Rationale for Recommendation 15 (specifically for gestational ages < 14 weeks)

A Cochrane Review served as the evidence base for this key question. Five studies reporting on pain management for medical abortion at gestational ages < 14 weeks were identified by the search strategy, conducted in Israel, the United Kingdom and the USA. A summary of the evidence is presented in Supplementary material 2, EtD framework for Pain management for medical abortion < 14 weeks.

Of these studies, three were assessed using the following comparisons:

• ibuprofen versus placebo
• prophylactic versus therapeutic NSAIDs
• ibuprofen versus paracetamol.

Women who received NSAIDs had lower mean pain scores and fewer women from that group required additional analgesic medication, based on high-certainty evidence. Discussions on the values and preferences of women with pain management during medical abortion and the resources required, cost-effectiveness and feasibility for NSAID administration resulted in a determination that favoured the intervention.

Rationale for Recommendations 15 (specifically for gestational ages ≥ 14 weeks) and 16

A systematic review was undertaken to address this key question. Eleven studies reporting on pain management for medical abortion at gestational ages ≥ 14 weeks were identified by the search strategy, conducted in Belgium, Canada, Germany, Israel, Italy, Sweden, Thailand and the USA. A summary of the evidence is presented in Supplementary material 2, EtD framework for Pain management for medical abortion ≥ 14 weeks.

Using data from these studies, the following comparisons were made:

• paracervical block (PCB) versus oral pain medication
• NSAIDs versus non-NSAIDs/placebo
• anti-emetics versus placebo
• anti-epileptics versus anxiolytics
• intermittent versus continuous epidural
• patient controlled epidural versus patient-controlled intravenous (IV) fentanyl
• patient controlled fentanyl versus patient-controlled morphine
• patient controlled IV tramadol versus patient-controlled IV fentanyl.

Comparison of PCB versus oral pain medication: In the studies that assessed this comparison, fewer women experienced severe pain and there was a lower expulsion time with the use of oral pain medication compared with PCB, based on moderate-certainty evidence.

Comparison of NSAIDs versus non-NSAIDs/placebo: In the studies that assessed this comparison, fewer women required supplemental narcotics after the use of NSAIDs, based on high certainty of evidence. In addition, fewer women receiving NSAIDs experienced side-effects, based on moderate-certainty evidence.

Comparison of anti-emetics versus placebo: In the studies that assessed this comparison, there was lower use of supplemental narcotics and lower expulsion time with the use of anti-emetics, based on moderate-certainty evidence.

Comparison of anti-epileptics versus anxiolytics: In the studies that assessed this comparison, there were lower mean pain scores, lower use of additional analgesics and lower mean expulsion times with the use of anti-epileptics, based on moderate-certainty evidence.

Comparison of intermittent versus continuous epidural: In the studies that assessed this comparison, there were fewer side-effects with the use of intermittent epidural, based on low- to high-certainty evidence. Satisfaction was higher among women who had intermittent epidural for their pain management, based on high-certainty evidence.

Comparison of patient-controlled epidural (PCE) versus patient controlled IV fentanyl: In the studies that assessed this comparison, there were lower mean pain scores and fewer side-effects of vomiting and sedation with the use of PCE, based on moderate-certainty evidence. In addition, satisfaction was higher among women in the PCE group, based on moderate-certainty evidence.

Comparison of patient-controlled morphine versus patient-controlled IV fentanyl: In the studies that assessed this comparison, there were lower pain scores and fewer side-effects with the use of patient-controlled fentanyl (50 μg), based on moderate- to high-certainty evidence.

Comparison of patient controlled IV tramadol versus patient controlled IV fentanyl: In the studies that assessed this comparison, pain control was comparable with the use of patient-controlled tramadol and fentanyl, based on low- to moderate-certainty evidence. Satisfaction ratings were also similar between the two groups, based on high-certainty evidence. Discussions on the values and preferences of women regarding pain management during medical abortion, and on the resources required, cost-effectiveness and feasibility for NSAID administration resulted in a determination that favoured the intervention.