during the procedure.

Studies investigating pain perception are challenging due to the complex nature of patients' pain perceptions and experiences. It is difficult to compare studies due to the variability of study designs and different pain scales used in research. There can also be a lack of correlation between a patient's pain score and her overall satisfaction with the procedure.^5–7

Nonpharmacologic Methods

Verbal support techniques can be used alone or as adjuncts to pharmacologic methods.⁵ These strategies include use of gentle language, positive suggestion, relaxation techniques, and/or guided imagery. Gentle language avoids using negative phrases such as “this medication may cause burning or stinging” and instead replacing these phrases with positive ones, such as “this medication will numb your cervix.”^4,5 Relaxation techniques include breathing exercises and coaching the patient to relax her muscles prior to starting the procedure. Guided imagery can also be an effective strategy to help patients relax and cope with procedure-induced pain.⁴ This technique involves harnessing a patient‘s imagination to focus attention on pleasant sensory experiences. Other nonpharmacologic approaches include acupuncture and transcutaneous electrical nerve stimulation.⁶ These methods may be used by the clinician performing the procedure, but may also be used by a trained support person or doula.⁶

Local Anesthesia

Local anesthesia is effective for reducing pain associated with abortion procedures.^4,5 The most-common local anesthetics used in abortion care are amides, such as 0.5% or 1% lidocaine or 0.25% bupivacaine.⁴ While bupivacaine has a longer duration of action than lidocaine (4–8 hours versus 1–2 hours), disadvantages include more-painful administration and a higher risk of cardiotoxicity.⁵ These amide local anesthetics can be buffered with sodium bicarbonate to decrease pain during administration. Local anesthetics may be used alone or mixed with vasoconstrictors, such as epinephrine or vasopressin.⁴ The addition of a vasoconstrictor also leads to slower reabsorption of the anesthetic, which can produce a longer-lasting anesthetic effect and lower serum levels.⁴ A commonly used solution is 20 mL of 1% buffered lidocaine mixed with 4 units of vasopressin.⁵ The addition of ketorolac to lidocaine has also been shown to decrease perceived pain associated with cervical dilation during first-trimester surgical abortion.⁸

Injection of local anesthesia to the anterior lip of the cervix can reduce pain associated with tenaculum placement quickly and effectively.⁵ A paracervical block is then completed by injection of local anesthetic, typically at the 4 and 8 o'clock positions. Injection at these positions anesthetizes the nerve bundles lateral to the cervix and uterosacral ligaments while avoiding direct injections into the cervical branches of the uterine arteries. Some clinicians inject the anesthetic directly into the cervical stroma (intracervical injections).⁴ The number and depth of injections varies by clinicians. The strength of the lidocaine (0.5% versus 1%), the type of anesthetic (lidocaine versus bupivacaine versus ropivacaine), the wait time (immediate versus waiting 3 minutes) have not been shown to affect efficacy. Slow injection (more than 60 seconds, compared to 30 seconds) and deep injection (3 cm versus 1.5 cm) may decrease pain.^4,5,9 The most commonly used technique by North American clinicians comprises 4 point paracervical injections at the 2, 4, 8, and 10 o'clock positions at a depth of less than 3 cm.⁴

Abortion-related deaths and adverse events due to local anesthesia are rare. To avoid fatal lidocaine toxicity, the maximum dose of lidocaine without epinephrine should not exceed 4.5 mg/kg or 300 mg total.⁵ At lower serum concentrations, lidocaine can cause tinnitus and oral paresthesia. At higher levels, seizures, arrythmias, or cardiorespiratory arrest can occur.^2,5 The commonly used dose of 20 mL of 1% of lidocaine (200 mg), with or without vasopressin, falls below the lidocaine toxicity threshold.^4,5 Allergic reactions to local anesthetics are also rare. Reactions are more common with ester anesthetics, such as procaine or when lidocaine with epinephrine is used, as this solution contains the preservative sodium metabisulfite.^4,5

Oral Medications

Several studies have evaluated the use of oral NSAIDs, antianxiolytics, and opioids for intraoperative and postoperative abortion procedure–related pain, either alone or in combination with local anesthesia. Studies investigating the administration of oral NSAIDs, including ibuprofen or naproxen 30 minutes to 2 hours before an abortion procedure, found better intraoperative and postoperative pain management than placebo or no medication.^2,6 Other studies investigating administration of preprocedural oral opioids, including hydrocodone–acetaminophen or tramadol, demonstrated these opioids were less effective for management of pain, compared to NSAIDs or placebo.^4,5 Preoperative administration of antianxiolytics may decrease anxiety, but studies to date have not demonstrated any benefit in reducing procedural pain.^5,6 Lorazepam is a commonly chosen antianxiolytic, with a typical dose of 1–2 mg administered either orally or sublingually.^5,6

IV Sedation

Different regimens may be used to induce sedation (depression of awareness), analgesia (insensibility to pain), and/or anesthesia (loss of sensation, with or without loss of consciousness).¹⁰ The ASA defines the continuum of depth of sedation by a patient's responsiveness, airway status, presence or absence of spontaneous ventilation, and overall cardiovascular function; these levels include minimal sedation, moderate sedation, deep sedation, and general anesthesia (Table 1).¹¹ The ASA also developed a physical-status classification system that can be used as a guide to assess a patient's anesthesia-related risk.^2,11 This classification system, by itself, cannot be used to describe patient risk from surgery adequately because the system does not specify type of anesthesia and lacks a risk index for the surgery itself. Anesthesia and surgical risks should be evaluated together when determining a patient's overall risk.^2,10

Table 1.

Continuum of Depth of Sedation

Levels of sedation	Definition
Minimal sedation	• Normal response to verbal stimulation • Airway and cardiovascular function unaffected
Moderate sedation	• Response to verbal commands or to light tactile stimulation • Airway remains patent without intervention • Ventilation is spontaneous and cardiovascular function usually maintained
Deep sedation	• Response to repeated painful stimulation • Intervention may be required to maintain a patent airway & spontaneous ventilation • Cardiovascular function usually unaffected
General anesthesia	• Cannot be aroused even by painful stimulation • Ability to maintain ventilatory function or a patent airway independently is often impaired • Positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function • Cardiovascular function may be impaired

Adapted from references 10 & 11.

Both NAF and PPFA have policies that regulate the use and dosing schedules of specific medications used for sedation (Table 2).^1,3,10 When sedation is used, the medication should be started at a low dose and titrated as needed based on individual factors, such as a patient's weight and drug tolerance.¹

Table 2.

Recommended Dosing for Commonly Used Medications to Induce Moderate Sedation

Drug	Usual initial dose	Maximum initial dose	Usual incremental dose	Maximum incremental dose	Onset of Action	Duration
Fentanyl (opioid analgesic)	50–100 μg	200 μg	50–100 μg	100 μg	Almost immediate	0.5–1 hrs
Midazolam (benzodiazepine sedative)	1–3 mg	4 mg	1–2 mg	2 mg	3–5 min	< 2 hrs

Adapted from references 1 & 10.

hrs, hours; min, minutes.

Moderate sedation is often referred to as “conscious sedation.”^1,11 Fentanyl and midazolam are the most commonly used medications in combination to induce moderate sedation.⁴ Midazolam is a benzodiazepine that works as a sedative and anxiolytic. It also induces retrograde amnesia. There is little effect on the cardiovascular or pulmonary system; however, if needed, the effect can be reversed with the antagonist flumazenil. Midazolam is shorter-acting, compared to other benzodiazepines, which can lead to faster anesthesia recovery time for patients. Fentanyl is a narcotic that provides analgesia and mild euphoria. This narcotic has a rapid onset and short duration of action. Fentanyl is also 100 times more potent than morphine, and administration can result in dose-dependent respiratory depression. Naloxone, an opioid antagonist, can reverse the respiratory effect efficiently without comprising the analgesic effect of fentanyl.⁴

Several studies have demonstrated that moderate sedation can decrease procedure-related and postoperative pain and can also improve a patient's satisfaction related to the procedure.¹⁰ In 1 study, patients who received moderate sedation and local anesthesia reported better pain control and overall satisfaction, compared to patients who only received local anesthesia.⁷ Another benefit of sedation is improved operative conditions for the clinician by facilitation of muscle relaxation and visualization.⁴ Use of sedation can also decrease use of postoperative analgesia.⁴

Propofol is the most commonly used medication for inducing deep sedation and general anesthesia.⁴ Once administered, propofol has a rapid onset with unconsciousness achieved in less than 30 seconds. Combining propofol with other medications such as fentanyl can enhance the analgesia effect but can also lead to respiratory depression. There is no specific reversal agent for propofol. Other side-effects of propofol include pain during injection and risk of an allergic reaction.

Halogenated agents, such as halothane or isoflurane, cause uterine relaxation, which can increase bleeding. These agents are typically not recommended for use in abortion procedures. There are limited data regarding bleeding risk of sevoflurane, a newer halogenated agent.¹⁰

Risks of Opioids and Sedatives

Anesthesia side-effects range from mild to life-threatening. Nausea and vomiting are common side-effects of several anesthesia medications. Other anesthesia-specific side-effects include pruritus from opioids or paradoxical agitation from benzodiazepine use.^4,5,10 More-serious adverse events are possible with specific anesthesia agents. When opioids and benzodiazepines are used in combination, their sedative effects may be additive.¹⁰ The Centers for Disease Control and Prevention reported anesthesia-related abortion mortality in the United States for 1998–2010, noting that, with ∼16.1 million abortion procedures, 108 deaths occurred (a mortality rate of 0.7 per 100,000 procedures), with 22 deaths (20% of the total) attributed to anesthesia complications. The report did not include information on clinical settings or the types of anesthesia used. In a systematic review of first-trimester abortion procedures, White et al. noted that 0.02% anesthesia-related complications occurred during procedures in office-based settings and during <0.5% of procedures in surgical centers and hospitals; there were no deaths.¹²

Pre- and Postoperative Anesthesia Evaluation

Patient evaluation and preparation for the intended level of sedation is primarily based on the patient's anesthesia and surgical risk and the facility's ability to manage these complications. Patient should undergo a presedation evaluation, including a medical history; a review of systems; a medication review; a targeted examination of the heart, lungs, and airway; and a review of baseline vital signs.^1,2

IV sedation can be administered safely by nonanesthesia clinicians. Specific licensure may be required due to state and/or hospital restrictions.¹³ Care by an anesthesia professional should be considered for patients with atypical airway assessments or ASA Physical Status Classifications ≥3.¹ When moderate sedation or deeper sedation is provided, other than the clinician performing the procedure, a person who is trained to monitor appropriate physiologic parameters must be present.^1,2 For moderate sedation, time from last meal should not limit access to abortion care. Pulse oximetry should be used, and the patient should be checked frequently for verbal responsiveness.

Anesthesia-related complications and deaths may result from inadequate postanesthesia monitoring.¹⁰ Postsedation goals and monitoring are similar for patients receiving moderate sedation, deep sedation, and general anesthesia.¹⁰ Patients are at risk of hypoxemia following sedation; therefore, their ventilation and circulation should be monitored at regular intervals until there is a return to baseline consciousness.² The ASA recommends that all patients should be observed in an appropriately staffed and equipped (Table 3) area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression.¹³

Table 3.

Recommended Emergency Equipment for Sedation and Analgesia^a

IV equipment	Basic airway management equipment	Advanced airway management equipment^b	Pharmacologic antagonists	Emergency medications
Gloves	Source of compressed oxygen	Laryngeal mask airways	Naloxone	Epinephrine
Tourniquets	Suction source and catheters	Laryngoscope handles	Flumazenil	Ephedrine
Alcohol wipes	Face masks	Laryngoscope blades		Vasopressin
Sterile gauze padsIV cathetersIV tubingIV fluidAssorted drug needles & syringesTape	Self-inflating breathing bag–valve setOral and nasal airwaysLubricant	Endotracheal tubes & stylets		AtropineNitroglycerinLidocaineGlucose, 50%Diazepam or midazolamDiphenhydramine, hydrocortisone, methylprednisolone, or dexamethasone

Appropriate medications & equipment, including a defibrillator, should be available whenever drug regimens to induce cardiorespiratory depression are administered. This list is a guide that can be tailored to individual practice needs.

For practitioners with intubation skills.

Adapted from Reference 11.

IV, intravenous.

Legal Restrictions

The World Health Organisation (WHO) has published guidance stating that abortion procedures can be performed safely (with or without sedation) in outpatient clinics.^14,15 Clinicians must follow federal and state-level safety standards stipulated and monitored by regulatory agencies, such as the Occupational Safety and Health Administration and The Joint Commission.¹⁵ In addition to these regulatory bodies, NAF and PPFA have published guidelines on infection prevention, analgesia and sedation, treatment of complications, and protocols for managing onsite emergencies and hospital transfers (Table 3).^1,3,15

Some legal restrictions that limit abortion practice are designed to specifically limit abortion access and do not improve patient safety based on scientific evidence.¹⁵ For example, some state laws require office-based abortion care facilities to meet ambulatory surgical center (ASC) requirements, including minimum procedure-room dimensions and hospital-grade ventilation systems.¹⁵ Procedures performed in ASCs, such as arthroplasty, colonoscopy, or tonsillectomy, are more invasive and typically require higher levels of sedation than required for abortion care. When similar regulations are imposed onto clinics that provide medication-based or surgical abortions, such restrictions raise financial and logistic difficulties without improving patient safety or quality of care.¹⁵

Only 0.3% of patients undergoing abortion in the United States experience major complications that require hospitalization; however some state laws require abortion clinicians to have hospital admitting privileges.^14,15 Federal law already requires all hospitals treat patients experiencing emergencies regardless if these patients' clinicians have admitting privileges.¹⁵ Requiring clinicians who provide abortions to have specific admitting privileges creates an unnecessary barrier. Often, the agreement for admitting privileges requires that the clinician live near the hospital and admit a minimum number of patients per year. Given the safety of abortion and rarity of requiring hospital admission to manage abortion-related complications, the clinician will be unlikely to meet these minimal requirements.¹⁵

Due to personal safety concerns based on direct threats to their lives, their families, and assets, clinicians also may not live near the clinics where they work, which may also limit their ability to obtain admitting privileges. Imposing these targeted regulations on clinicians who provide abortions can be prohibitive for clinics to maintain service delivery, contributing to clinic closures, thereby limiting patients' access to safe abortion services.¹⁵

Conclusions

Patients seeking abortions should be counseled on all pain-management options. Informed consent regarding the risks and benefits of the various methods should be obtained. There are several factors that can influence a patient's decision when choosing anesthesia. Some patients prefer local anesthesia as they may wish to avoid conscious-altering effects of sedation that may affect recovery length, transportation and/or self-care, and care for any dependents after discharge. Other patients prefer sedation, which has added benefits, such as procedural amnesia. If a patient expresses a preference of a method that is not available in the setting, a clinician should refer that patient to a facility equipped to offer that preferred method.

Abortion care practices should have pertinent anesthesia and procedural policies that are consistent with the care setting, whether they are hospital-based or free-standing sites. These policies should follow guidelines set by the ASA, NAF, PPFA, and WHO and not include additional targeted regulation of clinics or providers of abortion care.^1–3,15

Footnotes

Authors' Contributions

Drs. Brown and Cansino contributed to designing, analyzing, writing, and editing this article.

Author Disclosure Statement

No financial conflicts of interest exist.

Funding Information

The authors received no financial support for this work on this article.

References

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Planned Parenthood Federation of America National Medical Division. Manual of Medical Standards and Guidelines, 2 vol. looseleaf set New York: National Medical Division Planned Parenthood Federation of America, 2014.

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