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Paracervical local anaesthesia for cervical dilatation and uterine intervention

  1. Thumwadee Tangsiriwatthana1,*,
  2. Ussanee S Sangkomkamhang1,
  3. Pisake Lumbiganon2,
  4. Malinee Laopaiboon3

Editorial Group: Cochrane Anaesthesia Group

Published Online: 30 SEP 2013

Assessed as up-to-date: 20 AUG 2013

DOI: 10.1002/14651858.CD005056.pub3


How to Cite

Tangsiriwatthana T, Sangkomkamhang US, Lumbiganon P, Laopaiboon M. Paracervical local anaesthesia for cervical dilatation and uterine intervention. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD005056. DOI: 10.1002/14651858.CD005056.pub3.

Author Information

  1. 1

    Khon Kaen Hospital, Department of Obstetrics and Gynaecology, Khon Kaen, Thailand

  2. 2

    Khon Kaen University, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen, Thailand

  3. 3

    Khon Kaen University, Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen, Thailand

*Thumwadee Tangsiriwatthana, Department of Obstetrics and Gynaecology, Khon Kaen Hospital, Khon Kaen, 40000, Thailand. thumwadee@hotmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 30 SEP 2013

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Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 
Summary of findings for the main comparison. Paracervical versus placebo for cervical dilatation and uterine intervention

Paracervical versus placebo for cervical dilation and uterine intervention

Patient or population: patients with cervical dilatation and uterine intervention
Settings:
Intervention: paracervical versus placebo

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlParacervical versus placebo

Pain dilating cervixThe mean pain dilating cervix in the intervention groups was
0.37 standard deviations lower
(0.58 to 0.17 lower)
381
(4 studies)
⊕⊕⊕⊕
high
SMD -0.37 (-0.58 to -0.17)

Pain during uterine intervention - Risk of any painStudy populationRR 0.85
(0.54 to 1.34)
242
(2 studies)
⊕⊕⊝⊝
low1

926 per 1000787 per 1000
(500 to 1000)

Moderate

910 per 1000773 per 1000
(491 to 1000)

Pain during uterine intervention - Risk of severe painStudy populationRR 0.16
(0.04 to 0.74)
242
(2 studies)
⊕⊕⊕⊝
moderate2

149 per 100024 per 1000
(6 to 110)

Moderate

156 per 100025 per 1000
(6 to 115)

Postoperative pain - Immediately after the procedureThe mean postoperative pain - immediately after the procedure in the intervention groups was
0.34 standard deviations lower
(0.92 lower to 0.24 higher)
223
(3 studies)
⊕⊕⊝⊝
low
SMD -0.34 (-0.92 to 0.24)

Adverse effects - Nausea and vomitingStudy populationRR 0.24
(0.02 to 2.8)
429
(3 studies)
⊕⊕⊕⊝
moderate

265 per 100064 per 1000
(5 to 742)

Moderate

250 per 100060 per 1000
(5 to 700)

Adverse effects - SweatingStudy populationRR 1.08
(0.7 to 1.67)
142
(1 study)
⊕⊕⊕⊝
moderate

352 per 1000380 per 1000
(246 to 588)

Moderate

352 per 1000380 per 1000
(246 to 588)

Adverse effects - HypotensionStudy populationRR 3.06
(1.21 to 7.78)
171
(2 studies)
⊕⊕⊕⊝
moderate

58 per 1000178 per 1000
(70 to 452)

Moderate

50 per 1000153 per 1000
(61 to 389)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Heterogeneity between studies may arise from differences in outcomes
2 Limitation of design: lack of allocation concealment

 Summary of findings 2 Paracervical versus no anaesthesia for cervical dilatation and uterine intervention

 Summary of findings 3 Paracervical block versus other regional anaesthesia for cervical dilatation and uterine intervention

 Summary of findings 4 Paracervical versus systemic analgesia for cervical dilatation and uterine intervention

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of the condition

Indications for cervical dilatation and uterine intervention include abnormal uterine bleeding that does not respond to medical treatment, postmenopausal bleeding, and abortion. General anaesthesia provides adequate operating conditions for cervical dilatation and uterine intervention. However, there are some situations where general anaesthesia is hazardous, for example when patients are frail, unwell, or when no anaesthesiologist is available. The choice of anaesthesia and analgesia is dependent on effectiveness, cost, safety, and side effects. Other factors are the patient's and physician's preferences. Paracervical local anaesthesia offers an alternative for cervical dilatation and uterine intervention as it does not require general anaesthetic equipment or personnel trained to give general anaesthesia.

 

Description of the intervention

Paracervical block has been performed since 1925 (Aimakhu 1972). Injection of local anaesthetic around the cervix, at the 'three and nine o'clock positions', anaesthetizes the second to fourth sacral nerve roots as they pass through Frankenhäuser's plexus at a depth of 2 to 4 mm (Piyamongkol 1998). Physical pain originates from the S2 to S4 parasympathetic fibres (the Frankenhäuser plexus) that innervate the cervix and the lower part of the uterine body (Scott 1976; Smith 1991). The uterine fundus and lower part of the uterine body are innervated by sympathetic fibres from T10 to L1 via the inferior hypogastric nerve and the ovarian plexus (Maltzer 1999).

 

How the intervention might work

Most gynaecologic procedures cause pain or discomfort, especially on cervical dilatation. The pain is transmitted by sensory and sympathetic pathways to the lateral spinothalamic tracts of the spinal cord. Paracervical anaesthetics block transmission of pain through sympathetic, parasympathetic and sensory fibres before they enter the uterus at the level of the internal os (Chanrachakul 2001).

 

Why it is important to do this review

Many gynaecologists inject paracervical local anaesthetic before cervical dilatation and uterine intervention, but its effectiveness is unclear. The effectiveness of paracervical blockade may be affected by the anatomical and physiological changes that accompany pregnancy and the menopause. We compared the effectiveness and safety of paracervical blockade before cervical dilatation and uterine interventions versus no treatment, placebo, other methods of regional anaesthesia, sedation and systemic analgesia, and general anaesthesia.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The objectives of this review were to determine the effectiveness and safety of paracervical local anaesthesia for cervical dilatation and uterine intervention, versus no treatment, placebo, other methods of regional anaesthesia, sedation and systemic analgesia, and general anaesthesia.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included randomized controlled trials (RCTs) in which allocation was either randomized or pseudo-randomized (alternate days, weeks, odd and even hospital numbers). We excluded concurrent cohort and observational studies.

 

Types of participants

We included women of any age who underwent cervical dilatation and uterine intervention for any indication.

 

Types of interventions

We included studies in which at least one group had paracervical block. The comparison interventions were: placebo; no treatment; other regional anaesthesia; sedation and systemic analgesia. We did not compare one type of local anaesthetic with another.

We anticipated that we would conduct meta-analyses for the following comparisons.

  1. Paracervical local anaesthesia versus placebo.
  2. Paracervical local anaesthesia versus no anaesthesia.
  3. Paracervical local anaesthesia versus other methods of regional anaesthesia.
  4. Paracervical local anaesthesia versus systemic analgesia.
  5. Paracervical local anaesthesia versus general anaesthesia.

 

Types of outcome measures

We included pain, adverse effects, and patient satisfaction.

 

Primary outcomes

  1. Pain during or after cervical dilatation and uterine intervention, measured as categorical or continuous data (for example on a visual analogue scale)
  2. Adverse effects (such as nausea, vomiting, hypotension)
  3. The requirement of additional analgesia

 

Secondary outcomes

  1. Patient satisfaction (as defined by the study authors)

 

Search methods for identification of studies

 

Electronic searches

We reran our search to August 2013. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 8) (Appendix 1), MEDLINE via OvidSP (1966 to August 2013) (Appendix 2), EMBASE via OvidSP (January 1980 to August 2013) (Appendix 3), and reference lists of articles. Our original search was performed in January 2006.

We combined our search strategies with the Cochrane highly sensitive search strategy for RCTs as contained in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

We searched for ongoing and recently published studies in www.controlled-studies.com. We did not apply any language restrictions.

 

Searching other resources

We handsearched the reference lists of reviews, randomized and non-randomized studies, and editorials for additional studies. We contacted the main authors of studies and experts in this field to ask for any missed, unreported, or ongoing studies.

 

Data collection and analysis

 

Selection of studies

We did not blind the names of the study authors, institutions, or journals of publication. Two authors (TT and US) independently evaluated the eligibility of studies from their title, abstract, and the full paper. We analysed the results of the randomized controlled studies that we had selected and graded their methodological quality by using the GradeProfiler programme version 3.2.2 and through construction of the risk of bias tables for the following items: random sequence generation; allocation concealment; blinding of the intervention administered; incomplete data; selective reporting; and other bias. We used the GradeProfiler programme version 3.2.2 to grade the quality of the relevant articles in terms of their: limitation of design; inconsistency; indirectness; imprecision; and publication bias. The quality of evidence across studies for the outcome was graded into four levels: high; moderate; low; and very low. We resolved any disagreements through discussion. The third author (PL) evaluated disputed studies to obtain a consensus.

 

Data extraction and management

We used the standard methods of the Cochrane Anaesthesia Review Group. Two authors (TT and US) scrutinized all the titles and abstracts for their suitability and independently extracted data. One author (TT) checked the data and entered them into RevMan 5.1. We contacted the authors of any study that had missing data.

 

Assessment of risk of bias in included studies

We evaluated the validity and design characteristics of each trial. We assessed: random sequence generation, allocation concealment, blinding, incomplete data, selective reporting, and other bias. We performed summary assessments of the risk of bias for each important outcome (across domains) within and across studies. We applied a 'Risk of bias' graph and a 'Risk of bias' summary figure (Higgins 2011) (Figure 1, Figure 2). We planned to include high and low risk studies, and to present multiple analyses.

 FigureFigure 1. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

 

Unit of analysis issues

The unit of analysis was the individual participant. In this review we included only parallel group trials, with only one measurement per participant.

 

Dealing with missing data

We contacted Chanrachakul 2001 in order to retrieve the relevant data but the data were unavailable. We chose to explore selective outcome reporting by comparing publications with their protocols, if the latter were available.

 

Assessment of heterogeneity

When we suspected important heterogeneity, determined by an I2 statistic greater than 50% (Higgins 2003), we investigated differences in clinical factors between studies. When meta-analysis was inappropriate, we drew conclusions from the descriptive elements of the studies; methodological quality; number of studies with consistent findings; plausibility of the results; and the strength of the associations in the primary studies as well as consensus among authors.

 

Assessment of reporting biases

We planned to explore whether the included articles had any reporting biases, both publication and funding biases.

 

Data synthesis

Where appropriate, we analysed pooled data using RevMan 5.1. The method of meta-analysis was dependent on the nature of the outcomes. For categorical data (for example the proportion of participants with an event) we related the number reporting an event to the number at risk in each group to derive a relative risk (RR) and 95% confidence interval (CI). We pooled continuous differences between groups in the meta-analysis (for example pain relief on a visual analogue scale (VAS)) as mean differences (MD) or standardized mean differences (SMD), as appropriate, with their 95% CIs. In the case of various units of pain score measurements among studies, we used SMD for analysis. We used a fixed-effect model unless significant heterogeneity was encountered, in which case we used a random-effects model.

 

Subgroup analysis and investigation of heterogeneity

We considered subgroup analyses based on:

  • patients' characteristics e.g. menopausal status (before versus after), parity (zero versus the rest);
  • types of diseases;
  • nature, dose, and duration of interventions.

We did not perform any subgroup and sensitivity analyses because of the small number of included studies; and no data were available on potential factors for subgroup analysis.

 

Sensitivity analysis

We planned the following sensitivity analyses: quality of allocation concealment (adequate, unclear, or inadequate); blinding outcome assessment (adequate, unclear, or inadequate or not performed); and rates of withdrawals for each outcome.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

 

Results of the search

We identified 1218 studies of which 96 had relevant titles and abstracts. We excluded 10 of these studies (Agostini 2008; Allen 2006; Allen 2009; Cansino 2009; Habersetzer 1972; Harper 1997; Karasahin 2011; Manyou 2008; Naki 2011; Phittayawechwiwat 2007) (see Characteristics of excluded studies). We excluded 70 studies in total (Figure 3). We found no ongoing trials. Titles and abstracts were unclear in three studies (Chaudhuri 1980; Regina 1987; Sen 1980) and we put them into 'Studies awaiting classification'. We identified 26 relevant studies with 28 comparisons as Kan 2004 and Sharma 2009 studied more than two groups (see Characteristics of included studies), involving a total of 2790 women, that were published in full. Our full search results are in Figure 3.

 FigureFigure 3. Searching results

 

Included studies

In our original review we included 17 studies. In this updated review we included nine new studies (Al-Sunaidi 2007; Amirian 2009; Chudnoff 2010; Lazenby 2009; Lopez 2007; Mankowski 2009; Renner 2012; Sharma 2009; Thongrong 2011) making a total of 26 studies. Two of the new studies compared paracervical block versus placebo (Amirian 2009; Chudnoff 2010) making a total of 10 studies. We included three additional studies (Lopez 2007; Sharma 2009; Thongrong 2011) of paracervical block versus sedation and systemic analgesia; two additional studies (Al-Sunaidi 2007; Mankowski 2009) versus other regional techniques; and one additional study versus no treatment (Renner 2012). We did not find any studies of paracervical block versus general anaesthesia.

 

Excluded studies

In our original review, we excluded 80 studies.

In our updated review we excluded an additional 10 newly identified studies (Agostini 2008; Allen 2006; Allen 2009; Cansino 2009; Habersetzer 1972; Harper 1997; Karasahin 2011; Manyou 2008; Naki 2011; Phittayawechwiwat 2007). We then re-evaluated the studies we had excluded in our previous review. We removed 18 studies from the list of excluded studies as they were not RCTs (Amyot-Legault 1981; Coker 1968; Fernandez 1997; Ferry 1994; Formiga-Filho 1974; Gad 1967; Lewis 1971; Littlepage 1969; Readman 2004; Reguer Noriega 1973; Rotchell 1976; Sandmire 1974; Santonja 1974; Strausz 1971; Thonneau 1998; Toth 2000; Van Praagh 1967; Walden 1973).

 

Studies awaiting classification

Three studies remain unavailable to us in full text (Chaudhuri 1980; Regina 1987; Sen 1980).

 

Risk of bias in included studies

Please see the table Characteristics of included studies for the detailed descriptions of bias. The domains of bias are presented in the 'Risk of bias' graph and 'Risk of bias' summary figures (Figure 1, Figure 2).

 

Allocation

We judged 17 studies to have a low risk of bias for random sequence generation (Al-Sunaidi 2007; Amirian 2009; Carroll 2005; Chanrachakul 2001; Chudnoff 2010; Cicinelli 1998; Egziabher 2002; Glantz 2001; Gómez 2004; Guida 2003; Kan 2004; Lau 1999; Lopez 2007; Mankowski 2009; Renner 2012; Sharma 2009; Vercellini 1994). There was an unclear risk of bias in seven studies (Buppasiri 2005; Chatfield 1970; Lazenby 2009; Miller 1996; Mola 1996; Titapant 2003; Yazaci 2003), and a high risk of bias in two studies (Finikiotis 1992; Thongrong 2011). We judged allocation concealment to be low risk of bias in 14 studies (Amirian 2009; Carroll 2005; Chanrachakul 2001; Chudnoff 2010; Cicinelli 1998; Glantz 2001; Gómez 2004; Kan 2004; Lau 1999; Lazenby 2009; Lopez 2007; Mankowski 2009; Mola 1996; Renner 2012), unclear in six studies (Buppasiri 2005; Egziabher 2002; Guida 2003; Miller 1996; Titapant 2003; Yazaci 2003), and at a high risk of bias in six studies (Al-Sunaidi 2007; Chatfield 1970; Finikiotis 1992; Sharma 2009; Thongrong 2011; Vercellini 1994).

 

Blinding

Of the 26 studies, 15 adequately blinded women to their allocated intervention (Amirian 2009; Chanrachakul 2001; Chatfield 1970; Chudnoff 2010; Cicinelli 1998; Egziabher 2002; Glantz 2001; Gómez 2004; Kan 2004; Lau 1999; Lazenby 2009; Mankowski 2009; Miller 1996; Renner 2012; Titapant 2003). Nine studies adequately blinded treatment providers to the allocated intervention (Amirian 2009; Chanrachakul 2001; Chatfield 1970; Cicinelli 1998; Egziabher 2002; Glantz 2001; Lau 1999; Miller 1996; Titapant 2003). Thirteen studies adequately blinded outcome assessors to the allocated intervention (Amirian 2009; Chanrachakul 2001; Chatfield 1970; Chudnoff 2010; Cicinelli 1998; Egziabher 2002; Glantz 2001; Gómez 2004; Kan 2004; Lau 1999; Miller 1996; Renner 2012; Titapant 2003). Three of these studies (Chatfield 1970; Cicinelli 1998; Glantz 2001) blinded assessors to outcomes other than abdominal pain.

 

Incomplete outcome data

All studies completed follow up for all women. Seven studies were at high risk of incomplete outcome data (Al-Sunaidi 2007; Amirian 2009; Buppasiri 2005; Chanrachakul 2001; Chatfield 1970; Chudnoff 2010; Cicinelli 1998; Kan 2004; Lau 1999; Lazenby 2009); risk of attrition bias was unclear in two (Finikiotis 1992; Mola 1996), and low in 17 studies (Carroll 2005; Egziabher 2002; Glantz 2001; Guida 2003; Gómez 2004; Kan 2004; Lau 1999; Lazenby 2009; Lopez 2007; Mankowski 2009; Miller 1996; Renner 2012; Sharma 2009; Thongrong 2011; Titapant 2003; Vercellini 1994; Yazaci 2003).

 

Selective reporting

Of the 26 studies, 24 were free of selective reporting (Al-Sunaidi 2007; Amirian 2009; Buppasiri 2005; Chanrachakul 2001; Chatfield 1970; Chudnoff 2010; Cicinelli 1998; Egziabher 2002; Finikiotis 1992; Glantz 2001; Gómez 2004; Guida 2003; Kan 2004; Lau 1999; Lazenby 2009; Lopez 2007; Mankowski 2009; Miller 1996; Mola 1996; Sharma 2009; Thongrong 2011; Titapant 2003; Vercellini 1994; Yazaci 2003), one was unclear (Carroll 2005), and one was at high risk (Renner 2012) (see Figure 1, Figure 2).

 

Other potential sources of bias

Two studies (Kan 2004; Lazenby 2009) presented the trust fund information. Sample size calculations were presented in 14 studies (Chanrachakul 2001; Chudnoff 2010; Cicinelli 1998; Egziabher 2002; Glantz 2001; Gómez 2004; Guida 2003; Kan 2004; Lau 1999; Lazenby 2009; Lopez 2007; Renner 2012; Thongrong 2011; Vercellini 1994). Amirian 2009 excluded the participants who had uterine perforation or severe bleeding during curettage after the allocation concealment was performed. We judged one study to be unclear of other potential biases (Al-Sunaidi 2007).

 

Effects of interventions

See:  Summary of findings for the main comparison Paracervical versus placebo for cervical dilatation and uterine intervention;  Summary of findings 2 Paracervical versus no anaesthesia for cervical dilatation and uterine intervention;  Summary of findings 3 Paracervical block versus other regional anaesthesia for cervical dilatation and uterine intervention;  Summary of findings 4 Paracervical versus systemic analgesia for cervical dilatation and uterine intervention

 
Paracervical local anaesthesia versus placebo

( Analysis 1.1 to  Analysis 1.9)
Ten studies compared paracervical block versus placebo (Amirian 2009; Chanrachakul 2001; Chatfield 1970; Chudnoff 2010; Cicinelli 1998; Egziabher 2002; Glantz 2001; Lau 1999; Miller 1996; Titapant 2003). Uterine interventions included hysteroscopy, endometrial biopsy, fractional curettage, and vacuum aspiration. The local anaesthetics used were lidocaine, chloroprocaine, and xylocaine (see Characteristics of included studies for details).

Pain during speculum insertion ( Analysis 1.1)

There was no evidence of an effect of paracervical block, SMD 0.20 (95% CI -0.35 to 0.74).

Pain on tenaculum placement ( Analysis 1.2)

There was no evidence of an effect of paracervical block, MD -0.70 (95% CI -2.26 to 0.86).

Pain dilating cervix ( Analysis 1.3)

There was evidence that paracervical block reduced the pain of cervical dilatation, SMD -0.39 (95% CI -0.72 to -0.07).

Pain during uterine interventions ( Analysis 1.4)

There was evidence that paracervical block reduced the pain of uterine interventions (carbon dioxide insufflation, endometrial biopsy, fractional curettage, suction evacuation, or aspiration), SMD -0.74 (95% CI -1.19 to -0.28). However, there was substantial heterogeneity across these subgroups (I2 = 85%, P < 0.0001). Within the subgroups there was evidence of an effect for endometrial biopsy and suction aspiration (SMD -1.71, 95% CI -2.26 to -1.17; and SMD -0.90, 95% CI -1.47 to -0.32 respectively).

Pain during uterine interventions (risk of pain) ( Analysis 1.5,  Analysis 1.6)

There was evidence that paracervical block reduced the risk of severe pain but not any pain (RR 0.16, 95% CI 0.04 to 0.74; RR 0.87, 95% CI 0.68 to 1.12 respectively). Chanrachakul 2001 reported that paracervical block significantly reduced the median pain score during fractional curettage, from 6.0 to 4.0 (statement unsupported by a P value). There was no evidence of an effect in a study of tubal insert placement (Chudnoff 2010) (see Additional  Table 1, Appendix 4).

Postoperative pain ( Analysis 1.7)

There was no evidence that paracervical block reliably reduced postoperative pain (see also Appendix 5, Appendix 6, Appendix 7).

Shoulder pain ( Analysis 1.8)

There was no evidence that paracervical block reduced the risk of shoulder pain.

Adverse effects ( Analysis 1.9)

Paracervical block did not change the risk of sweating, nausea or vomiting. In one study (Lau 1999) the risk of hypotension after paracervical block was greater than after placebo injection, RR 3.06 (95% CI 1.21 to 7.78). In Miller 1996 3/27 women developed symptoms consistent with lidocaine toxicity (tingling lips, dizziness).

Additional drug requirement

There was no evidence that paracervical block reduced the need for additional drugs, including general anaesthesia (Amirian 2009) (see Appendix 8, Appendix 9).

 
Paracervical local anaesthesia versus no anaesthesia

( Analysis 2.1)

Six studies compared paracervical block versus no treatment (Carroll 2005; Gómez 2004; Kan 2004; Lazenby 2009; Renner 2012; Vercellini 1994). In two studies women had a hysteroscopy (Carroll 2005; Vercellini 1994) and in four studies women had suction termination or evacuation of incomplete miscarriages (Gómez 2004; Kan 2004; Lazenby 2009; Renner 2012).

Pain during the procedure

Meta-analysis was not performed for this outcome. Kan 2004 and Lazenby 2009 found no evidence that paracervical block reduced median pain scores during or after suction termination under sedation when compared to no block. Gómez 2004 reported no difference in intraoperative pain as recalled 10 minutes after the procedure (Appendix 10). There was no evidence for significant differences in pain during hysteroscopy and endometrial biopsy in Vercellini 1994 (Additional  Table 2), but Renner 2012 reported different results on pain reduction (Additional  Table 2). This study found that baseline pain and pain on speculum insertion were not significantly different between paracervical local anaesthesia and no treatment (Appendix 11, Appendix 12). Pain during paracervical injection was greater in the paracervical local anaesthesia group (Appendix 13) but pain on cervical dilation and aspiration was significantly lower with paracervical local anaesthesia than with no treatment (Appendix 14, Appendix 15).

Postoperative pain ( Analysis 2.1)

There was no evidence that paracervical block reduced postoperative pain (also see Appendix 16).

Adverse effects

No study found evidence for differences in the risks of adverse effects.

Patient satisfaction

Kan 2004 did not find evidence for differences in patient satisfaction. Renner 2012 found that paracervical block increased the median satisfaction with pain control and with the procedure (73 versus 49, P < 0.01; and 90 versus 84, P = 0.04 respectively).

Requirement of additional analgesia

There was no evidence that paracervical block affected this outcome (Renner 2012).

 
Paracervical local anaesthesia versus other regional anaesthesia

( Analysis 3.1 to  Analysis 3.3)

Five studies (Al-Sunaidi 2007; Finikiotis 1992; Kan 2004; Mankowski 2009; Yazaci 2003) compared paracervical block to other local anaesthetic techniques: uterosacral block (Finikiotis 1992), intracervical block (Al-Sunaidi 2007; Kan 2004; Mankowski 2009), and intrauterine topical analgesia (Yazaci 2003).

Pain during cervical dilatation ( Analysis 3.1)

There was no evidence that paracervical block affected this outcome.

Pain during uterine intervention ( Analysis 3.2)

Statistically, the studies were too heterogeneous to summate. There was no evidence that paracervical block reduced severe pain, moderate or severe pain during hysteroscopy (Finikiotis 1992) (RR 0.17, 95% CI 0.42 to 3.27; and RR 1.22, 95% CI 0.80 to 1.85 respectively), see Appendix 17. Yazaci 2003 reported that intrauterine instillation of local anaesthetic caused worse pain than paracervical block, SMD 9.49 (95% CI 4.20 to 14.78) (Appendix 18). There was no evidence that pain was different during suction termination under sedation with paracervical block versus intracervical block (Kan 2004), or during hysteroscopy (Al-Sunaidi 2007) or uterine curettage (Mankowski 2009). Paracervical block slightly reduced pain during endometrial biopsy compared with intrauterine local anaesthetic installation, MD on a 100-point scale of 6.9 (95% CI 2.5 to 11.3, P = 0.002) (Yazaci 2003), see Additional  Table 3.

Postoperative pain at different times ( Analysis 3.3)

The studies were statistically too heterogeneous to summate. Paracervical block reduced postoperative pain in two studies (MD 4.63, 95% CI 0.24 to 9.02 (Yazaci 2003); and MD 0.40, 95% CI 0.29 to 0.51 (Al-Sunaidi 2007) at 10 minutes, MD 0.70, 95% CI 0.61 to 0.79 at 30 minutes, and MD 0.20, 95% CI 0.13 to 0.27 at 60 minutes postoperation) (see Appendix 19).

Adverse effects

Yazaci 2003 did not find any difference in the risk of a vasovagal reaction (Appendix 20).

 
Paracervical local anaesthesia versus systemic analgesia

( Analysis 4.1 to  Analysis 4.3)

Six studies (Buppasiri 2005; Guida 2003; Lopez 2007; Mola 1996; Sharma 2009; Thongrong 2011) compared paracervical block with systemic analgesics and sedatives: mefenamic acid (Buppasiri 2005); fentanyl and midazolam (Guida 2003); paracervical block plus diclofenac and meperidine plus diclofenac (Lopez 2007); pethidine and diazepam (Mola 1996); drotaverine with mefenamic acid and diazepam with pentazocine (Sharma 2009); and intravenous morphine (Thongrong 2011). The studies included women undergoing: fractional curettage (Buppasiri 2005; Thongrong 2011); hysteroscopy (Guida 2003); manual vacuum aspiration (Lopez 2007); bi-manual removal of retained placenta (Mola 1996); hysteroscopy with endometrial biopsy (Sharma 2009).

Pain during uterine intervention ( Analysis 4.1)

The studies were statistically too heterogeneous to summate. There was no evidence that pain during uterine intervention differed with paracervical block compared to systemic analgesia (also see Appendix 21 and Appendix 22).

Postoperative pain ( Analysis 4.2)

Statistically the studies were too heterogeneous to summate. There was no evidence that pain after uterine intervention differed with paracervical block compared with systemic analgesia (also see Appendix 23).

Adverse effects ( Analysis 4.3)

There was no evidence that the rates of pallor, hypotension, dizziness, or nausea or vomiting differed with paracervical block compared with systemic analgesia.

Requirement for postoperative analgesia

There was no evidence that the rates or doses of postoperative analgesics differed with paracervical block versus systemic analgesia. Buppasiri 2005 reported that three patients in each group needed additional drugs (intravenous pethidine). Guida 2003 and Lopez 2007 reported no significant difference in postoperative analgesic requirement between paracervical block and systemic analgesia (Appendix 24).

Patient satisfaction

There was no evidence for a difference in this outcome (see Appendix 25, Appendix 26).

 
Paracervical local anaesthesia versus general anaesthesia

We found no studies for this comparison.

Subgroup analysis

We did not perform any subgroup analysis because of the small number of included studies, and no data were available on potential factors for subgroup analysis.

Sensitivity analysis

We did not do sensitivity analyses because few studies were included in the review.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Summary of main results

Twenty-six included studies involving 2790 women compared paracervical block and other anaesthetic and analgesic methods for women undergoing uterine interventions. There was little evidence to support the belief that paracervical block made any consistent difference to any outcome.

 

Overall completeness and applicability of evidence

We were unable to assess the comparative effects of paracervical local anaesthesia (PLA) versus general anaesthesia as we did not find any studies. There appeared to be sufficient studies and measurements to address the other objectives of this review. Ten included studies, with 984 women, compared paracervical block with placebo (Amirian 2009; Chanrachakul 2001; Chatfield 1970; Chudnoff 2010; Cicinelli 1998; Egziabher 2002; Glantz 2001; Lau 1999; Miller 1996; Titapant 2003). PLA was compared with no anaesthesia in six studies (776 women) (Carroll 2005; Gómez 2004; Kan 2004; Lazenby 2009; Renner 2012; Vercellini 1994), with other regional anaesthesia methods in five studies (450 women) (Al-Sunaidi 2007; Finikiotis 1992; Mankowski 2009; Kan 2004; Yazaci 2003), and systemic analgesia in six studies (580 women) (Buppasiri 2005; Guida 2003; Lopez 2007; Mola 1996; Sharma 2009; Thongrong 2011). All 26 studies measured pain as an outcome. Ten studies (Buppasiri 2005; Cicinelli 1998; Egziabher 2002; Guida 2003; Kan 2004; Lau 1999; Miller 1996; Renner 2012; Thongrong 2011; Yazaci 2003) had information on adverse effects, three studies reported patient satisfaction (Guida 2003; Kan 2004; Renner 2012), and five studies reported on postoperative analgesic requirements (Amirian 2009; Gómez 2004; Kan 2004; Lazenby 2009; Renner 2012). The women included in this review underwent both obstetric (dilatation curettage, manual placenta removal, manual vacuum aspiration) and gynaecologic (hysteroscopy, fractional curettage, endometrial biopsy or ablation) interventions.

 

Quality of the evidence

Fourteen of the 26 included studies (Amirian 2009; Carroll 2005; Chanrachakul 2001; Chudnoff 2010; Cicinelli 1998; Glantz 2001; Gómez 2004; Kan 2004; Lau 1999; Lazenby 2009; Lopez 2007; Mankowski 2009; Mola 1996; Renner 2012) had adequate random allocation concealment but we could not perform sensitivity analyses to evaluate the robustness of the result. This was because we had more than one comparison and each comparison had a limited number of included studies. Of the 26 included studies, 15 reported using some form of blinding. In conclusion, half of the included studies had adequate quality in terms of randomised allocation concealment and blinding.

 

Potential biases in the review process

We strictly followed the search strategies recommended by the Cochrane Anaesthesia Review Group (CARG). We searched all recommended databases and retrieved all the potential studies, except for three that remain unavailable in full text (Chaudhuri 1980; Regina 1987; Sen 1980). Since we used the recommended review process described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) any bias in the review should be minimal.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

All of the techniques used in the 26 included studies failed to reliably prevent pain in conscious women having uterine interventions. The available evidence does not show if paracervical block is inferior, equivalent, or superior to the alternative analgesic techniques, either in terms of efficacy or safety. Some women are likely to experience severe pain if they undergo uterine interventions with paracervical blockade, or one of the other conscious methods assessed in this review. Either general anaesthesia or neuraxial blockade is probably necessary to avoid severe pain during uterine intervention. Clinicians should stop using paracervical block as a method of pain control.

 
Implications for research

Our systematic review showed that pain experienced by women having uterine interventions is inadequately controlled by paracervical block. The findings of the 26 included studies suggest that the other methods that were compared with paracervical block (local anaesthetic methods, sedation and systemic analgesics) also inadequately control the pain. Researchers should conduct systematic reviews of these other methods to confirm or refute this finding. Should they do so, potential participants in trials should be informed of the results of this systematic review, which should also inform the design of any future randomized controlled trials.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

As part of the pre-publication editorial process, this review has been commented on by content and statistical editors, two peer referees (who are external to the editorial team), one or more members of the Cochrane Consumer Network’s international panel of consumers, and the Anaesthesia Group’s Trials Search Co-ordinator.

We would like to thank John Carlisle, Nathan Pace, Martin Sowter, Steven Knight, Amy Woodruffe, and Kathie Godfrey for their help and editorial advice during the preparation of this review.

Special thanks to Jane Cracknell for providing valuable advice, support, encouragement and feedback; Karen Hovhannisyan for his help and advice; and Tom Pederson, Anne Roelsgaard Obling and Nete Villebro for their advice, encouragement and support during the preparation of this review.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. Paracervical versus placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain on speculum insertion2202Std. Mean Difference (IV, Random, 95% CI)0.20 [-0.35, 0.74]

 2 Pain on tenaculum placement3249Mean Difference (IV, Random, 95% CI)-0.70 [-2.26, 0.86]

 3 Pain dilating cervix4381Mean Difference (IV, Random, 95% CI)-0.96 [-1.91, -0.01]

 4 Pain during uterine interventions6696Std. Mean Difference (IV, Random, 95% CI)-0.74 [-1.19, -0.28]

    4.1 Pain when the uterus is distended by carbon dioxide
199Std. Mean Difference (IV, Random, 95% CI)0.0 [-0.39, 0.39]

    4.2 hysteroscopy
172Std. Mean Difference (IV, Random, 95% CI)-1.71 [-2.26, -1.17]

    4.3 Endometrial biopsy
2171Std. Mean Difference (IV, Random, 95% CI)-0.85 [-2.44, 0.74]

    4.4 Uterine curettage
2220Std. Mean Difference (IV, Random, 95% CI)-0.90 [-1.47, -0.32]

    4.5 Suction evacuation or aspiration
2134Std. Mean Difference (IV, Random, 95% CI)-0.38 [-1.02, 0.25]

 5 Risk of any pain during uterine interventions2242Risk Ratio (M-H, Random, 95% CI)0.87 [0.68, 1.12]

 6 Risk of severe pain during uterine intervention2242Risk Ratio (M-H, Random, 95% CI)0.16 [0.04, 0.74]

 7 Postoperative pain6Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    7.1 Immediately after the procedure
3223Std. Mean Difference (IV, Random, 95% CI)-0.34 [-0.92, 0.24]

    7.2 5 min after the procedure
180Std. Mean Difference (IV, Random, 95% CI)0.09 [-0.35, 0.53]

    7.3 15 minutes after the procedure
172Std. Mean Difference (IV, Random, 95% CI)-0.94 [-1.43, -0.45]

    7.4 30 minutes after the procedure
4371Std. Mean Difference (IV, Random, 95% CI)-0.04 [-0.26, 0.18]

 8 Shoulder pain2Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    8.1 During the procedure
2144Risk Ratio (M-H, Fixed, 95% CI)0.5 [0.05, 5.39]

    8.2 After the procedure
2241Risk Ratio (M-H, Fixed, 95% CI)1.33 [0.51, 3.49]

 9 Adverse effects4Risk Ratio (M-H, Random, 95% CI)Subtotals only

    9.1 Nausea/vomiting
3429Risk Ratio (M-H, Random, 95% CI)0.24 [0.02, 2.80]

    9.2 Sweating
1142Risk Ratio (M-H, Random, 95% CI)1.08 [0.70, 1.67]

    9.3 Hypotension
2171Risk Ratio (M-H, Random, 95% CI)3.06 [1.21, 7.78]

 
Comparison 2. Paracervical versus no anaesthesia

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Postoperative pain at different times2Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 Immediately after the procedure
2128Std. Mean Difference (IV, Fixed, 95% CI)-0.37 [-0.72, -0.02]

    1.2 5 minutes after the procedure
158Std. Mean Difference (IV, Fixed, 95% CI)-0.25 [-0.77, 0.27]

    1.3 10 minutes after the procedure
158Std. Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.55, 0.48]

 
Comparison 3. Paracervical block versus other regional anaesthesia

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain during cervical dilatation2163Std. Mean Difference (IV, Random, 95% CI)-1.04 [-2.99, 0.91]

 2 Pain during uterine intervention: continuous3271Mean Difference (IV, Random, 95% CI)-0.55 [-1.24, 0.13]

    2.1 Endometrial biopsy
155Mean Difference (IV, Random, 95% CI)-0.69 [-1.13, -0.25]

    2.2 Uterine curettage
1132Mean Difference (IV, Random, 95% CI)0.60 [-0.32, 1.52]

    2.3 Hysteroscopy
184Mean Difference (IV, Random, 95% CI)-1.1 [-1.21, -0.99]

 3 Postoperative pain at different time: continuous2307Mean Difference (IV, Fixed, 95% CI)-0.39 [-0.44, -0.35]

    3.1 10 minutes after the procedure
184Mean Difference (IV, Fixed, 95% CI)-0.40 [-0.51, -0.29]

    3.2 15 minutes after the procedure
155Mean Difference (IV, Fixed, 95% CI)-0.46 [-0.90, -0.02]

    3.3 30 minutes after the procedure
184Mean Difference (IV, Fixed, 95% CI)-0.7 [-0.79, -0.61]

    3.4 60 minutes after the procedure
184Mean Difference (IV, Fixed, 95% CI)-0.20 [-0.27, -0.13]

 
Comparison 4. Paracervical versus systemic analgesia

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain during uterine intervention3362Mean Difference (IV, Fixed, 95% CI)0.36 [0.16, 0.57]

    1.1 hysteroscopic electrosurgery
1166Mean Difference (IV, Fixed, 95% CI)0.20 [-0.03, 0.43]

    1.2 manual vacuum aspiration
176Mean Difference (IV, Fixed, 95% CI)0.40 [-0.82, 1.62]

    1.3 Hysteroscopy and endometrial biopsy:1
160Mean Difference (IV, Fixed, 95% CI)1.80 [1.12, 2.48]

    1.4 Hysteroscopy and endometrial biopsy:2
160Mean Difference (IV, Fixed, 95% CI)0.35 [-0.37, 1.07]

 2 Postoperative pain2904Mean Difference (IV, Fixed, 95% CI)-1.57 [-0.03, 0.03]

    2.1 at 15 minutes
1166Mean Difference (IV, Fixed, 95% CI)0.10 [-0.19, 0.39]

    2.2 at 30 minutes
1120Mean Difference (IV, Fixed, 95% CI)0.53 [0.21, 0.85]

    2.3 at 1 hour
2286Mean Difference (IV, Fixed, 95% CI)0.42 [0.23, 0.62]

    2.4 at 24 hours
1166Mean Difference (IV, Fixed, 95% CI)-0.20 [-0.31, -0.09]

    2.5 at 3 days
1166Mean Difference (IV, Fixed, 95% CI)0.0 [-0.03, 0.03]

 3 Adverse effects3571Risk Ratio (M-H, Random, 95% CI)0.51 [0.21, 1.20]

    3.1 Pallor or hypotension
1166Risk Ratio (M-H, Random, 95% CI)0.82 [0.23, 2.94]

    3.2 Nausea and vomiting
2242Risk Ratio (M-H, Random, 95% CI)0.38 [0.10, 1.50]

    3.3 Dizziness
2163Risk Ratio (M-H, Random, 95% CI)1.01 [0.04, 25.55]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. Search strategy for CENTRAL (The Cochrane Library)

#1 paracerv* or (paracerv* near an?esth*) or (paracerv* near block*) or (lidocain* or lignocain* or bupivacain* or marcain* or levobupivacain* or prilocain* or chlorprocain* or procain* or xylocain* or ropivacain* or tetracain* or amethocain* or mepivacain*)
#2 MeSH descriptor Anesthesia, Obstetrical explode all trees
#3 (#1 OR #2)
#4 ((obstet* or cervic* or uter*) near intervent*)
#5 (cervic* near dilat*)
#6 (curett* or dilat*):ti,ab
#7 MeSH descriptor Dilatation and Curettage explode all trees
#8 (vacuum near (extract* or aspirat*))
#9 MeSH descriptor Vacuum Curettage explode all trees
#10 MeSH descriptor Vacuum Extraction, Obstetrical explode all trees
#11 (#4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10)
#12 (#3 AND #11)

 

Appendix 2. Search strategy for MEDLINE (OvidSP)

1. (paracerv* or (paracerv* adj6 an?esth*) or (paracerv* adj3 block*) or (lidocain* or lignocain* or bupivacain* or marcain* or levobupivacain* or prilocain* or chlorprocain* or procain* or xylocain* or ropivacain* or tetracain* or amethocain* or mepivacain*)).mp.
2. exp Anesthesia Obstetrical/
3. 1 or 2
4. exp "Dilatation and Curettage"/
5. (((obstet* or cervic* or uter*) adj5 intervent*) or (cervic* adj5 dilat*)).mp. or (curett* or dilat*).ti,ab. or (vacuum adj3 (extract* or aspirat*)).mp.
6. exp Vacuum Curettage/ or exp Vacuum Extraction, Obstetrical/
7. 6 or 4 or 5
8. 3 and 7
9. ((randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or drug therapy.fs. or randomly.ab. or trial.ab. or groups.ab.) not (animals not (humans and animals)).sh.
10. 8 and 9

 

Appendix 3. Search strategy for EMBASE (OvidSP)

1. exp uterine cervix dilatation/ or curettage/ or exp vacuum extractor/ or exp vacuum 
extraction/ or ((obstet* or cervic* or uter*) adj5 intervent*).mp. or (cervic* adj5 
dilat*).mp. or (vacuum adj3 (extract* or aspirat*)).mp. or (curett* or dilat*).ti,ab.
2. exp obstetric anesthesia/ or exp paracervical block/ or (paracerv* or (paracerv* 
adj6 an?esth*)).mp. or (paracerv* adj3 block*).mp. or (lidocain* or lignocain* or bupivacain* or marcain* or levobupivacain* or prilocain* or chlorprocain* or procain* or xylocain* or ropivacain* or tetracain* or amethocain* or mepivacain*).mp.
3. 1 and 2
4. (randomized-controlled-trial/ or randomization/ or controlled-study/ or  
multicenter-study/ or phase-3-clinical-trial/ or phase-4-clinical-trial/ or double- 
blind-procedure/ or single-blind-procedure/ or (random* or cross?over* or factorial*  
or placebo* or volunteer* or ((singl* or doubl* or trebl* or tripl*) adj3 (blind* or  
mask*))).ti,ab.) not (animals not (humans and animals)).sh.
5. 3 and 4

 

Appendix 4. Placement of tubal insert: PLA versus placebo, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Placement of tubal insertChudnoff 201080Mean Difference (IV, Random, 95%CI)-0.59 [-1.78 to 0.60]



 

Appendix 5. Postoperative abdominal pain (mild to moderate): PLA versus placebo, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Immediately after surgeryEgziabher 2002142Risk ratio (M-H, Random, 95%CI)0.72 [0.61 to 0.85]

30 minutes after surgeryEgziabher 2002142Risk ratio (M-H, Random, 95%CI)0.40 [0.26 to 0.60]



 

Appendix 6. Postoperative abdominal pain (severe): PLA versus placebo, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Immediately after surgeryEgziabher 2002142Risk ratio (M-H, Random, 95%CI)0.33 [0.04 to 3.13]

30 minutes after surgeryEgziabher 2002142Risk ratio (M-H, Random, 95%CI)No total



 

Appendix 7. Back pain: PLA versus placebo, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

During procedureEgziabher 2002142Risk ratio (M-H, Random, 95%CI)0.67 [0.50 to 0,90]

15 minutes after procedureEgziabher 2002142Risk ratio (M-H, Random, 95%CI)0.26 [0.10 to 0.67]

30 minutes after procedureEgziabher 2002142Risk ratio (M-H, Random, 95%CI)0.43 [0.12 to 1.59]



 

Appendix 8. Additional drug requirement: PLA versus placebo, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Additional drug requirementAmirian 2009150Odds Ratio (M-H, Fixed, 95%CI)0.78 [0.35 to 1.73]



 

Appendix 9. Need for general anaesthesia: PLA versus placebo, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Need for GAAmirian 2009150Odds Ratio (M-H, Fixed, 95%CI)0.59 [0.24 to 1.47]



 

Appendix 10. Pain during the procedure: PLA versus no anaesthesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Pain during the procedureGómez 2004215Mean Difference (IV, Fixed, 95% CI)-0.43 [-1.29 to 0.43]



 

Appendix 11. Baseline pain: PLA versus no anaesthesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Baseline painRenner 2012120Mean Difference (IV, Fixed, 95% CI)-5.00 [-10.78 to 0.78]



 

Appendix 12. Speculum insertion: PLA versus no anaesthesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Speculum insertionRenner 2012120Mean Difference (IV, Fixed, 95% CI)1.00 [-7.26 to 9.26]



 

Appendix 13. Pain during paracervical block: PLA versus no anaesthesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Paracervical blockRenner 2012120Mean Difference (IV, Fixed, 95% CI)24.00 [14.69 to 33.31]



 

Appendix 14. Pain during cervical dilation: PLA versus no anaesthesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Cervical dilationRenner 2012120Mean Difference (IV, Fixed, 95% CI)-36.00 [-44.64 to -27.36]



 

Appendix 15. Pain during aspiration: PLA versus no anaesthesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

AspirationRenner 2012120Mean Difference (IV, Fixed, 95% CI)-26.00 [-33.48 to -18.52]



 

Appendix 16. 30 minutes after the procedure: PLA versus no anaesthesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

30 min after the procedureRenner 2012120Mean Difference (IV, Fixed, 95% CI)10.00 [1.40 to 18.60]



 

Appendix 17. Pain during the procedure: PLA versus other regional anaesthesia, single study analysis  


OutcomesStudyParticipantsStatistical methodEffect estimate

Pain during the procedureFinikiotis 1992120Odds Ratio (M-H, Fixed, 95%CI)1.41 [0.68 to 2.91]

Severe painFinikiotis 1992120Odds Ratio (M-H, Fixed, 95%CI)0.17 [0.42 to 3.27]

Moderate to severe painFinikiotis 1992120Odds Ratio (M-H, Fixed, 95%CI)1.22 [0.80 to 1.88]



 

Appendix 18. Pain during anaesthetic application: PLA versus other regional anaesthesia, single study analysis  


OutcomesStudyParticipantsStatistical methodEffect estimate

Pain during anaesthetic applicationYazaci 2003114Mean Difference (IV, Random, 95%CI)9.49 [4.20 to 14.78]



 

Appendix 19. Postoperative pain at difference times: PLA versus other regional anaesthesia, single study analysis  


OutcomesStudyParticipantsStatistical methodEffect estimate

10 minutesAl-Sunaidi 200784Mean Difference (IV, Random, 95%CI)-0.40 [-0.51 to -0.29]

15 minutesYazaci 2003114Mean Difference (IV, Random, 95%CI)-4.63 [-9.02 to -0.24]

30 minutesAl-Sunaidi 200784Mean Difference (IV, Random, 95%CI)-0.70 [-0.79 to -0.61]

60 minutesAl-Sunaidi 200784Mean Difference (IV, Random, 95%CI)-0.20 [-0.27 to -0.13]



 

Appendix 20. Adverse effects: PLA versus other regional anaesthesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Vasovagal reactionYazaci 2003114Risk Ratio (M-H, Random, 95%CI)0.69 [0.13 to 3.82]



 

Appendix 21. Pain during uterine intervention: PLA versus systemic analgesia, single study analysis  


OutcomesStudyParticipantsStatistical methodEffect estimate

Hysteroscopic electrosurgeryGuida 2003166Mean Difference (IV, Random, 95%CI)0.20 [-0.03 to 0.45]

Manual vacuum aspirationLopez 2007113Mean Difference (IV, Random, 95%CI)0.40 [-0.82 to 1.62

Hysteroscopy and endometrial biopsy:1Sharma 2009120Mean Difference (IV, Random, 95%CI)1.80 [1.24 to 2.36]

Hysteroscopy and endometrial biopsy:2Sharma 2009a120Mean Difference (IV, Random, 95%CI)0.35 [-0.26 to 0.96]



 

Appendix 22. Pain during uterine intervention:PLA versus systemic analgesia, single study analysis  


OutcomesStudyParticipantsStatistical methodEffect estimate

Pain during uterine interventionMola 199630Risk Ratio (M-H, Random, 95%CI)0.82 [0.49 to 1.37]



 

Appendix 23. Postoperative pain: PLA versus systemic analgesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

15 minutesGuida 2003166Mean Difference (IV, Random, 95%CI)0.10 [-0.19 to 0.39]

24 hoursGuida 2003166Mean Difference (IV, Random, 95%CI)-0.20 [-0.31 to -0.09]

3 daysGuida 2003166Mean Difference (IV, Random, 95%CI)0.00 [-0.03 to 0.03]



 

Appendix 24. Requirement for postoperative analgesia: PLA versus systemic analgesia, single study analysis  


OutcomesStudyParticipantsStatistical methodEffect estimate

Requirement of analgesiaGuida 2003166Risk Ratio (M-H, Random, 95%CI)1.28 [0.36 to 4.60]



 

Appendix 25. Patient satisfaction: PLA versus systemic analgesia, single study analysis


OutcomesStudyParticipantsStatistical methodEffect estimate

Patient satisfactionGuida 2003166Risk Ratio (M-H, Random, 95%CI)0.99 [0.91 to 1.07]



 

Appendix 26. Operator's perception of the analgesia: PLA versus systemic analgesia, single study analysis  


OutcomesStudyParticipantsStatistical methodEffect estimate

Operator's perceptionMola 199630Risk Ratio (M-H, Random, 95%CI)1.50 [0.71 to 3.16]



 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 20 August 2013.


DateEventDescription

26 September 2013New citation required and conclusions have changedWe updated our search from January 2006 to August 2013. We included nine new studies (26 included studies in total) involving 2790 participants (Al-Sunaidi 2007; Amirian 2009; Chudnoff 2010; Lazenby 2009; Lopez 2007; Mankowski 2009; Renner 2012; Sharma 2009; Thongrong 2011). We excluded 10 new studies (Agostini 2008; Allen 2006; Allen 2009; Cansino 2009; Habersetzer 1972; Harper 1997; Karasahin 2011; Manyou 2008; Naki 2011; Phittayawechwiwat 2007).

We re-evaluated the list of excluded studies in our previously published review (Tangsiriwatthana 2009) and removed any that did not meet our inclusion criterion of randomized controlled trial (RCT). We removed 18 studies from the list of excluded studies as they were not RCTs (Amyot-Legault 1981; Coker 1968; Fernandez 1997; Ferry 1994; Formiga-Filho 1974; Gad 1967; Lewis 1971; Littlepage 1969; Readman 2004; Reguer Noriega 1973; Rotchell 1976; Sandmire 1974; Santonja 1974; Strausz 1971; Thonneau 1998; Toth 2000; Van Praagh 1967; Walden 1973).

Therefore, the total number of excluded studies in the updated review is 70 studies. Three studies are still awaiting classification (Chaudhuri 1980; Regina 1987; Sen 1980).

The nine new studies have minimally changed the review's results and conclusions.

We included risk of bias and summary of findings tables in this updated review.

26 September 2013New search has been performedWe changed some search strategies from those in the published protocol for higher sensitivity. See details in the 'Appendices'.

We used the GradeProfiler Program to grade the quality of the studies.



 

History

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 4, 2004
Review first published: Issue 1, 2009


DateEventDescription

12 March 2007New citation required and conclusions have changedSubstantive amendment



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Conceiving the review: Thumwadee Tangsiriwatthana (TT)

Co-ordinating the review: Ussanee Swadpanich (US)

Undertaking manual searches: TT and US

Screening search results: TT and US

Organizing retrieval of papers: TT

Screening retrieved papers against inclusion criteria: TT, US and Pisake Lumbiganon (PL)

Appraising quality of papers: TT and US

Abstracting data from papers: TT and US

Writing to authors of papers for additional information: TT

Providing additional data about papers: TT

Obtaining and screening data on unpublished studies: TT and US

Data management for the review: TT

Entering data into Review Manager (RevMan 5.1): TT

RevMan statistical data: Malinee  Laopaiboon (ML)

Other statistical analysis not using RevMan: ML

Double entry of data: (data entered by person one: TT; data entered by person two: US)

Interpretation of data: TT, US and PL

Statistical inferences: ML

Writing the review: TT, US, PL and ML

Securing funding for the review: PL

Performing previous work that was the foundation of the present study: PL

Guarantor for the review (one author): PL

Persons responsible for reading and checking review before submission: TT, US, PL and ML

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Thumwadee Tangsiriwatthana: none know

Ussanee S Sangkomkamhang: none known

Pisake Lumbiganon: none known

Malinee Laopaiboon: none known

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • Medical Education Centre, Khon Kaen Regional Hospital, Thailand.
  • Khon Kaen University, Thailand.

 

External sources

  • Thai Cochrane Network, Thailand.
  • Thailand Research Fund (Senior Research Scholar), Thailand.
  • Cochrane Anaesthesia Review Group (CARG), Denmark.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

In the updated review (final search run August 2013) we changed some of the search strategies from the previously published review for higher sensitivity (Tangsiriwatthana 2009). See details in the Appendices (Appendix 1, Appendix 2, Appendix 3).

 

Index terms

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Medical Subject Headings (MeSH)

Anesthesia, Local [adverse effects; *methods]; Anesthesia, Obstetrical [adverse effects; *methods]; Anesthetics, Local [administration & dosage; adverse effects]; Biopsy [adverse effects]; Dilatation and Curettage [*adverse effects]; Endometrium [pathology]; Hysteroscopy [adverse effects]; Nerve Block [*methods]; Pain [*prevention & control]; Pain, Postoperative [prevention & control]; Randomized Controlled Trials as Topic; Uterus [*surgery]

MeSH check words

Female; Humans; Pregnancy

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Al-Sunaidi 2007 {published data only}
  • Al-Sunaidi M, Tulandi T. A randomized trial comparing local intracervical and combined local and paracervical anesthesia in outpatient hysteroscopy. Journal of Minimally Invasive Gynacology 2007;14:153-5. [PUBMED: 17368248]
Amirian 2009 {published data only}
  • Amirian M, Rajai M, Alavi A, Zare S, Aliabadi E. Comparison of lidocaine 1% and normal saline in paracervical anesthesia for decreasing of pain in curettage. Pakistan Journal of Biological Sciences 2009;12(11):877-81. [PUBMED: 19803123]
Buppasiri 2005 {published data only}
  • Buppasiri P, Tangmanowutikul S, Yoosuk W. Randomized controlled trial of mefenamic acid vs paracervical block for relief of pain for outpatient uterine curettage. Journal of the Medical Association of Thailand 2005;88(7):881-5. [PUBMED: 16241013]
Carroll 2005 {published data only}
  • Carroll Sr CS, Hines RS, Haddad GF, Robinette LG, May WL, Cowan BD. Randomized trial of paracervical block with endometrial biopsy. Journal of Pelvic Medicine and Surgery 2005;11(1):45-8. [EMBASE: 2005159680]
Chanrachakul 2001 {published data only}
  • Chanrachakul B, Likittanasombut P, O-Prasertsawat P, Herabutya Y. Lidocaine versus plain saline for pain relief in fractional curettage: a randomized controlled trial. Obstetrics and Gynecology 2001;98(4):592-5. [PUBMED: 11576573]
Chatfield 1970 {published data only}
  • Chatfield WR, Suter PE, Kotonya AO. Paracervical block anaesthesia for the evacuation of incomplete abortion - a controlled trial. The Journal of Obstetrics and Gynaecology of the British Commonwealth 1970;77:462-3. [PUBMED: 4913514]
Chudnoff 2010 {published data only}
  • Chudnoff S. Paracervical block efficacy in office hysteroscopic sterilization. Obstetrics and Gynecology January 2010;115(1):26-34. [PUBMED: 20027030]
Cicinelli 1998 {published data only}
  • Cicinelli E, Didonna T, Schonauer LM, Stragapede S, Falco N, Pansini N. Paracervical anesthesia for hysteroscopy and endometrial biopsy in postmenopausal women: a randomized, double-blind, placebo-controlled study. The Journal of Reproductive Medicine 1998;43(12):1014-8. [PUBMED: 9883403 ]
Egziabher 2002 {published data only}
  • Egziabher TG, Ruminjo JK, Sekadde-Kigondu C. Pain relief using paracervical block in patients undergoing manual vacuum aspiration of uterus. East African Medical Journal 2002;79(10):530-4. [PUBMED: 12635758]
Finikiotis 1992 {published data only}
Glantz 2001 {published data only}
  • Glantz JC, Shomento S. Comparison of paracervical block techniques during first trimester pregnancy termination. International Journal of Gynaecology and Obstetrics 2001;72:171-8. [PUBMED: 11166751]
Gómez 2004 {published data only}
  • Gómez PI, Gaitán H, Nova C, Paradas A. Paracervical block in incomplete abortion using manual vacuum aspiration: randomized clinical trial. Obstetrics and Gynecology 2004;103(5):943-51. [PUBMED: 15121569]
Guida 2003 {published data only}
  • Guida M, Pellicano M, Zullo F, Acunzo G, Lavitola G, Palomba S, et al. Outpatient operative hysteroscopy with bipolar electrode: A prospective multicentre randomized study between local anaesthesia and conscious sedation. Human Reproduction 2003;18(4):840-3. [PUBMED: 12660281]
Kan 2004 {published data only}
  • Kan AS, Ng EH, Ho PC. The role and comparison of two techniques of paracervical block for pain relief during suction evacuation for first-trimester pregnancy termination. Contraception 2004;70:159-63. [PUBMED: 15288222]
Lau 1999 {published data only}
Lazenby 2009 {published data only}
  • Lazency GB, Fogelson NS, Aeby T. Impact of paracervical block on postabortion pain in patients undergoing abortion under anesthesia. Contraception 2009;80:578-82. [CENTRAL: 00732391]
Lopez 2007 {published data only}
  • Lopez JC, Vigil-De-Gracia P, Vega-Malek JC, Ruiz E, Vergara V. A randomized comparison of different methods of analgesia in abortion using manual vacuum aspiration. International Journal of Gynecology and Obstetrics Nov 2007;99(2):91-4. [PUBMED: 17628562]
Mankowski 2009 {published data only}
  • Mankowski JL, Kingston J, Moran T, Nager CW, Lukacz ES. Paracervical compared with intracervical lidocaine for suction curettage: A randomized controlled trial. Obstetrics and Gynecology May 2009;113(5):1052-7. [CENTRAL: 00698461]
Miller 1996 {published data only}
Mola 1996 {published data only}
  • Mola G, Sapuri M, Bergström S. Simplified care of women with prolonged or persistent retention of the placenta: the use of paracervical block. Tropical Doctor 1996;26(3):116-8. [PUBMED: 8783954]
Renner 2012 {published data only}
  • Renner RM, Nichols MD, Jensen JT, Li H, Edelman AB. Paracervical block for pain control in first-trimester surgical abortion: A randomized controlled trial. Obstetrics and Gynecology 2012;119(5):1030-7. [PUBMED: 22525915]
Sharma 2009 {published data only}
  • Sharma JB, Aruna J, Kumar P, Roy KK, Malhotra N, Kumar S. Comparison of efficacy of oral drotaverine plus mefenamic acid with paracervical block and with intravenous sedation for pain relief during hysteroscopy and indometrial biopsy. Indian Journal of Medical Sciences 2009;63(6):244-52. [PUBMED: 19602758]
Thongrong 2011 {published data only}
  • Thongrong P, Jarruwale P, Panichkul P. Effectiveness of paracervical block versus intravenous morphine during uterine curettage: A randomized controlled trial. Journal of The Medical Association of Thailand 2011;94(4):403-7. [PUBMED: 21591523 ]
Titapant 2003 {published data only}
  • Titapant V, Chawanpaiboon S, Boonpektrakul K. Double-blind randomized comparison of xylocaine and saline in paracervical block for diagnostic fractional curettage. Journal of the Medical Association of Thailand (Chotmaihet Thangphaet) 2003;86(2):131-5. [PUBMED: 12678150]
Vercellini 1994 {published data only}
  • Vercellini P, Colombo A, Mauro F, Oldani S, Bramante T, Crosignani PG. Paracervical anesthesia for outpatient hysteroscopy. Fertility and Sterility 1994;62(5):1083-5. [PUBMED: 7646610]
Yazaci 2003 {published data only}
  • Yazici FG, Arslan M, Birbicer H, Kanik A, Aban M, Oral U. Comparison of the intrauterine topical anaesthesia and paracervical block on pain in patients undergoing endometrial biopsy. The Pain Clinic 2003;15(3):339-43. [CENTRAL: CN-00474484; EMBASE: 2003375070]

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Agostini 2003 {published data only}
  • Agostini A, Bretelle F, Cravello L, Maisonneuve AS, Roger V, Blanc B. Acceptance of outpatient flexible hysteroscopy by premenopausal and postmenopausal women. The Journal of Reproductive Medicine 2003;48(6):441-3. [PUBMED: 12856515]
Agostini 2008 {published data only}
  • Agostini A, Provansal M, Collette E, Capelle M, Estrade JP, Cravello L, et al. Comparison of ropivacaine and lidocaine for paracervical block during surgical abortion. Contraception 2008;77(5):382-5. [PUBMED: 18402857 ]
Allen 2006 {published data only}
  • Allen RH, Kumar D, Fitzmaurice G, Lifford KL, Goldberg AB. Pain management of first-trimester surgical abortion: effects of selection of local anesthesia with and without lorazepam or intravenous sedation. Contraception 2006;74(5):407-13. [PUBMED: 17046383]
Allen 2009 {published data only}
  • Allen RH, Fitzmaurice G, Lifford KL, Lasic M, Goldberg AB. Oral compared with intravenous sedation for first-trimester surgical abortion: A randomized controlled trial. Obstetrics and Gynecology 2009;113(2 Part 1):276-83. [PUBMED: 19155895]
Bain 2001 {published data only}
Baskett 1974 {published data only}
Bradley 1995 {published data only}
  • Bradley LD, Widrich T. State-of-the-art flexible hysteroscopy for office gynecologic evaluation. The Journal of the American Association of Gynecologic Laparoscopists 1995;2(3):263-7. [PUBMED: 9050568]
Broadbent 1992 {published data only}
Canni 2001 {published data only}
  • Cannì M, Gallia L, Fanzago E, Bocci F, Bertini U, Barbero M. Day-surgery operative hysteroscopy with loco-regional anesthesia. Minerva Ginecologica 2001;53(5):307-11. [PUBMED: 11549994]
Cansino 2009 {published data only}
  • Cansino C, Edelman A, Burke A, Jamshidi R. Paracervical block with combined ketorolac and lidocaine in first-trimester surgical abortion: A randomized controlled trial. Obstetrics and Gynecology Dec 2009;114(6):1220-6. [PUBMED: 19935022]
Cetin 1997 {published data only}
  • Cetin A, Cetin M. Effect of deep injections of local anesthetics and basal dilatation of cervix in management of pain during legal abortions. A randomized, controlled study. Contraception 1997;56(2):85-7. [PUBMED: 9315416]
Chen 1994 {published data only}
  • Chen RJ, Chow SN, Huang SC. A study on the usefulness of local anaesthesia for the laser vaporization of conizations in the uterine cervix. Annals of the Academy of Medicine, Singapore 1994;23(1):46-8. [PUBMED: 8185271]
Duggan 1999 {published data only}
  • Duggan PM, Dodd J. Endometrial balloon ablation under local analgesia and intravenous sedation. The Australian & New Zealand Journal of Obstetrics & Gynaecology 1999;39(1):123-6. [PUBMED: 10099769]
Duncan 2005 {published data only}
  • Duncan ID, McKinley CA, Pinion SB, Wilson SM. A double-blind, randomized, placebo-controlled trial of prilocaine and felypressin (Citanest and Octapressin) for the relief of pain associated with cervical biopsy and treatment with the Semm coagulator. Journal of Lower Genital Tract Disease 2005;9(3):171-5. [PUBMED: 16044058]
Edelman 2004 {published data only}
  • Edelman A, Nichols MD, Leclair C, Astley S, Shy K, Jensen JT. Intrauterine lidocaine infusion for pain management in first-trimester abortions. Obstetrics and Gynecology 2004;103(6):1267-72. [PUBMED: 15172863]
Esteve 2002 {published data only}
Grimes 1979 {published data only}
  • Grimes DA, Schulz KF, Cates W Jr, Tyler CW Jr. Local versus general anesthesia: which is safer for performing suction curettage abortions?. American Journal of Obstetrics and Gynecology 1979;135(8):1030-5. [PUBMED: 517587]
Guasch 2005 {published data only}
  • Guasch E, Ardoy M, Cuadrado C, González Gancedo P, González A, Gilsanz F. Comparison of 4 anesthetic techniques for in vitro fertilization [Comparacion de cautro tecnicas anaestesicas para fedundacion in vitro]. Revista Espanola de Anestesiologia y Reanimacion 2005;52(1):9-18. [PUBMED: 15747701]
Gudgeon 1968 {published data only}
  • Gudgeon DH. Paracervical block with bupivacaine 2.5 per cent. British Medical Journal 1968;18(2):403. [PUBMED: 5649001]
Habersetzer 1972 {published data only}
  • Habersetzer B, Raudrant D, Broussard P. Uterine evacuation under local anesthesia by paracervical block with xylocaine (apropos of 40 cases). Journal de Médecine de Lyon 1972 Nov 5;53(236):1495-513. [PUBMED: 4644343]
Harper 1994 {published data only}
  • Harper DM, Walstatter BS, Lofton BJ. Anesthetic blocks for loop electrosurgical excision procedure. The Journal of Family Practice 1994;39(3):249-56. [PUBMED: 8077904]
Harper 1997 {published data only}
  • Harper DM. Paracervical block diminishes cramping associated with cryosurgery. The Journal of Family Practice 1997 Jan;44(1):71-5. [PUBMED: 9010373]
Harper 1998 {published data only}
  • Harper DM, Cobb JL. Cervical mucosal block effectively reduces the pain and cramping from cryosurgery. The Journal of Family Practice 1998;47(4):285-9. [PUBMED: 9789514]
Hasham 1993 {published data only}
Hedberg 1966 {published data only}
Jensen 1984 {published data only}
  • Jensen F, Qvist I, Brocks V, Secher NJ, Westergaard LG. Submucous paracervical blockade compared with intramuscular meperidine as analgesia during labor: a double blind study. Obstetrics and Gynecology 1984;64(5):724-7. [PUBMED: 6387560]
Johnson 1989 {published data only}
  • Johnson N, Crompton AC, Ramsden SV. The efficacy of paracervical injections of lignocaine before laser ablation of the cervical transformation zone. A randomized placebo-controlled double-blind clinical trial. British Journal of Obstetrics and Gynaecology 1989;96(12):1410-2. [PUBMED: 2695156]
Johnson 1996 {published data only}
  • Johnson N, Crompton AC, Doodek U. Comparing paracervical with direct infiltration of lignocaine for cervical laser surgery. Journal of Gynecologic Surgery 1996;12(3):197-9. [CENTRAL: CN-00171124; EMBASE: 1996335557]
Kamat 1979 {published data only}
  • Kamet DS, Dani SP, Anjaneyulu R. Paracervical block with vacuum aspiration. Journal of Obstetrics and Gynaecology of India 1979;29(3):557-60. [PUBMED: 12335917]
Karasahin 2011 {published data only}
  • Karasahina KM, Alanbaya I, Ercana CM, Mestenb Z, Simsek C, Baser I. Lidocaine spray in addition to paracervical block reduces pain during first-trimester surgical abortion: a placebo-controlled clinical trial. Contraception 2011;83:362-6. [PUBMED: 21397096 ]
Kaya 2004 {published data only}
  • Kaya K, Yalcin Cok O, Ozturk E, Gunaydin B. Effect of premedication on intravenous remifentanil infusion with paracervical block combination for hysteroscopy: Evaluation of preliminary results. Regional Anesthesia and Pain Medicine 2004;29 Suppl 2:94. [DOI: 10.1016/j.rapm.2004.07.209]
Kun 1999 {published data only}
  • Kun KY, LO L, Ho MW, Tai CM. A prospective randomized study comparing hysteroscopy and curettage (H & C) under local anaesthesia (LA) and general anaesthesia (GA) in Chinese population. Journal of Obstetrics and Gynaecology Research 1999;25(2):119-27. [PUBMED: 10379127]
Lee 1986 {published data only}
  • Lee ET, Ozumba EN, Bevan JR. A randomized trial of Citanest with Octapressin for relief of pain associated with laser vaporization of the cervix. British Journal of Obstetrics and Gynaecology 1986;93(9):967-9. [PUBMED: 2429687]
Lee 1998 {published data only}
  • Lee CC, Martin JS, Newton CR, Tummon IS, Fisher J. Randomised comparison of vaginal versus paracervical xylocaine for oocyte retrieval. Fertility and Sterility 1998;70(3):S345. [CENTRAL: CN-00224478]
Longhi 1996 {published data only}
  • Longhi K. Uterine curettage with pudendal and paracervical blocks [Legrado uterino con anestesia regional]. Boletim Medico Postgrado 1996;12(3):52-8.
Mackay 1985 {published data only}
  • Mackay HT, Schulz KF, Grimes DA. Safety of local versus general anaesthesia for second-trimester dilatation and evacuation abortion. Obstetrics and Gynecology 1985;66(5):661-5. [PUBMED: 4058825]
Makris 2001 {published data only}
  • Makris N, Xygakis A, Dachlythras M, Prevedourakis C, Michalas S. Mepivacaine local cervical anesthesia for diagnostic hysteroscopy: A randomized placebo-controlled study. Journal of Gynecologic Surgery 2001;17(1):7-11. [CENTRAL: CN-00442113; EMBASE: 2001162075]
Manyou 2008 {published data only}
  • Manyou B, Phupong V. Prospective randomized, double-blinded, placebo-controlled trial of preoperative etoricoxib for pain relief in uterine fractional curettage under paracervical block. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2008;140(1):90-4. [PUBMED: 18396369]
Mckenzie 1978 {published data only}
  • McKenzie R, Shaffer WL. A safer method for paracervical block in therapeutic abortions. American Journal of Obstetrics and Gynecology 1978;130(3):317-20. [PUBMED: 623172]
Mercorio 2002 {published data only}
  • Mercorio F, De Simone R, Landi P, Sarchianaki A, Tessitore G, Nappi C. Oral dexketoprofen for pain treatment during diagnostic hysteroscopy in postmenopausal women. Maturitas 2002;43:277-81. [PUBMED: 12468136]
Moller 1978 {published data only}
  • Møller BR, Hansen JT, Diederich P, Oram V. Therapeutic abortion in an out-patient clinic. A prospective investigation of complications and patient acceptability. Acta Obstetricia et Gynecologica Scandinavica 1978;57(1):41-4. [PUBMED: 622891]
Naki 2011 {published data only}
  • Naki MM, Api O, Acioglu HC, Uzun MG, Kars B, Unal O. Analgesic efficacy of forced coughing versus local anesthesia during cervical punch biopsy. Gynecologic and Obstetic Investigation 2011;72:5-9. [PUBMED: 21606634]
Nielsen 1975 {published data only}
  • Nielsen JB, Madsen OG, Campbell UD. Diazepam as a sedative in induced abortion. Acta Obstetricia et Gynecologica Scandinavica 1975;54(3):237-9. [CENTRAL: CN-00012626; EMBASE: 1976135589; PUBMED: 1099860]
Nielsen 1988 {published data only}
  • Nielsen HK, Klünder K, Møller JT, Werner MU. Midazolam combined with paracervical blockade compared to general anaesthesia for curettage of the uterus. Acta Anaesthesiologica Scandinavia 1988;32:643-6. [CENTRAL: CN-00057437; EMBASE: 1989002355; PUBMED: 3063045]
O'Neal 2003 {published data only}
  • O'eal MG, Beste T, Shackelford DP. Utility of preemptive local analgesia in vaginal hysterectomy. American Journal of Obstetrics and Gynecology 2003;189(6):1539-41. [PUBMED: 14710057 ]
Owalabi 2005 {published data only}
Oyama 2003 {published data only}
  • Oyama IA, Wakabayashi MT, Frattarelli LC, Kessel B. Local anesthetic reduces the pain of colposcopic biopsies: a randomized trial. American Journal of Obstetrics and Gynecology 2003;188(5):1164-5. [PUBMED: 12748465]
Peretz 1982 {published data only}
  • Peretz BA, Friedman M, Goldstein I. Curettage by paracervical block associated with intravenous premedication [Curetage par blocage paracervical associe a une premedication intraveineuse]. Revue Française de Gynécologie et d'Obstétrique 1982;77(3):197-9.
Peters 1978 {published data only}
  • Peters FD, Hirsch HA. Comparison between intra and paracervical anaesthesia in therapeutic abortion (author's transl). Geburtshilfe und Frauenheilkunde 1978;38(11):946-9. [PUBMED: 710880]
Phair 2002 {published data only}
  • Phair N, Jensen JT, Nichols MD. Paracervical block and elective abortion: the effect on pain of waiting between injection and procedure. American Journal of Obstetrics and Gynecology 2002;186(6):1304-7. [PUBMED: 12066113]
Phittayawechwiwat 2007 {published data only}
  • Phittayawechwiwat W, Thanantaseth C, Ayudhya NI, O-Prasertsawat P, Kongprasert J. Oral etoricoxib for pain relief during fractional curettage: a randomized controlled trial. Journal of the Medical Association of Thailand (Chotmaihet Thangphaet) 2007;90(6):1053-7. [PUBMED: 17624196]
Picton 1968 {published data only}
  • Picton FC. Paracervical block with bupivacaine. British Medical Journal 1968;2(604):561. [PUBMED: 5749470]
Prest 1976 {published data only}
  • Prest J, Funck-Rasmussen L, Olavsgaard P, Jensen JG. Outpatient legal abortion. 500 operations with paracervical anesthesia. Ugeskrift for Laeger 1976;138(6):333-5. [PUBMED: 1251505]
Raeder 1992 {published data only}
  • Raeder JC. Propofol anaesthesia versus paracervical blockade with alfentanil and midazolam sedation for outpatient abortion. Acta Anaesthesiologica Scandinavica 1992;36:31-7. [PUBMED: 1539476]
Ragab 1978 {published data only}
  • Ragab MI, Edelman DA, Laufe L. The effects of long acting paracervical block anesthesia on the abortifacient efficacy of intra-amniotic PGF2alpha and hypertonic saline. Acta Obstetricia et Gynecologica Scandinavica 1978;57(4):327-31. [PUBMED: 358727]
Rattanachaiyanont 2005 {published data only}
  • Rattanachaiyanont M, Leeasiri P, Indhavivadhana S. Effectiveness of intrauterine anesthesia for pain relief during fractional curettage. Obstetrics and Gynecology 2005;106(3):533-9. [PUBMED: 16135583]
Rogstad 1992 {published data only}
Ruoss 1968 {published data only}
  • Ruoss C, Beazley JM. Paracervical block with bupivacaine. British Medical Journal 1968;2(605):622-3. [PUBMED: 5658909]
Sammarco 1993 {published data only}
  • Sammarco MJ, Hartenbach EM, Hunter VJ. Local anesthesia for cryosurgery on the cervix. The Journal of Reproductive Medicine 1993;38(3):170-2. [PUBMED: 8487231]
Scott 1968 {published data only}
  • Scott DB, Galloway RK, Lees MM, Livingstone JR. Bupivacaine in paracervical block. Proceedings of the Royal Society of Medicine 1968;61(11 Part 1):1158-9. [PUBMED: 4952985]
Shapiro 1975 {published data only}
Stefanidis 1998 {published data only}
  • Stefanidis K, Paschopoulos M, Dusias B, Adonakis G, Lolis D. A randomized study of local or general anesthesia for laser conization of the cervix. Archives of Gynecology and Obstetrics 1998;261(2):75-8. [PUBMED: 9544371]
Stuart 1993 {published data only}
  • Stuart GC, Nation JG. Outpatient laser cone biopsy under local anesthesia. Canadian Journal of Surgery. Journal Canadien de Chirurgie 1993;36(1):41-3. [PUBMED: 8443716]
Teramo 1975 {published data only}
  • Teramo K, Kivalo I, Huovinen K. Obstetric paracervical blockade with etidocaine. Acta Anaesthesiologica Scandinavica. Supplementum 1975;60:100-5. [PUBMED: 241196]
Wallage 2003 {published data only}
Whitehouse 1968 {published data only}
  • Whitehouse DB. Paracervical block with bupivacaine. British Medical Journal 1968;2(607):764. [PUBMED: 5656287]
Wiebe 2005 {published data only}
Willdeck 1975 {published data only}
  • Willdeck LG, Zador G. Paracervical block with etidocaine for out-patient abortion. Acta Anaesthesiologica Scandinavica. Supplementum 1975;60:106-9. [PUBMED: 1101603]
Winkler 1997 {published data only}
  • Winkler M, Wolters S, Funk A, Rath W. Does para-cervical block offer additional advantages in abortion induction with gemeprost in the 2nd trimester [Bietet die Parazervikalblockade zusatzliche Vorteile bei der Abortinduktion mit Gemeprost im II trimenon]. Zentralblatt für Gynäkologie 1997;119(12):621-4. [PUBMED: 9483814]
Wong 2002 {published data only}
  • Wong CY, Ng EH, Ngai SW, Ho PC. A randomized, double blind, placebo-controlled study to investigate the use of conscious sedation in conjunction with paracervical block for reducing pain in termination of first trimester pregnancy by suction evacuation. Human Reproduction 2002;17(5):1222-5. [PUBMED: 11980742]

References to studies awaiting assessment

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Chaudhuri 1980 {published data only}
  • Chaudhuri P, Drogendijk AC. Open therapeutic evaluation of paracervical infiltration anesthesia with mepivacaine for out-patients dilatation and curettage. Tijdschrift voor Geneesmiddelenonderzoek 1980;5(4):711-3. [: ISSN:0166-2384]
Regina 1987 {published data only}
  • Regina CT, Peruffo GF, Beatriz GL. Efficacy paracervical block in uterine curettage by abortion [Eficacia do bloqueio paracervical em curetagem uterina por abortamento]. Revista da AMRIGS 1987;31(4):262-4. [: ISSN:0102-2105]
Sen 1980 {published data only}
  • Sen GS, Das A, Bora L. Evaluation of the efficacy of paracervical block in minor gynaecological operations (a study of 50 cases). The Clinician 1980;44(8):365-7. [: ISSN:0009-9341]

Additional references

  1. Top of page
  2. Abstract
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. Additional references
  24. References to other published versions of this review
Aimakhu 1972
  • Aimakhu VE, Ogunbode O. Paracervical block anesthesia for minor gynecologic surgery. International Journal of Gynecology and Obstetrics 1972;10:66-71.
Amyot-Legault 1981
  • Amyot-Legault A. Systemic use of paracervical block during the insertion of an I.U.D. L'Union Medicale du Canada 1981;110(8):721-6. [PUBMED: 7292804]
Coker 1968
  • Coker OO. Paracervical block in minor gynaecological operations. The West African Medical Journal and Nigerian Practitioner 1968;17(6):179-80. [PUBMED: 5703566]
Fernandez 1997
  • Fernandez H, Capella S, Audibert F. Uterine thermal balloon therapy under local anaesthesia for the treatment of menorrhagia: a pilot study. Human Reproduction 1997;12(11):2511-4. [PUBMED: 9436696]
Ferry 1994
  • Ferry J, Rankin L. Low cost, patient acceptable, local analgesia approach to gynaecological outpatient surgery. A review of 817 consecutive procedures. The Australian & New Zealand Journal of Obstetrics & Gynaecology 1994;34(4):453-6. [PUBMED: 7848239]
Formiga-Filho 1974
  • Formiga-Filho JF, Parente JV, Lago AL. Paracervical anesthesia in dilatation of the cervix. Anestesia Paracervical na Dilatacao do Colo Uterino 1974;20(3-4):233-8.
Gad 1967
  • Gad C. Paracervical block. Acta Obstetricia et Gynecologica Scandinavica 1967;46(7):7-18. [PUBMED: 6025358]
Higgins 2003
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Lewis 1971
  • Lewis SC, Lal S, Beard RW, Branch B. Outpatient termination of pregnancy. British Medical Journal 1971;4:606-10. [PUBMED: 5130219]
Littlepage 1969
  • Littlepage BN, Daniel DG, Ahmad S, Turnbull AC. Paracervical block anaesthesia for minor gynaecological operations. The Journal of Obstetrics and Gynaecology of the British Commonwealth 1969;76:163-4. [PUBMED: 5765810]
Maltzer 1999
  • Maltzer DS, Maltzer MC, Wiebe ER, Halvorson-Boyd G, Boyd C. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG editor(s). A clinician’s guide to medical and surgical abortion. Philadelphia PA: Churchill Livingstone, 1999:73-89.
Piyamongkol 1998
  • Piyamongkol W. Obstetrics [Obstetric anaesthesiology]. In: Tongsong T, Wanapirak C,editor(s). 4th Edition. Bangkok: P.B. Foreign Book Center, 1998:155-68.
Readman 2004
  • Readmen E, Maher PJ. Pain relief and outpatient hysteroscopy: a literature review. The Journal of the American Association of Gynecologic Laparoscopists 2004;11(3):315-9. [PUBMED: 15559340]
Reguer Noriega 1973
  • Reguer Noriega A. Pericervical block in curettage of the uterus [Bloqueo pericervical en al legrado uterino]. Ginecología y Obstetricia de México 1973;34(202):95-102. [PUBMED: 4753793]
RevMan 5.1
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan).Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.
Rotchell 1976
  • Rotchell YE. An evaluation of paracervical block anaesthesia for use in minor gynaecological surgery. The West Indian Medical Journal 1976;25(1):35-8. [PUBMED: 1266208]
Sandmire 1974
Santonja 1974
  • Santonja J, Andreu E, Bonilla MF. Paracervical anaesthesia in gynecology [LA anestesia paracervical en ginecologia]. Revista Española de Obstetricia y Ginecología 1974;33(194):142-5.
Scott 1976
Smith 1991
  • Smith RP, Heltzel JA. Interrelation of analgesia and uterine activity in women with primary dysmenorrhea. A preliminary report. Journal of Reproductive Medicine 1991;36:260-4. [PUBMED: 2072357]
Strausz 1971
Thonneau 1998
  • Thonneau P, Fougeyrollas B, Ducot B, Boubilley D, Dif J, Lalande M, et al. Complications of abortion performed under local anesthesia. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1998;81:59-63. [PUBMED: 9846716]
Toth 2000
  • Tóth D, Kuzel D, Parízek A, Fucíková Z, Zivný J, Marusicová P, et al. Paracervical anesthesia in hysteroscopy and transcervical surgery. Ceská Gynekologie / Ceská lékarská spolecnost J. Ev. Purkyne 2000;65(1):42-5. [PUBMED: 10750297]
Van Praagh 1967
  • Van Praagh IG, Povey WG. Paracervical block anesthesia for dilatation and curettage. Obstetrics and Gynecology 1967;29(2):167-9. [PUBMED: 6018161]
Walden 1973