Anesthesia for Pregnancy Termination Procedures
Pregnancy termination can be a complicated procedure for both the patient and the provider. Patients may have different preferences for anesthesia or sedation,1 and providers may have to alter the procedure depending on the patient’s gestational age.2 During the first trimester, an abortion procedure can be completed with manual vacuum aspiration (MVA) or electric vacuum aspiration.3 Later procedures may require dilation and evacuation (D&E) or dilation and extraction (D&X), which involve hours to days of cervical preparation and widening.2,4 The pre-abortion process entails counseling, paperwork, a thorough medical history, physical examination, blood test, screening for sexually transmitted infections and an ultrasound to confirm the age of the pregnancy.2 During the procedure, anesthesia and analgesia may consist of local anesthesia and analgesic or sedative medications.5 Anesthesiology professionals and abortion providers should be aware of the variety of medications used for pregnancy termination procedures, as well as the efficacy of certain medications and practices.
Because pregnancy termination is a relatively routine procedure, most abortions can be performed on an outpatient basis.6 Thus, an anesthesiologist may not always be necessary. Instead, nurses and nurse practitioners who have special training in abortion procedures may administer local anesthesia and moderate sedation.6 The type of provider who administers anesthesia or sedation and the type of medication used may differ across clinics and based on gestational age.7 For example, most providers give patients oral pain medication, such as ibuprofen, before the procedure in order to prevent pain.5-7 In some practices, oral medication may include a sedative, such as a benzodiazepine (e.g., Valium) or a stronger pain medication, such as an opioid (e.g., Vicodin).6 Also, some patients may request intravenous mild, moderate or heavy sedation to reduce anxiety and pain during the procedure.8 Moderate sedation will allow the patient to stay awake but very relaxed, while heavy sedation means complete loss of consciousness.7 In addition to these anesthetic and analgesic medications, the patient will receive antibiotics to reduce risk of infection, as well as medications to soften the cervix depending on gestational age.8 Guidelines for eating or drinking before a procedure vary based on gestational age and clinic practices, including use of anesthetics. While some procedures do not require fasting before the appointment,6,7 others may entail foregoing food for several hours in preparation for heavy sedation.8 Overall, anesthetic practices for pregnancy termination depend on procedure type, gestational age and the preferences of both the patient and provider.
Due to these various factors, the efficacy of anesthetic techniques varies widely between patients. For abortion procedures without intravenous medications, Allen and Singh recommend a multimodal approach to pain management, such as premedication with a non-steroidal anti-inflammatory drug (NSAID), emotional support person, visual or auditory distraction and local anesthesia to the cervix with lidocaine.9 According to their review, oral opioids did not reduce procedural pain and oral anxiolytics decreased anxiety (but not pain) in patients who did not use intravenous anesthesia.9 In their study, Hamoda et al. found that MVA under local anesthesia was effective and acceptable to patients.10 Meanwhile, a study by Xia and Chen found that local anesthesia combined with psychological intervention was more effective in pain relief and patient satisfaction than local anesthesia alone, suggesting that nonpharmacological interventions may be useful in cases without intravenous sedation.11 Other research has approached intravenous medications for patients who necessitate or request it. Rawling and Wiebe’s study found that intravenous fentanyl was not significantly effective in pain reduction compared to placebo.12 Zhang et al. showed that intravenous propofol and dezocine led to more pain reduction and shorter recovery time than propofol alone.13 In regards to complications, Clare et al. found that inhaled sevoflurane or desflurane led to greater intraoperative blood loss than intravenous propofol.14 Another study by Gokhale et al. found that intravenous sedation with fentanyl without tracheal intubation did not increase risk of complications in obese patients compared to non-obese patients.15 Evidently, a variety of intravenous, inhaled and oral medications can be used to induce different levels of anesthesia.
Anesthesia provision for pregnancy termination is complex, as it depends on gestational age, patient and provider preferences and institutional practices. Analgesia and anesthesia in abortion can range from no sedation to complete loss of consciousness, and can be provided through oral, intravenous or inhaled routes. Future research is needed to evaluate the best forms of pharmacologic and nonpharmacologic pain control in patients who do not use moderate or heavy sedation.9 Additionally, policies should aim to standardize care across clinics in order to effectively assess different anesthetic practices for pregnancy termination.
1. Singh R. Patient Preferences in Anesthesia for Abortion Care (PAC). ClinicalTrials.gov October 26, 2017.
2. Johnson TC. What Are the Types of Abortion Procedures? Women’s Health March 30, 2019; https://www.webmd.com/women/abortion-procedures.
3. Goldberg AB, Dean G, Kang MS, Youssof S, Darney PD. Manual versus electric vacuum aspiration for early first-trimester abortion: A controlled study of complication rates. Obstetrics & Gynecology. 2004;103(1):101–107.
4. Blanchard K, Fried MG, Issokson D, et al. Dilation and Evacuation Abortion. Abortion April 2, 2014; https://www.ourbodiesourselves.org/book-excerpts/health-article/dilation-and-evacuation-abortion/.
5. Sharma M. Manual vacuum aspiration: An outpatient alternative for surgical management of miscarriage. The Obstetrician & Gynaecologist. 2015;17(3):157–161.
6. UCSF Health. Surgical Abortion (First Trimester). In: The Regents of the University of California, ed. Treatments A–Z. Web 2020.
7. Planned Parenthood Federation of America. What happens during an in-clinic abortion? In-Clinic Abortion 2020; https://www.plannedparenthood.org/learn/abortion/in-clinic-abortion-procedures/what-happens-during-an-in-clinic-abortion.
8. UCSF Health. Surgical Abortion (Second Trimester). In: The Regents of the University of California, ed. Treatments A–Z. Web 2020.
9. Allen RH, Singh R. Society of Family Planning clinical guidelines pain control in surgical abortion part 1—Local anesthesia and minimal sedation. Contraception. 2018;97(6):471–477.
10. Hamoda H, Flett GM, Ashok PW, Templeton A. Surgical abortion using manual vacuum aspiration under local anaesthesia: A pilot study of feasibility and women’s acceptability. The Journal of Family Planning and Reproductive Health Care. 2005;31(3):185–188.
11. Xia L, Chen Y. Effect of lidocaine combined with local anesthesia and psychological intervention on induced abortion. Chinese Journal of Biochemical Pharmaceutics. 2017;37(6):351–352.
12. Rawling MJ, Wiebe ER. A randomized controlled trial of fentanyl for abortion pain. American Journal of Obstetrics & Gynecology. 2001;185(1):103–107.
13. Zhang M, Ying C, Wei H. Evaluation of different doses dezocine combined with propofol intravenous anesthesia for artificial abortion. Chinese Journal of Primary Medicine and Pharmacy. 2016;23(12):1824–1827.
14. Clare CA, Hatton GE, Shrestha N, et al. Intraoperative Blood Loss during Induced Abortion: A Comparison of Anesthetics. Anesthesiology Research and Practice. December 2, 2018;2018:5.
15. Gokhale P, Lappen JR, Waters JH, Perriera LK. Intravenous Sedation Without Intubation and the Risk of Anesthesia Complications for Obese and Non-Obese Women Undergoing Surgical Abortion: A Retrospective Cohort Study. Anesthesia & Analgesia. 2016;122(6):1957–1962.