Severe Pain

OVERVIEW OF SEVERE PAIN

What kind of pain is associated with medical abortion?

Pain resulting from uterine cramping is an expected part of the abortion process. ⁽¹⁾

The severity of cramping pain associated with medical abortion ranges from mild to severe. ⁽¹⁾

During medical abortion with mifepristone and misoprostol, nearly all women will have abdominal pain. ⁽²⁾

Abdominal pain is experienced in nearly 960-980 per 1000 women who elect to have a medical abortion. ⁽²⁾

A U.S. study and prospective analysis of 77.1% (771 per 1000 women) mifepristone medical abortion patients reported significantly greater pain versus 10.5% (105 per 1000 women) who received suction curettage abortion. ⁽³⁾

Women receiving mifepristone/misoprostol for medical abortion are more likely to experience significantly greater pain, nausea, vomiting, longer bleeding, and remain at risk for surgical completion curettage for several weeks than women who choose the option of a suction curettage abortion. ^{(3) (4)}

Approximately 500 per 1000 women will likely have abdominal pain that can be considered severe. ⁽²⁾

In one study, approximately 295 per 1000 women cited the amount and length of pain as the worst feature of medical abortion with a median duration of 72 hours. ⁽⁵⁾

Many women undergoing early medical abortion experience pain of a severity that requires narcotic analgesia; 23% of women experience severe pain that they rate “as almost being as bad as it can be.” ⁽⁶⁾

If pain is severe and not relived by the use of analgesics (painkillers) and other measures (heating pad, hot water bottle, or abdominal massage), or if the pain begins more than 24 hours after taking misoprostol, the patient should contact her provider or seek medical attention right away, including going to an Emergency Room, if none of the provided contacts are unreachable. ^{(7) (8)} (See BOXED WARNINGS and WARNINGS)

PAIN IN LONGER DURATIONS OF PREGNANCY

What are women’s experiences with pain the longer duration of pregnancy? 

Women who are at gestations more than 49 days have been reported to significantly receive more analgesia and opiates for severe pain than women who were 49 days’ duration or less. ⁽²⁾

A higher incidence of adverse events is expected with longer durations of pregnancy. ⁽²⁾

SEVERE PAIN & COMPLICATIONS

What potential health risks may be associated with severe pain during medical abortion?

The patient should immediately contact their provider if they experience severe, continuous or increasing abdominal pain. ^{(7) (9)}

Persistent or recurrent bleeding and pain may be associated with incomplete medical abortion. ⁽⁴⁾

Patients with retained products commonly present with sharp or crampy lower abdominal pain and bleeding. ⁽¹⁰⁾

Patients with intense or severe abdominal pain that may persists for longer than 4-6 hours after taking misoprostol, or if the patient reports intense, prolonged pain unrelieved with pain medicines and mild narcotics, the following possibilities should be considered: ^{(8) (11) (12)} (See WARNINGS and BOXED WARNINGS)

• Pregnancy tissue fragments trapped in the cervical opening
• Incomplete Abortion
• Ectopic Pregnancy
• Upper Reproductive Tract Infection
• Sepsis (serious infection involving the bloodstream)
• Poor pain tolerance

PATIENTS & NARCOTIC PAINKILLERS

What patient characteristics may indicate a higher use of narcotic painkillers?

The following patient characteristics emerge consistently as predictors of narcotic analgesic use: ⁽⁶⁾

• Higher gestational age
• Younger patient age
• Lower parity (number of term births)

The proportion of women undergoing medical abortion who use narcotic analgesia varies among studies, but is generally around 750 per 1000 women. ⁽⁶⁾

PAINKILLERS – ANALGESIC DRUG TYPES

What kind of pain drugs are used in medical abortion?

Both non-narcotic and narcotic analgesics have been used for pain control in medical abortion. ⁽¹⁾

Approximately 70% percent of women may receive at least one non-narcotic drug (usually acetaminophen) for abdominal pain, and 30% percent may receive narcotic painkillers (usually acetaminophen with hydrocodone, codeine or oxycodone) for severe pain. ^{(1) (2)}

HARMFUL EFFECTS OF NARCOTIC PAINKILLERS

What are the harmful effects of using narcotics for pain in medical abortion?

The harmful effects of narcotic pain medication use for medical abortion may include symptoms of lightheadedness or dizziness, sedation, nausea, and vomiting. ⁽¹¹⁾

Medications used for pain control are one of the few potentially life-threatening aspects of abortion care. ⁽¹³⁾

It is important for providers to pay close attention to the patient’s medical history, allergies, and concurrent medications that might interact with pain drugs that are planned for use as well as following recommended dose range limits. ⁽¹³⁾