Pain management for medical and surgical termination of pregnancy between 13 and 24 weeks of gestation: a systematic review

BACKGROUND: High‐quality care for termination of pregnancy (TOP) requires pain to be effectively managed; however, practices differ, and the available guidelines do not specify optimal strategies. OBJECTIVE: To guide providers in effective pain management for second‐trimester medical and surgical TOP. SEARCH STRATEGY: We searched PubMed, Cochrane and Embase databases, and the US National Library of Medicine clinical trials registry, from inception to the end of June 2019, and hand‐searched reference lists. SELECTION CRITERIA: Trials comparing pain management strategies with no treatment, placebo or active interventions during induced medical or surgical TOP, occurring between 13 and 24 weeks of gestation, and reporting direct or indirect measures of pain. DATA COLLECTION AND ANALYSIS: Both authors summarised and systematically assessed the evidence and risk of bias using standard tools. MAIN RESULTS: We included seven medical and four surgical TOP studies, with 453 and 349 participants, respectively. The heterogeneity of interventions and outcomes prevented pooled analyses. Medical TOP: women receiving routine or continuous epidural analgesia experienced mild pain. The prophylactic use of nonsteroidal anti‐inflammatory drugs (NSAIDs) decreased pain (mean difference −0.5, P < 0.001) and additional opioid requirements (3.5 versus 7 mg, P = 0.04) compared with placebo/other treatment. Paracervical block was ineffective. No studies assessed intramuscular (IM)/intravenous (IV) opioid or nonpharmacological treatment. Surgical TOP: general anaesthesia/deep IV sedation alleviated pain. Nitrous oxide was ineffective. No studies assessed moderate IV sedation, IV/IM opioid, paracervical block without sedation, NSAID or nonpharmacological treatment. CONCLUSION: Based on limited data, regional analgesia and NSAIDs mitigated second‐trimester medical TOP pain; general anaesthesia/deep IV sedation alleviated surgical TOP pain. TWEETABLE ABSTRACT: Although women experience intense pain during second‐trimester termination of pregnancy, few data are available to inform their treatment.