Comparison of the efficacy of paracervical block in first-trimester surgical abortion to endometrial sampling and its relation to anxiety by Sule Atalay Mert in Journal of Clinical Case Reports Medical Images and Health Sciences

 Comparison of the efficacy of paracervical block in first-trimester surgical abortion to endometrial sampling and its relation to anxiety by Sule Atalay Mert in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract 

Background:

 Psychological support, analgesics, and local anesthesia are the most widely used methods preferred for pain management during minor outpatient surgeries. The World Health Organization's (WHO) Safe Abortion Technical and Policy Guidance for Health Systems Guideline recommends the use of manual vacuum aspiration for first-trimester induced abortions for pain management. We aimed to compare the efficacy of lidocaine used for pain management in first-trimester voluntary termination to endometrial sampling

Study Design:

 Sixty patients who had a first-trimester voluntary surgical abortion were recruited to the study as Group 1. In comparison, 60 patients who had endometrial sampling due to abnormal uterine bleeding were taken as Group 2. Beck Anxiety Inventory (BAI) performed before the procedure. Patients in both groups had a paracervical block with a 1% lidocaine injection prior to manual vacuum aspiration (MVA). The pain intensity was evaluated 

Results: 

The BAI scales of both groups were similar (8.95±10.0 vs. 8.8± p>0.05). VAS scores were measured during cervix tenaculum application (VAS1), paracervical block injection (VAS2), and cannula insertion (VAS3). They were similar in both groups. However, VAS scores measured during aspiration (VAS4), half an hour after the procedure (VAS5), and overall pain related to the 

Conclusions: 

The conclusion was that the paracervical block was effective, particularly in intrauterine aspiration and overall pain control in Group 2. However, its effectiveness was less apparent in the induced abortion group,  

Introduction 

Paracervical block (PCB) with local anesthetics is commonly used for pain management. It blocks sensation at the internal cervical ostium, just before nerves enter the uterus, and also causes nerve capsule distension [1-3]. Paracervical saline instillation may help ease pain during dilation by causing nerve capsule distension. However, local anesthetics are still needed during evacuation [4]. World Health Organization (WHO) Abortion Care Guideline (2022): The guideline suggests using manual vacuum aspiration (MVA) or electrical vacuum aspiration for first-trimester surgical abortions. It also recommends paracervical block for first trimester surgical abortions and supports the use of pain relief methods like analgesics, local anesthesia, or conscious sedation, along with verbal reassurance [5,6]. General anesthesia may also be used in cases that require a longer period of pain control, but the higher incidence of mortalityand severe morbidity related to general anesthesia should not be underestimated when choosing a method for pain control. The pain during MVA performed for first-trimester surgical abortion was found to be related to age, parity, previous vaginal delivery, gestational age of the current pregnancy, the duration of the procedure, and psychological status [7-10]. Endometrial sampling procedures (ESP) are often preferred for the differential diagnosis of uterine pathologies that cause abnormal uterine bleeding. Pain during this procedure can come from applying the tenaculum to the cervix, pulling the cervix to straighten its angle, or dilating the cervix if necessary. Endometrial sampling involves various tools, like a Karman-type cannula-curette and a manual vacuum aspirator. Different techniques, including low-pressure pipettes, high-pressure vabra aspirators, and sharp curettage, can also be used. Various biopsy techniques have been developed in order to obtain adequate tissue samples with minimal pain [11]. Conscious sedation, paracervical block, or intrauterine anesthetic application are often preferred for pain management [12-13]. This study aims to compare how effective paracervical block is in first-trimester surgical abortions using MVA and Karman cannulas. It also explores how anxiety influences pain perception in both groups.

Materials and Methods 

The study was conducted at a tertiary-level women’s hospital after obtaining institutional approval from the local ethics committee with the ID number 172 and date of March 25, 2014. Sixty patients aged 18 to 44 who applied to our outpatient clinic for voluntary pregnancy termination and 60 patients scheduled for endometrial sampling were included in the study. The aim and protocol of the study were explained to the volunteering patients, and informed consent was obtained prior to the recruitment. Patients with bleeding diathesis, pathology in pain perception, or patients who underwent surgery under general anesthesia due to intrauterine ex fetus, blighted ovum, or missed abortion were excluded from the study. The study noted patients' background details like age, pregnancy history, childbirth experience, and any past surgical or spontaneous abortions. Information on uterine interventions, previous delivery methods, the last menstrual period, and results from physical, gynecological, and ultrasound exams was also collected. Pre- and post-procedure serum hemoglobin (Hb) and hematocrit (Hct) measurements were carried out, and the results were recorded.

Paracervical Block Procedure

 Patients were assessed in the lithotomy position. Following the insertion of a sterile bivalve speculum, thevagina and cervix were cleaned with an antiseptic solution. Before holding the cervix with the tenaculum, 2 ml of tamponade lidocaine was injected at twelve o’clock in the cervix. After holding the same point with a tenaculum, 18 ml of lidocaine was injected into the cervix at 4 different sites (2, 4, 8, and 10 o’clock). The injections were performed slowly to a depth of 3 cm within 60 seconds. Aspiration of the uterine cavity was performed 3 minutes after the paracervical block. No premedication was given to patients before the procedure. All the patients were followed up for 30 minutes after the curettage procedure before discharge to record their vital signs and any complications (respiratory arrest and bradycardia) or side effects that occurred.

Visual Analogue Scale (VAS)

 The patients were asked to evaluate their pain level on a 100-mm visual acuity scale (VAS). The pain levels were rated from 0 (no pain) to 10 (the worst pain). Pain was measured at six stages: when the cervix was grasped (VAS1 ), during lidocaine injection (VAS2 ), during cannula insertion (VAS3 ), during evacuation (VAS4 ), thirty minutes after the procedure (VAS5 ), and overall pain evaluation (VAS6 ).

Statistical analysis

 Statistical analysis of the data was done using SPSS for Windows 11 and 5 packaged programs. The comparison of two normally distributed continuous variables was done using the independent T-test. Mann-Whitney U test was used for the comparison of abnormally distributed data. Kruskall-Wallis variance analysis was used for the comparison of abnormally distributed continuous variables of more than two. Also, a chi-square test was performed to evaluate the relationship between categorical variables. The Pearson correlation test was performed for the relationship between the Beck Anxiety Inventory and VAS values. P< 0.05 was accepted as statistically significant.

Results 

Group-1 had a significantly lower average age than Group-2 (31.14 ± 6.33 versus 38.68 ± 6.37, p < 0.001). However, there were no significant differences between the two groups in terms of pregnancy history, childbirth experience, induced and spontaneous abortions, stillbirth, or living children (p > 0.05) (Table 1). More than twothirds (69.7%) of the patients in Group 2 had no history of pregnancy termination, whereas 60.3% of the patients in Group 1 had at least one before. The VAS scores of the two groups were compared at each step, and VAS scores during aspiration (VAS4 ), half an hour after the procedure (VAS5 ), and the overall score (VAS6 ) were statistically significantly lower in Group 1. No statistical difference was found between the VAS1 , VAS2 , and VAS3 scores of the two groups (Table 2). In both groups, VAS scores were highest at the stage of aspiration (VAS4 ). The patients were grouped according to their ages: 20–30, 31–40, and above 40. No statistically significant difference was observed for the VAS scores in any age group between Group 1 and Group 2 (P › 0.05). VAS scores were independent of the age of the patients. VAS scores of the patients within each group were compared according to the mode of delivery, either vaginal delivery (VD), cesarean section (C/S), or vaginal delivery followed by cesarean section (VD + C/S). In Group 1, the VAS6 score was statistically significantly lower in women with previous VD compared to the other groups (VD: 29.46 vs. nulliparous: 58.0, C/S: 31.22, VD+C/S: 41.2, p = 0.015). In Group 2, there was no statistically significant difference among the patients at all VAS scores (p > 0.05). The patients in Group 1 were classified into three groups according to the gestational week (<7 weeks, 7 weeks, and >7 weeks). There was no statistically significant difference in VAS scores with respect to gestational weeks (P › 0.05). The patients in Group 2 were classified according to the endometrial thicknesses measured by transvaginal ultrasonography prior to the procedure (2–8 mm, 9–14

Discussion

 Since the approval of dilatation and curettage (D&C) operations at the end of the 1950s, many new techniques have been developed [15]. Office-based methods using MVA and pipeline aspiration catheters have become standard methods as they are less invasive and painful and are related to a decreased need for anesthesia [16,17]. Manual vacuum aspiration was initially introduced for the management of incomplete miscarriages in the 1970s, but since then it has been widely used for the management of miscarriages and first-trimester pregnancy terminations. Pain may occur during cervical dilatation, and this pain may be aggravated during aspiration due to uterine contractions. The paracervical block is used for endometrial biopsy and endometrial curettage, as well as pregnancy termination [3]. In a study, 120 patients had premedication with oral ibuprofen and lorazepam prior to first trimester abortions [18], then 60 patients had a paracervical block with 2 ml of 1% lidocaine, while 60 had no regional anesthesia. Paracervical block significantly reduced the pain felt during dilatation and aspiration and increased total satisfaction scores. In a randomized clinical study by Cansino et al. [19], half of 50 patients below 11 gestational weeks had a paracervical block with lidocaine after oral ibuprofen administration, and the other half had a paracervical block with lidocaine and ketorolac following placebo. No significant difference was detected between the two groups in terms of postoperative pain and total satisfaction scores (p = 0.93). However, the group who received lidocaine and oral ibuprofen had a significant reduction in pain scores during cervical dilatation. In our study of induced abortion cases (Group 1), the highest VAS score was noted during evacuation (VAS4 ). The pain scores during the insertion of the cannula (VAS3 ) and injection of the local anesthetic (VAS2 ) followed VAS4 . In the endometrial sampling group (Group 2), VAS4 had the highest score, followed by VAS3 and VAS6 . Açmaz et al [20]. divided 111 patients with 5during the procedure. However, in the presented study, the pain scores decreased in both groups after evacuation. Although the VAS scores after evacuation (VAS5 , VAS6 ) were lower in Group-1 in comparison to Group-2, the overall pain evaluation was low (VAS6 ) in both groups when compared to the scores during evacuation. Renner et al. reported improvement in mean pain scores during dilation and aspiration with carbonated lidocaine in the first trimester of abortions [9]. In a randomized controlled study, it was demonstrated that paracervical block with 1% lidocaine is more effective in reducing pain during manual vacuum aspiration compared to placebo. Additionally, it showed higher overall satisfaction rates and a decrease in the need for additional analgesia.21 The recent Cochrane Review found that paracervical block with local anesthetic reduces pain during dilatation and uterine intervention compared to placebo. However, its impact on postoperative pain, when compared to placebo, remains unclear [22]. Additionally, when comparing different anesthesia techniques for surgical evacuation of an incomplete miscarriage, paracervical block showed no significant effect on postoperative pain [23]. Nulliparity and young age were reported to be risk factors for increased pain perception, while previous vaginal delivery was related to decreased pain in patients who had induced abortions [8,9]. Except for their young age, similar findings were observed in Group-1 patients in the present study. However, no correlation was found between the VAS scores and gestational age of the terminated pregnancy in Group 1 and endometrial thickness in Group 2. Renner et al. reported that regardless of the gestational age, paracervical block was found to be effective in first-trimester surgical abortions, but pain control was better at earlier gestational weeks [18]. In the clinical update on reproductive health in 2022 by Ipas, it suggests the use of paracervical block as part of manual vacuum aspiration due to its effectiveness in pain control. In the same guidelines, it recommends a paracervical block injection at a depth of 3 cm, which can be administered at either 2 or 4 points. In our study, we opted for the technique applied to four quadrants at a depth of 3 cm [24]. In a study comparing the effect of transcervreported in patients who underwent induced abortion. Allen et al. reported a pain score of 6.2 (on a scale of 1–10) in 105 women who had suction curettage for pregnancy <14 weeks under local anesthesia, while this score was 6.8 for lorazepam and 5.7 for intravenous sedation. The positive predictors of pain were stated as increased preoperative anxiety, depression, and expected pain and a lower volume of local anesthesia used (10 mL vs. 20 mL) [26], Lauzon et al [27] found that 56.9% of the women were anxious before the operation, while this ratio decreased to 41.7% in the 3rd postoperative week. In our study, using the Beck Anxiety Inventory (BAI), we found that only a minority of the patients in both groups had moderate to severe anxiety. No significant relationship was found between the VAS scores and anxiety status in both groups. To the best of our knowledge, there is no study comparing the efficacy and safety of the paracervical block in induced abortion (pregnancies) to endometrial sampling in the Anglo-Saxon literature. In summary, using local anesthesia with a paracervical block is a safe and effective method for ending pregnancy and conducting endometrial sampling. It efficiently reduces pain during both the procedure and the recovery period, particularly during intrauterine evacuation. The weakness of this study might be the restricted number of patients and the lack of longerterm follow-up. Moreover, comprehensive studies with a larger number of patients are required in order to define the most effective and safe method of pain management during minor intrauterine surgical interventions.

Statements and Declarations 

Funding:

 The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing Interests

 The authors have no relevant financial or non-financial interests to disclose.

Ethics Approval 

This study was performed in line with the principles of the Declaration of Helsinki. The Ethics Committee of University B approved the study on March 25, 2014, under number 172.

Consent to Participate

 Informed consent was obtained from all individual participants included in the study.

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