Effects of Prophylactic Oxytocin on Bleeding Outcomes in Women Undergoing Dilation and Evacuation: A Randomized Controlled Trial.

OBJECTIVE: To estimate whether routine use of intravenous oxytocin decreases the frequency of interventions to control excess blood loss during dilation and evacuation (D&E). METHODS: In this multisite, randomized, double-blind, placebo-controlled trial, women undergoing D&E at 18-24 weeks of gestation received 30 units of oxytocin in 500 mL of intravenous fluid or 500 mL of intravenous fluid alone initiated on speculum placement. The primary outcome was the frequency of interventions to control excess bleeding. A sample size of 75 patients per group was needed to detect a 15% decrease in intervention from 20% to 5% with 80% power and two-sided alpha 0.05. Secondary outcomes included measured blood loss, complications, procedure duration, postoperative pain, and patient satisfaction. RESULTS: From November 2014 to February 2018, we screened 337 women and randomized 160 to receive prophylactic oxytocin (n=82) or placebo (n=78). Demographic characteristics were similar between groups. The frequency of interventions for bleeding, our primary outcome, was 7.3% in the oxytocin group vs 16.7% in the placebo group, difference of 9.4% (95% CI -21.0% to 1.9%). Interventions primarily included uterine massage and uterotonic administration. Among our secondary outcomes, median measured blood loss was lower in the oxytocin group at 152 (interquartile range 98-235) mL vs 317 (interquartile range 168-464) mL (95% CI 71.6-181.5). Frequency of hemorrhage, defined as blood loss of 500 mL or more and 1,000 mL or more, was lower in the oxytocin group at 3.7% vs 21.8%, difference of 18% (95% CI -29 to -6.9%) and 1.2% vs 10.3%, difference of 9.0% (95% CI -17 to -0.7%), respectively. Procedures were shorter in the oxytocin group at a median of 11.0 (interquartile range 8.0-14.0) vs 13.5 (interquartile range 10.0-19.0) minutes in the placebo group (95% CI 1.0-4.0). We found no differences in the frequency of nonhemorrhage complications, pain scores, or satisfaction scores between groups. CONCLUSION: Prophylactic use of oxytocin during D&E at 18-24 weeks of gestation did not decrease the frequency of interventions to control bleeding. However, oxytocin did decrease blood loss and frequency of hemorrhage. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT02083809.

Pain Management for First-Trimester Uterine Aspiration.

IMPORTANCE: First-trimester uterine aspiration can easily be performed in the office setting if adequate pain management for the patient is achieved. It is important for clinicians to understand evidence-based approaches for pain control to ensure a safe and efficient procedure. OBJECTIVE: This article reviews the literature regarding pharmacologic and nonpharmacologic pain control options for first-trimester abortion performed in the clinical setting. Preoperative, procedural, and postoperative pain control are all reviewed. EVIDENCE ACQUISITION: Authors searched the online database PubMed for relevant published literature through January 2018. To identify possible publications for review, the key word "abortion" was paired with the following key words: "pain," "pain-control," "pain management," "aspiration," "paracervical block," "sedation, "non-pharmacologic," and "post-operative." RESULTS: Optimizing pain control for first-trimester uterine aspiration may involve interventions before, during, and after the surgery. Evidence shows patients benefit from premedication with nonsteroidal anti-inflammatory drugs, a defined paracervical block technique, and an option to use one of several nonpharmacologic interventions. CONCLUSIONS AND RELEVANCE: Pain management for first-trimester uterine aspiration should be individualized for optimal patient satisfaction. Evidence supports multiple approaches to support this individualization. Targeted interventions before, during, and after the procedure should be offered to improve procedure experience and satisfaction.

Nonpharmaceutical Pain Control Adjuncts During First-Trimester Aspiration Abortion: A Review.

INTRODUCTION: First-trimester aspiration abortion is associated with moderate to severe pain. The effectiveness of adjunctive therapies for pain control is not well understood. This critical review summarizes the existing literature regarding nonpharmacologic interventions to reduce pain during first-trimester office-based abortion. METHODS: PubMed and Google Scholar were searched using the following search terms in various combinations: "abortion," "pain," "nonpharmaceutical," "nonpharmacologic," "anxiety," "fear," "pain management," "pain reduction," "anxiety reduction," "complementary and alternative medicine," and "integrative medicine." Seven articles meeting inclusion criteria were entered into a matrix for comparison. Findings from each study are summarized describing design, results, and themes. These results are summarized to provide evidence-based clinical guidelines and identify areas for further research. RESULTS: None of the nonpharmacologic interventions studied were significantly associated with a reduction in pain or anxiety scores. However, women in many studies strongly endorsed future use of these techniques. DISCUSSION: The data included in this critical review did not demonstrate a relationship between the nonpharmacologic interventions and pain or anxiety scores, yet participants endorsed these as positive and helpful. Women found value in these supportive interventions, and ongoing investigation into these techniques is warranted.