Prohibiting consent: what are the costs of denying permanent contraception concurrent with abortion care?

OBJECTIVE: Oregon and federal laws prohibit giving informed consent for permanent contraception when presenting for an abortion. The primary objective of this study was to estimate the number of unintended pregnancies associated with this barrier to obtaining concurrent tubal occlusion and abortion, compared with the current policy, which limits women to obtaining interval tubal occlusion after abortion. The secondary objectives were to compare the financial costs, quality-adjusted life years, and the cost-effectiveness of these policies. STUDY DESIGN: We designed a decision-analytic model examining a theoretical population of women who requested tubal occlusion at time of abortion. Model inputs came from the literature. We examined the primary and secondary outcomes stratified by maternal age (>30 and <30 years). A Markov model incorporated the possibility of multiple pregnancies. Sensitivity analyses were performed on all variables and a Monte Carlo simulation was conducted. RESULTS: For every 1000 women age <30 years in Oregon who did not receive requested tubal occlusion at the time of abortion, over 5 years there would be 1274 additional unintended pregnancies and an additional $4,152,373 in direct medical costs. Allowing women to receive tubal occlusion at time of abortion was the dominant strategy. It resulted in both lower costs and greater quality-adjusted life years compared to allowing only interval tubal occlusion after abortion. CONCLUSION: Prohibiting tubal occlusion at time of abortion resulted in an increased incidence of unintended pregnancy and increased public costs.

Pain control in first trimester surgical abortion.

BACKGROUND: First trimester abortions especially cervical dilation and suction aspiration are associated with pain, despite various methods of pain control. OBJECTIVES: Compare different methods of pain control during first trimester surgical abortion. SEARCH STRATEGY: We searched multiple electronic databases with the appropriate key words, as well as reference lists of articles, and contacted professionals to seek other trials. SELECTION CRITERIA: Randomized controlled trials comparing methods of pain control in first trimester surgical abortion at less than 14 weeks gestational age using electric or manual suction aspiration. Outcomes included intra- and postoperative pain, side effects, recovery measures and satisfaction. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data. Meta-analysis results are expressed as weighted mean difference (WMD) or Peto Odds ratio with 95% confidence interval (CI). MAIN RESULTS: We included forty studies with 5131 participants. Due to heterogeneity we divided studies into 7 groups:Local anesthesia: Data was insufficient to show a clear benefit of a paracervical block (PCB) compared to no PCB or a PCB with bacteriostatic saline. Pain scores during dilation and aspiration were improved with deep injection (WMD -1.64 95% CI -3.21 to -0.08; WMD 1.00 95% CI 1.09 to 0.91), and with adding a 4% intrauterine lidocaine infusion (WMD -2.0 95% CI -3.29 to -0.71, WMD -2.8 95% CI -3.95 to -1.65 with dilation and aspiration respectively).PCB with premedication: Ibuprofen and naproxen resulted in small reduction of intra- and post-operative pain.Analgesia: Diclofenac-sodium did not reduce pain.Conscious sedation: The addition of conscious intravenous sedation using diazepam and fentanyl to PCB decreased procedural pain.General anesthesia (GA): Conscious sedation increased intraoperative but decreased postoperative pain compared to GA (Peto OR 14.77 95% CI 4.91 to 44.38, and Peto OR 7.47 95% CI 2.2 to 25.36 for dilation and aspiration respectively, and WMD 1.00 95% CI 1.77 to 0.23 postoperatively). Inhalation anesthetics are associated with increased blood loss (p<0.001).GA with premedication: The COX 2 inhibitor etoricoxib, the non-selective COX inhibitors lornoxicam, diclofenac and ketorolac IM, and the opioid nalbuphine were improved postoperative pain.Non-pharmacological intervention: Listening to music decreased procedural pain.No major complication was observed. AUTHORS' CONCLUSIONS: Conscious sedation, GA and some non-pharmacological interventions decreased procedural and postoperative pain, while being safe and satisfactory to patients. Data on the widely used PCB is inadequate to support its use, and it needs to be further studied to determine any benefit.

Body mass index and sexual behavior.

OBJECTIVE: To characterize the relationship between body mass index and sexual behavior, including sexual orientation, age at first intercourse, ever having had sex with a male partner, number of partners, and frequency of intercourse. METHODS: This study employed the 2002 National Survey of Family Growth, a cross-sectional, nationally representative database in which women between the ages of 15 years and 44 years were surveyed regarding reproductive health outcomes. Sexual behavior was compared between body mass index groups-normal (less than 25 m/kg2), overweight (25-30 m/kg2), and obese (greater than 30 m/kg2)-using self-reported height and weight. Multiple logistic regression with adjustment for the sampling design was used to measure associations of interest. RESULTS: Body mass index was not significantly associated with sexual orientation, age at first intercourse, frequency of heterosexual intercourse, and the number of lifetime or current male partners. Overweight women and obese women were more likely to report ever having male sexual intercourse (P<.001). This difference persisted when we adjusted for age as well as type of residence. CONCLUSION: With the exception of ever engaging in sexual intercourse with a man, sexual behavior differs little between women of different body mass indices.

Predictors and perception of pain in women undergoing first trimester surgical abortion.

BACKGROUND: The aim of the study was to evaluate pain and predictors of pain in women undergoing electric (EVA) or manual vacuum aspiration (MVA) for first trimester surgical abortions and to examine how perceptions of pain differ among participants, advocates (participant support person) and physicians. STUDY DESIGN: In this randomized controlled study, women presenting for first trimester abortion underwent standardized EVA or MVA. Participants completed questionnaires, visual analog scales (VAS) and Likert scales for pain. Logistic and linear regression models were used to analyze the data. RESULTS: Nonwhite women and women who preoperatively expected more pain reported higher procedure-related pain scores. Vacuum source, previous history of abortion, comfort with decision to have an abortion and partner involvement did not affect participant pain scores. In the multivariable analyses, no single factor predicted procedure-associated pain. The advocates perceived that more educated women had less pain. Physicians felt longer procedures and a woman's fear of pelvic examinations caused more pain. Physicians believed women had less pain than the participants reported themselves (p<.001). Only physicians thought that EVA was less painful than MVA (p<.01). CONCLUSION: Distinct factors other than vacuum source affect the perception of abortion-related pain. Understanding these factors may help inform counseling strategies aimed at ameliorating pain perception during first trimester abortions.

Effect of "observed start" vs. traditional "Sunday start" on hormonal contraceptive continuation rates after medical abortion.

OBJECTIVE: This study was conducted to determine whether early initiation of combined hormonal contraception under direct clinical observation following successful medical abortion increases continuation rates with the method compared to traditional "Sunday start." STUDY DESIGN: Women enrolled in a multicenter medical abortion trial with mifepristone and misoprostol who requested combined hormonal contraception (pill, ring or patch) following medical abortion were recruited. Women were randomized to initiate the method under supervision either at the 1-week medical abortion follow-up visit ("observed start") or at the first Sunday following this visit ("Sunday start"). Primary outcome was continuation of the chosen method at 6 weeks. RESULTS: Of the 1128 women in the primary trial, 261 subjects enrolled in this substudy and 36/261 (13.8%) were lost to follow-up. There was no significant difference in method continuation at 6 weeks [observed start 108/114 (94.7%), Sunday start 101/111 (91.0%, p=.27]. CONCLUSION: Short-term continuation rates among those choosing hormonal contraception following medical abortion are high and are not significantly improved by initiating the method at the time of the first follow-up visit.

IVF patients' attitudes toward multifetal pregnancy reduction.

OBJECTIVE: To determine attitudes of in vitro fertilization (IVF) patients toward multifetal pregnancy reduction before and after embryo transfer. STUDY DESIGN: Women seeking IVF consultation were surveyed before and after embryo transfer regarding their attitudes toward multifetal pregnancy reduction. RESULTS: Thirty-one of 36 subjects completed the initial survey. The mean age was 32.9 years, 93% of subjects were Caucasian, and 61.3% were nulliparous. Most subjects described themselves as "pro-choice" (20 of 31, 64.5%). Overall, 22.6% (7 of 31) stated that they would never consider fetal reduction in a multifetal pregnancy and 77.4% (24 of 31) stated that they would consider multifetal pregnancy reduction. The threshold to consider fetal reduction was triplets. Prochoice subjects were significantly more likely to consider multifetal pregnancy reduction when compared to "prolife" subjects (p <0.01). Twelve of the 31 subjects underwent embryo transfer and completed the second survey. Patient attitude did not change significantly from the time of initial IVF consultation to after embryo transfer. CONCLUSION: Overall, women undergoing IVF would consider multifetal pregnancy reduction, and this view did not change after embryo transfer. Pro-choice subjects were more likely to consider multifetal pregnancy reduction.

Four percent intrauterine lidocaine infusion for pain management in first-trimester abortions.

OBJECTIVE: To study the effects of a 4% intrauterine lidocaine infusion on perceived patient pain in first-trimester abortions. METHODS: A randomized, double-blind, placebo-controlled trial of 80 women receiving either a 5-mL 4% lidocaine (n = 40) or saline (n = 40) intrauterine infusion and a standard paracervical block before first-trimester abortion. Women completed a series of 100-mm visual analog scales (anchors: 0 = none, 100 mm = worst imaginable) to measure their perceived pain (anticipated pain, after speculum insertion, after intrauterine infusion, after cervical dilation, after suction aspiration, and 30 minutes postprocedure). Eight women volunteered for serum lidocaine levels after the lidocaine infusion. RESULTS: Groups were similar in respect to age, parity, prior abortion, ethnicity, gestational age, and level of dysmenorrhea. Pain scores demonstrated a significant difference between groups during cervical dilation (saline 55 mm +/- 26, lidocaine 35 mm +/- 30, P < .01) and during aspiration (saline 71 mm +/- 20, lidocaine 43 mm +/- 30, P < .01). The lidocaine group reported significantly more symptoms (ie, oral numbness and tingling) than the saline group (saline 0/39, lidocaine 16/38, 42%, P < .01). The highest serum lidocaine level recorded was 4.0 microg/mL (lidocaine group). There was no difference in overall satisfaction between the 2 groups. CONCLUSION: Compared with paracervical block alone, the addition of a 4% intrauterine lidocaine infusion resulted in a significant reduction in patient perception of pain during first-trimester abortion. Although subjective symptoms of systemic lidocaine effect were common, no subjects demonstrated serum levels consistent with lidocaine toxicity. However, further studies to determine safety are needed. LEVEL OF EVIDENCE: I.

Cervical preparation using laminaria with adjunctive buccal misoprostol before second-trimester dilation and evacuation procedures: a randomized clinical trial.

OBJECTIVE: This study was undertaken to determine whether buccal misoprostol improves cervical preparation achieved with laminaria before second-trimester dilation and evacuation procedures. STUDY DESIGN: A randomized, double blind, placebo-controlled trial of preoperative cervical preparation with overnight laminaria and either buccal placebo or 400 microg buccal misoprostol approximately 90 minutes before second-trimester surgical abortion. Block randomization was used to provide balanced enrollment into 2 separate gestational age study groups: early (13-15(6/7)) and mid (16-20(6/7)) second trimester. Surgeons tested maximal cervical dilation by inserting the largest dilator that could be passed through the cervical os without force. Subject demographics and preprocedure symptoms were tracked. RESULTS: Groups were similar in regard to age, gravity, parity, delivery type, and gestational age. Data were analyzed from 125 women in the 13 to 15(6/7) (30 misoprostol, 32 placebo) and 16 to 20(6/7) (31 misoprostol, 32 placebo) gestational age groups. Overall, misoprostol treatment did not improve the initial mean dilation achieved with laminaria alone in either the 13 to 15(6/7) (46.0 fr +/- 5.0; placebo 45.0 fr +/- 6.2, P = .68) or 16 to 20(6/7) (50.9 fr +/- 5.6, placebo 48.9 fr +/- 5.2, P = .16) groups. However, a subanalysis of gestations 19 weeks or more demonstrated significantly greater dilation in the misoprostol group (53.6 fr fr +/- 5.3, placebo 48.5 fr +/- 5.0, P = .01). Subjects receiving misoprostol reported significantly more cramping than those receiving placebo (13-15(6/7) weeks misoprostol 25/30, 83%; placebo 17/32, 53%, P = .02; 16-20(6/7) week misoprostol 25/31, 81%, placebo 16/32, 50%, P = .02). CONCLUSION: Cervical dilation with laminaria is augmented by 400 microg buccal misoprostol in gestations 19 weeks or more, but not in earlier gestations. Misoprostol causes more abdominal cramping.

Refining paracervical block techniques for pain control in first trimester surgical abortion: a randomized controlled noninferiority trial.

OBJECTIVES: Our objective was to evaluate two different aspects of the paracervical block (PCB) technique for first trimester surgical abortion, to compare a 3-min wait prior to cervical dilation to no wait and to compare four-site with two-site injection. STUDY DESIGN: We conducted two consecutive randomized, single-blinded noninferiority trials. In the first trial, women <11 weeks gestational age received a 20-mL 1% buffered lidocaine four-site PCB with either a 3-min wait between PCB injection and dilation or no wait. In the second trial, we compared a four-site with a two-site PCB. We evaluated dilation pain [100-mm visual analogue scale (VAS)] as the primary outcome. Secondary outcomes included pain at additional time points, anxiety, satisfaction and adverse events. RESULTS: Both trials fully enrolled (total n=332). Results were inconclusive as to whether no wait was noninferior to waiting 3-min prior to cervical dilation for dilation pain [VAS: 63 mm (SD, 24 mm) vs. 56 mm (SD, 32mm)] and as to whether a two-site PCB was noninferior to a four-site block [VAS: 68 mm (SD, 21 mm) vs. 60 mm (SD, 30 mm)]. Noninferiority analysis was inconclusive because the confidence interval of the mean pain score difference between groups included the predefined inferiority margin of 13-mm pain difference. Superiority analysis showed the four-site PCB to be superior to the two-site PCB. CONCLUSION: It remained inconclusive whether a 3-min wait time between PCB and cervical dilation provides noninferior pain control for first trimester surgical abortion. However, a four-site PCB appeared to be superior to a two-site PCB. IMPLICATIONS: It remained inconclusive whether a 3-min wait time between PCB and cervical dilation or using a two-site instead of a four-site PCB provided noninferior pain control for first trimester surgical abortion. This study did not assess whether the combination of the two separate factors provides additive benefit.

Intrauterine device placement at 3 versus 6 weeks postpartum: a randomized trial.

OBJECTIVE: To investigate whether early placement of an intrauterine device (IUD) at 3 weeks after delivery, compared to placement at 6 weeks, is associated with greater use at 3 months postpartum. STUDY DESIGN: This prospective randomized, controlled trial enrolled inpatient postpartum women intending to use intrauterine contraception. Participants were assigned to an early (3 week) or standard (6 week) postpartum visit with IUD placement and were followed for 6 months. We used transvaginal ultrasonography to confirm placement and measure uterine dimensions. We measured pain with IUD insertion and satisfaction with IUD timing using 100-mm visual analog scales. Data were analyzed based on randomization and actual timing of insertion (18-24 vs. 39-45 days). RESULTS: Between February 2012 and December 2013, 201 subjects were enrolled (early=101; standard=100). Most participants returned for IUD placement as scheduled; 70.1% (53/75) in the early group, 74.3% (58/78) in the standard group (p=.06). IUD use did not differ between groups at 3 months (73/100, 73.0% and 73/97, 75.3%, respectively, p=.72) or 6 months (80.3% and 82.8%, p=.71) amongst those women for whom follow-up was available. Women randomized to 6-week insertion were more likely to have resumed intercourse prior to the IUD appointment (15/64, 23.4% vs. 5/68, 7.3%, p=.01). Pain with insertion (19.9 vs. 25.1, respectively, p=.21) and satisfaction (89.6 vs. 93.4, respectively, p=.23) did not vary based on actual timing of insertion. CONCLUSION: Offering IUD placement at 3 weeks postpartum compared to standard scheduling at 6 weeks does not result in increased use at 3 months. However, early IUD placement is acceptable to women and without increased pain. IMPLICATIONS: This study demonstrates that IUD placement as early as 3 weeks postpartum is feasible. Larger studies are needed to evaluate risks and benefits of IUD placement at this early interval. While earlier timing does not result in increased IUD uptake, early placement should be explored as an option since many women resume intercourse before 6 weeks.

An Evaluation of Oral Midazolam for Anxiety and Pain in First-Trimester Surgical Abortion: A Randomized Controlled Trial.

OBJECTIVE: To estimate the effect of oral midazolam on patient pain and anxiety perception during first-trimester surgical abortion. METHODS: Between May and December 2013, we conducted a randomized, double-blind, placebo-controlled trial. Patients between 6 0/7 and 10 6/7 weeks of gestation received 10 mg oral midazolam or placebo 30-60 minutes before surgical abortion. All patients received ibuprofen and a paracervical block. We powered the study (power=80%; significance level=.025) to detect a 15-mm difference in our two a priori primary outcomes of pain and anxiety with uterine aspiration on a 100-mm visual analog scale. Secondary outcomes were pain and anxiety at additional time points, memory, satisfaction, side effects, and adverse events. RESULTS: Demographics were similar between groups (placebo=62, midazolam=62). Compared with those randomized to placebo, patients who received midazolam had significantly less anxiety preoperatively (room entry: 51.4 mm compared with 34.5 mm, P<.001; positioning: 56.6 mm compared with 45.4 mm, P=.02). There was no difference in pain (P=.28) or anxiety (P=.14) during uterine aspiration or at other procedural time points. A significantly greater number of patients in the midazolam group reported partial amnesia (31/61 compared with 16/61, P=.005) and dizziness (30/61 compared with 18/61, P=.03). Controlling for baseline differences, patients who received midazolam reported more postoperative sleepiness (P<.001) and less postoperative nausea (P=.004). There was no difference in overall satisfaction (P=.88). CONCLUSION: Although oral midazolam reduces preprocedural anxiety, it does not reduce pain or anxiety with uterine aspiration during first-trimester surgical abortions. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01830881. LEVEL OF EVIDENCE: I.

Intrauterine lidocaine infusion for pain management in first-trimester abortions.

OBJECTIVE: To study the effects of an intrauterine lidocaine infusion on perceived patient pain in first-trimester abortions and to measure serum lidocaine levels. METHODS: A randomized, double-blind, placebo control trial of 80 women receiving either a 10-mL 1% lidocaine (n = 40) or saline (n = 40) intrauterine infusion and a standard paracervical block before first-trimester abortion was undertaken. Women completed a series of 100-mm visual analogue scales to measure their perceived pain (anticipated pain, after speculum insertion, after intrauterine infusion, after cervical dilation, after suction aspiration, and 30 minutes after procedure). Twenty women (10 in each group) volunteered for serum lidocaine levels at 10, 20, 30, 45, and 60 minutes after the lidocaine infusion. RESULTS: Groups were similar in respect to age, parity, prior abortion, ethnicity, gestational age, level of dysmenorrhea, and complications. Pain scores by visual analogue scale demonstrated no significant difference between groups at any time point during the procedure; in particular, pain during aspiration (saline infusion 51 +/- 26 mm, lidocaine infusion 47 +/- 28 mm; P =.51). Peak serum levels occurred at approximately 10 minutes after lidocaine infusion. The highest level recorded (lidocaine group) was 2.5 microg/mL (toxicity more than 5 microg/mL). CONCLUSION: Compared with paracervical block alone, the addition of a 1% intrauterine lidocaine infusion resulted in no improvement in patient perception of pain during first-trimester abortion. No subjects demonstrated symptoms or serum levels of lidocaine toxicity. LEVEL OF EVIDENCE: I

Bleeding patterns and patient acceptability of standard or continuous dosing regimens of a low-dose oral contraceptive: a randomized trial.

The purpose of this study is to compare bleeding patterns and acceptability of a contraceptive regimen of combined 20 microg ethinyl estradiol/100 microg levonorgestrel taken with and without a hormone-free interval. Thirty-two women desiring oral contraception were randomized to six 28-day cycles (standard group) or 168 days without a pill-free interval (continuous group). Participants kept a daily bleeding calendar documenting bleeding events (none, spotting or required sanitary protection) and side effects (headache, nausea, breast tenderness, depression, premenstrual syndrome and bloating). Primary outcome was number of bleeding days. Secondary outcomes included bleeding days requiring sanitary protection, amenorrhea, patient acceptability of bleeding patterns, method satisfaction and affective side effects. There were no differences in the baseline characteristics of the two groups. Although total bleeding days were fewer in the continuous group (mean = 25.9 vs. 34.9 days), this result did not reach statistical significance. However, women in the continuous group reported significantly fewer bleeding days that required protection (18.4 vs. 33.8 days, p < 0.01), and were more likely to have amenorrhea. Although both groups reported a high level of satisfaction with bleeding patterns and side effect profiles, women in the continuous group reported significantly fewer days of bloating (0.7 vs. 11.1 days, p = 0.04), and menstrual pain (1.9 vs. 13.3 days, p < 0.01). Continuous use of 20 microg ethinyl estradiol/100 microg levonorgestrel is associated with less bleeding requiring protection, and more amenorrhea than standard administration. Taken with or without a hormone-free interval, this oral contraceptive formulation is highly acceptable with regard to bleeding patterns and side effect profile. The continuous group had fewer light and moderate bleeding days, less bloating and menstrual pain. For patients who are seeking these results, this method may be more desirable.

Similarities in women's perceptions and acceptability of manual vacuum aspiration and electric vacuum aspiration for first trimester abortion.

This paper examines women's acceptability of and experiences with manual vacuum aspiration (MVA) as compared with electric vacuum aspiration (EVA) for first trimester abortion. Women requesting pregnancy terminations were randomly assigned to either MVA (n = 64) or EVA (n = 63). Participants completed questionnaires before and after their abortions and approximately 2-4 weeks later. We observed some differences by group in participants' ratings of the importance of method characteristics and in their perceptions of their abortion methods after their abortions. The two groups did not, however, differ in their reports of pain, anxiety or bleeding or in the acceptability of their method.

Comparison of interventions for pain control with tenaculum placement: a randomized clinical trial.

OBJECTIVE: Although previous studies have demonstrated that a variety of local anesthetics are effective to decrease pain associated with tenaculum placement, no studies directly compare an injection with a topical anesthetic. The objective of this study was therefore to compare mean pain scores with tenaculum placement after an intracervical lidocaine injection or topical lidocaine gel. STUDY DESIGN: A randomized, single-blinded trial of women presenting for office gynecologic procedures that required a tenaculum. Women aged 18 years or older were randomized to receive either a 1% lidocaine intracervical injection or topical application of 2% lidocaine gel to the cervix immediately prior to tenaculum placement. The primary outcome was pain at the time of tenaculum placement, measured on a 100 mm Visual Analog Scale. Secondary outcomes included pain with the intervention and satisfaction with tenaculum placement. RESULTS: Seventy-four women were enrolled and randomized; 35 subjects in each group met criteria for analysis. The two groups had similar socio-demographic characteristics. Women who received the injection had lower mean pain levels at tenaculum placement [12.3 mm (S.D. 17.4 mm) versus 36.6 mm (S.D. 23.0 mm), p<.001] but higher mean pain levels with study drug application [20.4 mm (S.D. 19.4 mm) versus 5.9 mm (S.D. 8.6 mm), p<.001]. Satisfaction with tenaculum placement was similar for the two groups. CONCLUSION: Mean pain with tenaculum placement is lower after receiving a lidocaine injection than after receiving a topical lidocaine gel. Satisfaction with tenaculum placement is similar with both interventions.

Paracervical block for pain control in first-trimester surgical abortion: a randomized controlled trial.

OBJECTIVE: Despite lack of efficacy data, the majority of first-trimester surgical abortions are performed with a paracervical block. Women may be unnecessarily exposed to a painful injection and potentially noxious medication. Our objective was to estimate the effect of a paracervical block and the effect of gestational age on patient pain perception. METHODS: This was a randomized, single-blind trial of patients undergoing abortion receiving paracervical block or sham stratified by gestational age (early: less than 8 weeks of gestation, n=60; late: 8-10 6/7 weeks of gestation, n=60). Premedicated with ibuprofen and lorazepam, all participants received 2 mL 1% buffered lidocaine injected at the tenaculum site followed by a slow, deep injection of 18 mL at four sites (block) or no injection (sham) with a 3-minute wait. The primary outcome was dilation pain (100-mm visual analog scale). Secondary outcomes included pain at additional time points, satisfaction, need for more analgesics, and adverse events. RESULTS: Full enrollment occurred (n=120). We used intent-to-treat analysis. Demographics did not differ between groups. Paracervical block administration was painful (mean 55 mm compared with sham 30 mm, P<.001) but decreased dilation pain (42 mm compared with 79 mm, P<.001) and aspiration pain (63mm compared with 89 mm, P<.001). These results were consistent for both gestational age strata; however, paracervical block benefit was greater at an earlier gestation. Satisfaction scores with pain control and the procedure were significantly higher in the block group. CONCLUSION: Although paracervical block is painful, it reduces first-trimester abortion pain regardless of gestational age, but the benefit on dilation pain was greater at earlier gestations. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01094366. LEVEL OF EVIDENCE: I.

Adolescent experience with intrauterine device insertion and use: a retrospective cohort study.

BACKGROUND: Adolescents contribute disproportionately to the epidemic level of unintended pregnancy in the USA. Intrauterine devices (IUDs) are highly effective but underutilized in this age group. STUDY DESIGN: We searched our electronic clinic database to identify females ≤ 19 years old who underwent attempted IUD insertion between January 2007 and June 2009. This retrospective cohort study primarily compared the insertion and postinsertion experiences between nulliparous and parous teens. RESULTS: Of the 307 charts reviewed, the majority of subjects were white (73.4%) and nulliparous (77.5%), with a median age of 18 years (range 15-19). The vast majority (96.4%, 296/307) had a successful IUD insertion upon first attempt; all of the 11 unsuccessful IUD insertion attempts were among nulliparous teens. Follow-up was available for 56% (172/307). During the first 12 months of use, there were 2.9% (5/172) IUD expulsions and 24.4% (42/172) removals, with no differences between nulliparous and parous teens. IUD continuation at 6 months was 83.3%. Pelvic inflammatory disease was diagnosed in 4.6% (8/172) of post-IUD insertions. There were no pregnancies reported in those teens with IUD continuation, while six were reported in subjects who underwent IUD removal. Independent predictors of IUD discontinuation were a history of chronic pelvic pain or dysmenorrhea, and bleeding and/or pain complaints at any post-IUD visit. CONCLUSIONS: Overall, adolescents experience minimal complications with IUD use, with similar rates of successful insertion as adults. IUD discontinuation rates were not significantly different between nulliparous and parous teens. While discontinuation was higher than reported in adults, it was lower than reported among teens using other forms of contraception.

Intrauterine lidocaine infusion for pain management during outpatient transcervical tubal sterilization: a randomized controlled trial.

BACKGROUND: The study was conducted to examine the effects of a 4% intrauterine lidocaine infusion on patient-perceived pain during transcervical sterilization. STUDY DESIGN: This was a randomized, double-blind, placebo-controlled trial. Subjects received standard premedication with 800 mg ibuprofen, 2 mg lorazepam, a 10-mL 1% lidocaine paracervical block and transcervical instillation of 5 mL of either 4% lidocaine or saline 3 min prior to insertion of the hysteroscope. Subjects completed a series of 100-mm visual analog scales to measure their perceived pain at set time points during and after the procedure. Serum lidocaine levels were obtained in a subset of subjects. RESULTS: Pain scores at all evaluation points did not significantly differ between groups (lidocaine n=29, saline n=29). Mean lidocaine levels did not differ between groups, and no subject demonstrated symptoms of lidocaine toxicity. The highest serum lidocaine level (4022 ng/mL) occurred 20 min after infusion in a lidocaine-treated subject. CONCLUSION: Intrauterine lidocaine prior to outpatient transcervical sterilization does not decrease pain.