Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Clinical services Recommendations 15 and 16: Pain management for medical abortion (3.3.6)
CLINICAL SERVICES Recommendations 15 and 16: Pain management for medical abortion
15. For medical abortion at any gestational age: Recommend that pain management should be offered routinely (e.g. non-steroidal anti-inflammatory drugs [NSAIDs]) and that it should be provided for the individual to use if and when wanted.
NEW RECOMMENDATION BELOW INDICATES PAIN MANAGEMENT THAT IS ADDITIONAL TO NSAIDS.
16. (NEW) For pain management for medical abortion at ≥ 12 weeks: Suggest consideration of other methods to control pain or discomfort due to increased pain with increasing gestational age. Such methods include certain anti-emetics and epidural anaesthesia, where available.
Remark:
- For medical abortion at gestational ages < 14 weeks, if NSAIDS (e.g. ibuprofen) are not available or not an option, then acetaminophen can be considered for pain control.
Source: Recommendation 15 updated from WHO (2012)(19). Recommendation 16 is new.
Note on updating of the recommendation: Recommendation 15 was previously published as part of Recommendation 14 in WHO (2012) (19), and evidence for it was reviewed using GRADE methodology. After review, in this updated version, we have split the first part of the original recommendation wording to apply to surgical abortion (see Recommendation 11a) and medical abortion (here in Recommendation 15), and revised the wording to mention provision.
No requirement for location (on-site vs off-site).
For information regarding which health workers can provide this intervention, refer to Recommendations 28 and 30 on medical abortion.
Implementation consideration for Recommendations 15 and 16
- Regardless of the service modality, there should be clear communication to the woman on the pain she may experience, which may vary based on pain perceptions and tolerance. In any event, she should be provided with information on pain management, and access to adequate pain medicines should be ensured.
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.
KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO PAIN MANAGEMENT
- States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.
- Denial of pain medication may violate a wide range of human rights, including the right to health and autonomy in decision-making.
- Denial of pain medication as punishment for abortion or because it is part of abortion care may violate the right to equality and non-discrimination.
- Denial of pain medication may violate the right to be free from cruel, inhuman and degrading treatment.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.