Management of Pain for Second-Trimester Dilatation & Evaluation (D&E) Abortion

1. Management of Pain for Second-Trimester Dilatation & Evaluation (D&E) Abortion

2. Objectives • State specific goals for pain management • Describe different approaches and routes for pain control • List pain medications commonly used in second-trimester procedures • Choose appropriate and optimal medication combinations

3. To help women remain as comfortable as possible, while minimizing medication-induced risks and side effects Goal of pain management

4. First- versus second-trimester procedures More pain with D&E • Greater depth of uterine exploration and manipulation • Greater dilatation of cervix • Emotional factors (Smith et al 1979; Belanger et al 1989)

5. Choosing Pain Management Factors to consider: • How severe will the pain be? • How long will the woman wait between taking the medication and having the procedure? • What systems are in place to ensure safe use of medications? • Don’t make assumptions regarding a woman’s perception of pain – ask her how she is doing.

6. Choosing Pain Management Staffing needs: • Trained provider assigned only to pain management and support during the procedure • Should be knowledgeable about the medications’ pharmacology • Able to monitor vital signs/physical status and verbally support client • Trained in cardiopulmonary resuscitation

7. Non-pharmacologic approaches • Verbal support • Person present during procedure dedicated to supporting the woman • Does not replace pain medications • Hot water bag/heating pad

8. Pharmacologic approaches • Local • Paracervical block • Oral medications • Intravenous medications • Intramuscular medications

9. Paracervical Block 10 to 20mL of 0.5 to 1% lidocaine Inject 1 to 2mL at 12 o’clock Place tenaculum through center of speculum grasping cervix vertically at 12 o’clock Using tenaculum, gently pull cervix outward and to one side to expose lateral fornix for injection at junction of cervix and vagina Insert tip of needle at 4 o’clock, aspirate, then slowly inject 2-5mL; repeat at 8 o’clock. Inject to a depth of 2.5 to 3.8cm Source: Ipas Woman-Centered Abortion Care Reference Manual

10. Paracervical Block

11. Safety: Lidocaine Dosing Maximum dose 4.5 mg/kg body weight For a 40 kg woman this is 18-20 mL of 1% lidocaine 1% solution is 10 mg per 1 mL 15 mL of 1% is 150 mg of lidocaine 20 mL of 1% is 200 mg lidocaine Most unsedated women given this dose report some effects: numbness around the mouth, ringing in ears, voices sound distant, and rarely, anxiety (Blanco et al 1982)

12. Lidocaine Toxicity To avoid toxicity: Be aware of your client’s weight Always aspirate before injecting If blood is encountered (i.e. you are in a vessel), move needle and aspirate again before injecting Know signs of toxicity/overdose: convulsions, then cardiovascular collapse

13. Lidocaine Toxicity • Stop injection • Benzodiazepines raise seizure threshold and can be protective • Supportive care • Reassurance, administer oxygen, intubate if necessary (anesthesia consultation) • True lidocaine overdose: persistent seizures, cardiovascular collapse • If cardiovascular collapse, closed chest cardiac massage

14. Pharmacologic approaches Most women should receive one from each category: • Non-narcotic analgesics • Non-steroidal anti-inflammatory drugs (NSAIDS), like ibuprofen • Narcotic analgesics • Pethidine, morphine, or fentanyl • If IV not available, consider IM or oral narcotics • Anxiolytics • Benzodiazepines such as Diazepam • Helpful because they reduce anxiety and relax muscles

15. Conscious Sedation In addition to oral NSAIDs, the woman should receive one drug from each category: Narcotic: initial doses Pethidine 25-50 mg IV or 50-125 mg IM Morphine 1-2 mg IV or 0.1-0.2 mg/kg IM Fentanyl 50-100 mcg IV or 50-100 mcg IM Anxiolytic (benzodiazepine): initial doses Diazepam 2-5 mg IV or 10 mg PO Midazolam 2-3 mg IV or 0.07-0.08 mg/kg IM Lorazepam 2 mg IV or 0.05 mg/kg IM (maximum dose 4 mg)

16. Conscious Sedation Administer each IV dose slowly, over 30-60 seconds Monitor vital signs IV medications effects are rapid in onset, but not instantaneous Wait a few minutes after giving medications to begin the procedure

17. Complications • Respiratory depression caused by anxiolytics (benzodiazepines) and narcotics • Assist with breathing (oxygen, ambu bag) as needed • Administer reversal agents • Benzodiazepine sedation reversal • Flumazenil 0.2 mg IV over 15 seconds, then 0.2 mg every 1 minute as needed up to 1 mg total dose

18. Complications Narcotic reversal • Naloxone 0.1-0.2 mg IV every 2-3 minutes as needed

19. Quality Assurance • Important to have emergency medications with dilutions/dosage information easily accessible • Check inventory of emergency medications regularly • Conduct emergency drills with staff • Need systems in place for adverse event monitoring and reporting

20. Questions?