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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. References

Objective  To assess analgesia use and the predictors for requiring analgesia in women undergoing medical abortion at all gestations up to 22 weeks.

Design  Retrospective observational study.

Setting  Aberdeen Royal Infirmary, Scotland.

Population  Consecutive women undergoing medical abortion under the terms of the 1967 Abortion Act.

Methods  Analgesia requirements and characteristics of women undergoing abortion were analysed using logistic regression.

Main outcome measures  The effect of age, gestation, reproductive history, route and dose of misoprostol administration on analgesia requirements.

Results  Of the total 4343 women included in this review, 3139 women (72%) required analgesia. Of these, 3054 women (97%) used oral analgesia, 75 women (2.4%) used opiates while 10 women (0.3%) had diclofenac sodium given rectally. There was no significant difference in analgesia use whether women used the vaginal or sublingual route of misoprostol administration. Logistic regression showed a significant positive association with gestation at termination (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.05–1.12), number of misoprostol doses used (OR 1.31, 95% CI 1.13–1.51) and induction to abortion interval (OR 1.08, 95% CI 1.03–1.12) and a negative association with the age of women undergoing abortion (OR 0.98, 95% CI 0.97–0.99) and previous live birth (OR 0.43, 95% CI 0.33–0.56).

Conclusions  Analgesia requirement was significantly higher in women of younger age, higher gestation, longer induction to abortion interval and with increased number of misoprostol doses used while women with previous live birth were significantly less likely to use analgesia.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. References

Medical abortion using the anti-progesterone mifepristone and the prostaglandin analogue misoprostol is now well established at all gestations with studies reporting high efficacy and good patient acceptability.1–7 During 2001, a total of 176,364 abortions were carried out in England and Wales, and of these, 13% were undertaken medically.8 During the year 2002, 11,594 abortions were carried out in Scotland, and of these, 56% were carried out medically.9

Abdominal pain is one of the most common adverse effects of medical abortion.5,10–14 However, analgesia requirements for medical abortion, reported in the literature, have varied widely.15 Westhoff et al.13 reported that analgesia use in women undergoing medical abortion up to 63 days of gestation increased with higher gestation, younger age and in nulliparous women.

We carried out this review to assess analgesia requirements in women undergoing medical abortion at all gestations up to 22 weeks. The aim was to assess the effect of age, gestation, reproductive history and route and dose of misoprostol administration on analgesia requirements in the population of women studied.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. References

Women undergoing medical abortion under the terms of the 1967 Abortion Act at the Aberdeen Royal Infirmary during the period November 1997 to August 2003 were included in this review. At the initial clinic appointment, women up to 13 weeks of gestation were given information on both medical and surgical methods by the medical staff and pregnancy counselling nurses prior to deciding on an abortion method, while those at gestations of 13 weeks or above were offered medical abortion. Exclusion criteria for receiving medical abortion were extremely unusual but included the following: suspected ectopic pregnancy, chronic adrenal failure, long term corticosteroid treatment, haemorrhagic disorders or treatment with anticoagulants, known allergy to mifepristone and smokers over the age of 35 with ECG abnormalities.

Women were given mifepristone 200 mg orally in hospital under nursing supervision and allowed home. They were admitted 36–48 hours later as day cases for misoprostol administration. Those up to eight weeks of gestation received a single dose of 800 μg given vaginally or 600 μg given sublingually (sublingual administration since March 2001). Women between eight and up to nine weeks of gestation received a repeat dose of misoprostol 400 μg, three hours later vaginally or orally depending on the amount of vaginal bleeding. This regimen was developed based on experience as reported by Ashok et al.2,16 If products of conception were not passed, the women were discharged home and a follow up appointment arranged one week later with a pelvic ultrasound performed. Women between 9 and 13 weeks of gestation were given further doses of misoprostol, 400 μg, vaginally, orally or sublingually at three hourly intervals as required, up to a maximum of five doses.1,17,18 If abortion did not occur, a pelvic ultrasound was performed and surgical treatment offered to women with a missed abortion or ongoing pregnancy. Women at 13 weeks of gestation or above were given a similar regimen. Where women did not pass products of conception with five doses of misoprostol or within 15 hours of administration of the first dose of misoprostol, they were considered to have failed medical abortion and received repeat doses of misoprostol the following day as per unit protocol.6,7 Gestational age was assessed by ultrasound scan measurement of the crown–rump length19 and products of conception were identified by visual inspection. Women were observed on the ward for two hours after passing the products of conception and before discharge home. The induction to abortion interval was defined as the time interval in hours from administration of misoprostol to passing the products of conception.

Women were counselled about the analgesia options available. The same information was provided to all women and analgesia was administered as required. Prescriptions used included oral analgesia (paracetamol 1 g and codeine phosphate 30–60 mg), non-steroidal anti-inflammatory drug (NSAID; diclofenac sodium 100 mg pr), and intramuscular opiate (morphine 15 mg). Women may have used more than one dose of each or a combination of therapy. The strongest therapy used was documented and used for the purpose of this review.

Normally distributed data are presented as means and standard deviations and non-normally distributed data as medians and range. Independent and paired t tests were used for continuous variables with normal distribution, while the Mann–Whitney U test was used for ordinal or non-normally distributed continuous variables. The χ2 test was used for independent nominal data. Confidence intervals (95% CI) were applied where appropriate and statistical significance was defined as a P value of less than 0.05. Multiple logistic regressions were carried out using analgesia requirement as the dependent variable and women's age, gestation at abortion, previous pregnancy, previous abortion, previous live birth, number of misoprostol doses given and induction to abortion interval as the independent variables. Statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS) Version 11.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. References

A total of 4343 consecutive women underwent medical abortion at the Aberdeen Royal Infirmary during the period stated and were included in this review. The mean age [SD] of women was 26 years [6.9]. A total of 1943 women (45%) were in their first pregnancy, 1259 women (29%) had a previous induced abortion while 1814 women (42%) had a previous live birth. A total of 408 women (9.4%) reported the use of emergency contraception while 279 women (6.4%) had Chlamydia trachomatis isolated on routine screening prior to abortion. A total of 1388 women (32%) were up to 8 weeks of gestation at the time of abortion, 810 women (19%) were between 8 and up to 9 weeks of gestation, 1333 women (31%) were between 9 and up to 13 weeks of gestation, 523 women (12%) were between 13 and up to 16 weeks, while 289 women (6.7%) were 16 weeks or above (overall range 4–22 weeks). Of the total number of women who underwent medical abortion during that period, 73 women (1.7%) aborted on mifepristone alone and did not receive misoprostol and 153 women (3.5%) underwent surgical evacuation for failed medical abortion. Of these, 110 women (2.5%) had incomplete abortion, 18 women (0.4%) had an ongoing pregnancy, 8 women (0.2%) had missed abortion, while 18 women (0.4%) required emergency surgical evacuation for bleeding.

Of the total number of women included in the study, 3139 women (72.2%) required analgesia. Of these, 3054 women (97.3%) used oral analgesia, 75 women (2.4%) used opiates, while 10 women (0.3%) had diclofenac sodium given rectally. The type of analgesia used in relation with the route of misoprostol administration and gestational age is shown in Table 1. The characteristics of the women and abortion features in relation with analgesia use are shown in Table 2.

Table 1.  Type of analgesia used in relation with the route of misoprostol administration and gestational age. Values are given as n (%).
 No analgesiaOral analgesiaIntramuscular opiatesNSAID (rectal Voltarol)P
  1. Route of administration and analgesia use was not documented in 82 women (1.9%). P value in boldface is significant.

Route of misoprostol administration
Vaginal1061 (27)2840 (71)70 (1.8)4 (0.1)0.81
Sublingual82 (29)200 (70)4 (1.4)None 
 
Gestation at abortion
Up to 8 weeks503 (37)863 (63)10 (0.7)3 (0.2) 
8 up to 9 weeks255 (32)537 (67)8 (1.0)3 (0.4) 
9 up to 13 weeks303 (23)1001 (75)19 (1.4)4 (0.3)<0.001
13 up to 16 weeks87 (17)415 (80)18 (3.5)None 
16 weeks and over27 (9.5)238 (84)20 (7.0)None 
Table 2.  Women's characteristics and abortion features in relation with analgesia use. Values are given as n (%) or mean [SD].
 AnalgesiaNo analgesiaAdjusted OR (logistic regression)95% CI for adjusted OR
Age (years)25 [6.6]28 [7.2]0.980.97–0.99
Gestation at termination (weeks)10.1 [3.4]8.7 [2.6]1.091.05–1.12
Previous pregnancy1573 (66)812 (34)0.890.66–1.20
No previous pregnancy1566 (81)363 (19)  
Previous live birth1103 (61)700 (39)0.430.33–0.56
No previous live birth2036 (81)475 (19)  
Previous abortion874 (70)375 (30)1.060.88–1.29
No previous abortion2265 (74)800 (26)  
Number of misoprostol doses1.9 [1.3]1.4 [0.8]1.311.13–1.51
Induction to abortion interval (hours)5.4 [5.1]4.0 [2.3]1.081.03–1.12

Logistic regression with analgesia requirement as the dependent variable showed a significant positive association with gestation at termination (odds ratio [OR] 1.09, 95% CI 1.05–1.12), number of misoprostol doses used (OR 1.31, 95% CI 1.13–1.51) and induction to abortion interval (OR 1.08, 95% CI 1.03–1.12). There was a negative association between analgesia use and the age of women undergoing abortion (OR 0.98, 95% CI 0.97–0.99) and a previous live birth (OR 0.43, 95% CI 0.33–0.56).

A total of 1377 women (32%) chose to have follow up in hospital, 1320 women (30%) with their general practitioner, 82 women (1.9%) at the Family Planning Clinic and 93 women (2.1%) at the Genito-Urinary Medicine Clinic. A total of 1411 women (33%) declined follow up, while details were not available for a further 38 women (0.9%).

During the same period, a total of 2590 women underwent surgical abortion at the Aberdeen Royal Infirmary. The mean age [SD] of the women was 26 years [6.9] and the mean gestation [SD, range] was 9.5 weeks [1.4, range 6–14.5]. Of the total number of women, 1047 (40%) were primigravidae, 836 (32%) had a previous abortion, while 1224 (47%) had a previous live birth. A total of 194 women (7.5%) reported the use of emergency contraception and 169 women (6.5%) had C. trachomatis isolated on routine screening prior to abortion.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. References

This review reports analgesia requirements among women undergoing medical abortion at all gestations up to 22 weeks in a Scottish teaching hospital. Findings from this study may provide useful information in counselling women undergoing medical abortion and may also be invaluable in planning and setting up a pregnancy advisory service. Analgesia requirement, and hence presumably the perception of pain, was significantly higher in women of younger age, higher gestation, those who had a longer induction to abortion interval and with increased number of misoprostol doses. Women with a previous live birth required significantly less analgesia compared with those with no previous live birth. The association between these variables and analgesia use was highly significant and the confidence intervals were narrow, but the odd ratios (except for previous live birth) were close to unity, suggesting that the effect of these variables on analgesia use may be marginal. There was no significant difference in analgesia requirements for women who received misoprostol vaginally or sublingually, although the sublingual route of administration has only been in use since March 2001, and therefore, a smaller group of women were available for comparison. The use of parenteral opiates increased significantly at higher gestations with women at 16 weeks of gestation or above being 10 times more likely to use intramuscular opiate compared with those up to 8 weeks of gestation.

Logistic regressions included the use of analgesia as the dependant variable, assuming that the greatest difference was between women who needed some analgesia and those who used no analgesia at all. We did not assess the difference between women who needed simple analgesia and those who required opiate analgesia or the NSAID (diclofenac sodium) as the number of women available for comparison for these groups was relatively small.

Spitz et al.5 reported the outcome of 2121 women undergoing medical abortion up to 63 days of gestation in 17 centres in the United States. Women received mifepristone 600 mg followed by a single dose of misoprostol 400 μg, administered orally two days later. In that study, 68% of women received oral analgesia (usually acetaminophen) and 29% also received opiates. Westhoff et al.13 studied the predictors for analgesia use in the same group of women and reported analgesia use to be less likely in older, parous women and those at lower gestations, but concluded that the clinic providing care for the women was the most important determinant of who received narcotic analgesia. In a randomised trial, El-Refaey et al.20 compared oral to vaginal administration of misoprostol in combination with mifepristone for women undergoing medical abortion up to 63 days of gestation. That study showed the vaginal route of misoprostol administration to be more effective and associated with a lower incidence of gastrointestinal side effects compared with oral administration, however, analgesia requirements (both non-narcotics and parenteral opiates) did not significantly vary between the two routes of misoprostol administration.

In a report on analgesia use for medical abortion using mifepristone 200 mg and home vaginal self-administration of misoprostol 800 μg, Westhoff et al.14 reported that 79% of women used narcotic analgesia in contrast to their previous report.13 However, in that study, 7 out of the 17 centres instructed women to take analgesia in advance of misoprostol use, with the intent of reducing pain. Women who were given analgesia supplies were more likely to use analgesia compared with those given a prescription. In turn, the latter group had higher analgesia use than those asked to use analgesia only as required. In our report, women were counselled about the analgesia options available by the pregnancy advisory team. The same information was provided to all women and analgesia was administered at women's request. Nonetheless, an element of bias in counselling women cannot be completely ruled out and these findings need to be further evaluated in the context of a randomised trial.

This retrospective study has highlighted those women who are more likely to require analgesia, but the effectiveness of the different methods of analgesia used with medical abortion and their effect on women acceptability of the procedure needs to be assessed in the context of a randomised controlled trial. Furthermore, research is needed to evaluate the role of advance or pre-emptive analgesia use and its effect on women's satisfaction with medical abortion.

CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. References

This report shows that predictors of analgesia use in women undergoing medical abortion at all gestations up to 22 weeks are similar to those reported for early medical abortion up to 63 days of gestation.2,13,14 Analgesia requirement was significantly higher in women of younger age, higher gestation, those who had a longer induction to abortion interval and with increased number of misoprostol doses used while women with previous live birth were significantly less likely to use analgesia.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. References

The authors would like to thank Louise Craigie and Jane Beattie from the Pregnancy Advisory Service for their contribution to this review and Francis McLeod for data entry.

References

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. References
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Accepted 10 March 2004