Pain management for medical and surgical abortion between 13 and 24 weeks gestation: A systematic review.

Jackson E, Kapp N

BJOG: An International Journal of Obstetrics and Gynaecology
Mar 2020


High‐quality abortion care requires pain be effectively managed, however practices differ, and available guidelines do not specify optimal strategies.


To guide providers in effective pain management for second‐trimester medical and surgical abortion.

Search strategy

We searched Pubmed, Cochrane, Embase databases and the US National Library of Medicine clinical trials registry through June 2019 and hand‐searched reference lists.

Selection criteria

Trials comparing pain management strategies to no treatment, placebo, or active interventions during induced medical or surgical abortion between 13 and 24 gestational weeks and reporting direct or indirect measures of pain.

Data collection and analysis

Both authors summarized and systematically assessed evidence and risk of bias using standard tools.

Main results

We included seven medical and four surgical abortion studies, with 453 and 349 participants, respectively. Heterogeneity of interventions and outcomes prevented pooled analyses. Medical abortion: women receiving routine or continuous epidural analgesia experienced mild pain. Prophylactic NSAIDs decreased pain (mean difference ‐0.5, p<0.001) and additional opioid requirements (3.5mg vs 7mg, p=0.04) compared to placebo/other treatment. Paracervical block was ineffective. No studies assessed IM/IV opioids or nonpharmacologic treatment. Surgical abortion: general anesthesia/deep IV sedation alleviated pain. Nitrous oxide was ineffective. No studies assessed moderate IV sedation, IV/IM opioids, paracervical block without sedation, NSAIDs or nonpharmacologic treatment.


Based on limited data, regional analgesia and NSAIDs mitigated second‐trimester medical abortion pain; general anesthesia/deep IV sedation alleviated surgical abortion pain.