Paracervical Block Volume and Pain Control During Dilation and Curettage
Dilation and Curettage (D&C) is often performed in the first trimester for surgical abortion and management of miscarriage and can be painful for patients before and after the procedure. Most procedures are performed while the patient is awake or with minimal sedation in the clinic setting, and a key component of pain control is the paracervical block, or injecting lidocaine into the tissue around the cervix1-10. A paracervical block with 20cc of 1% buffered lidocaine has been proven to provide superior pain control than a sham paracervical block13. However, many providers often use similar doses of lidocaine in a higher volume to improve pain control4-5. At UCSD and UCLA, some providers routinely use a 20cc of 1% buffered lidocaine block and some routinely use a 40cc of 0.5% buffered lidocaine block. This practice has not been studied in a randomized controlled trial. The purpose of this study is to compare pain control during D&C with a 20cc 1% buffered lidocaine with vasopressin paracervical block compared to a 40cc 0.5% buffered lidocaine with vasopressin paracervical block. An inclusion criterion for this study is that patients must specifically be referred to family planning clinics at UCSD and UCLA for an in-clinic D&C. Therefore, the D&C is a required procedure for both study groups. The only difference in care between the study groups will be which paracervical block they receive.
Assessing the Effect of Paracervical Block Volume on Pain Control for Dilation and Curettage: a Randomized Controlled Trial
OVERVIEW OF DESIGN This is a double center, randomized, 2 arm (1:1), single blinded clinical trial comparing pain control at the time of cervical dilation with two different paracervical blocks in women undergoing D&C in the first trimester for either surgical abortion or miscarriage management.
In patients undergoing first trimester D&C with minimal sedation, a 40cc buffered 0.5% lidocaine with 2 units of vasopressin paracervical block will improve pain control by 20-mm on a 100-mm visual analog scale (VAS) compared to a 20cc 1% lidocaine with 2 units of vasopressin paracervical block at the time of cervical dilation.
In patients undergoing first trimester dilation and curettage (D&C), a 40cc buffered 0.5% lidocaine with 2 units vasopressin paracervical block compared to a 20cc 1% lidocaine with 2 units vasopressin paracervical block will improve pain control by 20-mm on a 100-mm VAS at the time of paracervical block placement, uterine aspiration and 10 minutes after the procedure.
In order to investigate this hypothesis, the following study design is proposed:
The study will take place in the family planning clinics at UCSD and UCLA. At UCSD and UCLA, family planning clinics help guide patients in the management of their miscarriages and undesired pregnancies. Any clinician can refer patients to this clinic and appointments are coordinated by a Family Planning Coordinator. During this study, upon presentation to clinical care for termination of pregnancy or miscarriage, the clinician will take a full history, perform a physical exam, and counsel the patient about her options including using medications, performing a D&C in clinic, and performing a D&C under anesthesia in the operating room, all of which is standard for a clinic visit in the family planning clinics. If the patient desires a clinic-based D&C, a dating ultrasound will be performed, and the clinician will assess for medical contraindications to clinic D&C or chronic pain conditions, as is standardly done for every D&C in the family planning clinics. If she is eligible for D&C, informed consent will be obtained for the procedure, per standard clinic practice. The study coordinator will then assess if the patient is interested in participating in the study, ensure that the patient is willing to take the study medications and that she has not taken any pain medications that day. The study coordinator will then obtain written informed consent to participate and perform the baseline survey detailing her age, race, ethnicity, level of education, income level, height, weight, obstetric history, history of cervical procedures (eg LEEP procedure or Conization), current pregnancy status (undesired pregnancy vs. early pregnancy loss), baseline anxiety using the GAD-7 (a validated tool used to assess for anxiety in primary care settings18). The patient will then receive 60mg IM ketorolac, 10mg oral Versed, and 500mg oral Azithromycin 30 minutes prior to the procedure per usual clinic protocol.
Block randomization will be performed (alternating block sizes of 4 and 6). The study coordinator will pick the designated sealed, opaque envelope containing the type of paracervical block and hand it to the physician performing the procedure. The physician will then open the envelope and prepare the designated paracervical block, as it is standard practice for physicians to prepare their own paracervical blocks prior to performing any D&C in-clinic. The paracervical block will contain 2U Vasopressin, 2cc of 8.4% sodium bicarbonate, and either 1% lidocaine or 0.5% lidocaine, depending on the study group. The physician will bring the paracervical block into the clinic room where the procedure will be performed on a covered tray. The physician will perform the standardized procedure for the D&C.
The study coordinator, who will be blinded to the type of paracervical block, will present the VAS to the participant ask her to mark her level of pain at baseline, speculum insertion, paracervical block placement, cervical dilation, immediately after uterine aspiration, 10 minutes after the procedure, and overall pain. Additionally, after paracervical block placement, the participant will be asked about side effects of lightheadedness, tinnitus, circumoral tingling, and a metallic taste in the mouth. The physician will perform the D&C in the usual fashion, and the study coordinator will record the time from speculum insertion to speculum removal.
After the procedure, the physician will answer a questionnaire detailing if there were any adverse events related to either the paracervical block or the D&C, such as cardiac arrest, uterine perforation, or hemorrhage. The physician will also note the uterine position, how much cervical dilation was performed, and their level of training and prior experience with the procedure. That patient will also answer questions about satisfaction with pain control.
Abortion, Spontaneous Abortion in First Trimester Pain Uterus Dilation & curettage Paracervical block Dilatation, Pathologic Lidocaine Vasopressins Arginine Vasopressin 0.5% Lidocaine 1% Lidocaine
You can join if…
Open to females ages 18 years and up
- Women over the age of 18 presenting to UC San Diego and UC Los Angeles
- Undesired pregnancy or missed abortion < 11 weeks 6 days gestation
- Must speak English or Spanish
- Desire surgical termination of pregnancy or management of miscarriage in clinic
You CAN'T join if...
- Women with a diagnosis of inevitable or incomplete abortion
- Desire for general anesthesia or IV sedation
- Chronic pain conditions
- Any medical comorbidities that are a contraindication to performing the procedure in the clinic setting
- Allergy to or refusal of ketorolac, oral Versed, or a paracervical block
- If they have taken any pain medications the day of presentation to clinic
- If they have taken Misoprostol the day of presentation to clinic
- not yet accepting patients
- Start Date
- Completion Date
- University of California, San Diego
- Guttmacher Institute: Facts on Induced Abortion Worldwide
- Chapter 8: Pain Management. In Management of Unintended and Abnormal Pregnancy
- Phase 3
- Lead Scientist
- Bonnie Crouthamel
- Study Type
- Last Updated
- August 16, 2018