CHAPTER 5 TEACHING POINTS:
MEDICATIONS AND PAIN MANAGEMENT

EXERCISE 5.1

Purpose: To review management of side effects and complications from medications used to manage pain and anxiety. How would you manage the following case scenarios of people undergoing uterine aspiration?

1. A person states that last year they had an allergic reaction to the local anesthetic that the dentist used.

• • It is important to distinguish between allergic reaction, side effect, and toxicity.
  • There are two classes of anesthetics, esters (e.g. lidocaine) and amides (e.g. chloroprocaine). Allergy to one class does not infer an allergy to the other.
  • Allergic reactions to -caines are extremely rare, and mostly occur from the preservative or epinephrine. Allergic reactions include itching, hives, bronchospasm, and progression to anaphylaxis.
  • If the reaction appears to have been a true allergy, the safest alternative may be to avoid local anesthetic. If the type of anesthetic is known, the alternative class can be used. Or if unknown, may use saline (plain or bacteriostatic), which is less effective than lidocaine (Chanrachakul 2001).
  • Additionally you can maximize systemic medications and sedation.

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2. A person chooses to have IV sedation for pain management. You administer midazolam 1 mg IV and fentanyl 100 mcg IV. As you dilate the cervix and begin aspiration, the patient falls asleep and is not arousable to chin tilt and repeated stimulation, and their oxygen saturation falls from 99% to 88%.

Both medications cause sedation and respiratory depression. Individuals react differently due to interaction with other agents (e.g. alcohol) or genetic differences in metabolism. Prevention can be aided by using a stepwise approach to pain management.

• • Smaller doses for low weight individuals.
  • Serial doses until adequate pain management is achieved.
  • Use of chin tilt, patient stimulation, and oxygen supplementation as needed.
  • Reversal using antagonists, in a stepwise and titrated fashion.

• • Hypoxic patients who have received both an opioid and a benzodiazepine should generally receive naloxone before flumazenil. Naloxone reverses both opioid sedation and respiratory depression. Flumazenil has not been shown to reliably reverse respiratory depression, and also carries seizure risk if the individual has benzodiazepine tolerance or a seizure disorder.
  • Monitoring is recommended for two hours after use of reversal agents, because the sedative may last longer than the antagonist (ASA 2002).

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3. A person at 5 weeks by LMP has a history of alcohol and heroin use, and states that they last used heroin yesterday. The person requests IV sedation. Venous access is limited, but you are able to insert an IV, and administer midazolam 1 mg and fentanyl 100 mcg. You insert the speculum, and the person pulls away stating “I can feel everything.”
   
   1. What can be done before this point to improve the chance of success?
      • Especially given disparities in pain management for people with substance use disorder, it is valuable to establish good rapport, use trauma-responsive care, counsel about all pain management options, and prioritize a multi-modal approach.
      • This can include non-pharmacologic support (breath, music, heat, low lighting, and mindfulness techniques), NSAIDs, acetaminophen, topical anesthetics, and cervical block, as well as adequate sedation in the likely setting of tolerance.
   2. How would you treat this person’s pain?
      • Remember to utilize non-opioid forms of pain management and anxiolysis (as with all people), and to maximize cervical block.
      • People with regular opioid use have likely developed upregulation of receptors and tolerance and often require higher doses of opioid medication to achieve pain management. A reasonable starting place for someone with significant tolerance would be to double the starting dose of fentanyl, or to consider ketamine as an alternative, if available.
      • Caution with rapid reversal of opiates or benzodiazepines in people who chronically use these medications, which can also provoke withdrawal or seizures respectively.
   3. How would this change if the person were taking buprenorphine (Suboxone)?
      • Be aware that individuals on MAT or on chronic opioid pain medications often have higher tolerance of opioids.
      • Additionally, buprenorphine has a high affinity for the mu opioid receptor, thus higher doses of a similarly high affinity opioid (fentanyl or hydromorphone) are needed to overcome this effect.
      • Those who are prescribed MAT or chronic opioids should continue taking their medications as prescribed. MAT does not contribute to analgesia.
      • If possible, communicate with their prescriber to plan for the procedure and follow- up or provide a note for the individual regarding medications used.
      • Increase opioid dose as needed, guided by monitoring, reported pain, alertness, and vital signs.
      • Encourage the person to have close follow-up with their prescribing physician.
   4. How would this change if the person disclosed using heroin today?
      • Substance use (when chronic) on the day of the procedure should not impact pain management decisions other than awareness of possible drug interactions.
      • Ability to complete a consent form is based on standard protocols for consent. Most individuals with active substance use are able to consent to a procedure regardless of prior use that day. Someone with withdrawal may in fact be less capable of providing consent depending on their symptoms.
      • Increase opioid dose as needed or consider ketamine as an alternative if available, guided by monitoring, reported pain, alertness and vital signs.

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4. Consider the consent process for each of the following people. What factors contribute to informed consent? What questions would you ask or what information would help you to make a decision in each case?

• • Consider the following key elements of medical decision making capacity:
    • The person is able to demonstrate an understanding of the benefits and risks of a procedure/treatment as well as alternative options.
    • The person is able to demonstrate an appreciation of those benefits and risks.
    • The person shows reasoning in making a decision.
    • The person can clearly communicate their choice.
    • In those who have psychiatric illness where all of the above are not possible, evaluate for clear and consistent preferences, as abortion should not be withheld in these individuals.
      • a. A person at 5 weeks by LMP who appears nervous. When you enter the room you can smell marijuana.
        • Substance use including marijuana in most cases does not interfere with informed consent.
        • Techniques for evaluating if people are able to consent include asking orientation questions and having them repeat information back after reviewing it together.
        • If a person is drowsy or not able to answer orienting questions, consider allowing them to rest awhile and then reevaluate for consent.

        b. A person at 12 weeks by LMP is on methadone for opioid use disorder. They have been on the same dose for 8 years, and last took their medication this morning.

        • Substance use disorder history, and use of MAT medications does not alter the informed consent process.
        • Using methadone on procedure day is recommended and in fact a state of withdrawal can more greatly interfere with informed consent.

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EXERCISE 5.2

Purpose:To become familiar with other medications used with uterine aspiration. Please answer the following questions.

1. In which of the following situations is administration of RhIG (Rhogam) suggested in a person ≥ 12-weeks gestation?
   1. A person with a positive anti-D antibody titer.
      • The person may already be sensitized (in which case RhIG will not help).
      • Or the person recently received RhIG and still has those anti-D antibodies in their blood (t 1/2 is 24 days).
      • In either case, don’t give RhIG unless there is a new indication and 3 weeks have elapsed since the last dose.
   2. An Rh-negative person who received RhIG 4 weeks ago during evaluation for threatened abortion.
      • RhIG may be present for up to 9-12 weeks after full-dose administration (Bichler 2003), but the manufacturer advises that it be given if three or more weeks have elapsed since the initial injection in term pregnancies.
      • Until further data delineates therapeutic levels after mini-dose RhIG, redosing after 3 elapsed weeks may be prudent.
   3. A Rh-negative person who is 4 days post-abortion and did not receive RhIG at the uterine aspiration visit.
      • RhIG should ideally be administered within 72 hours.
      • Beyond 72 hours, some recommend anti-D still be given as soon as possible, for up to 28 days (Horvath 2023, WHO 2022)
      • For medication abortion, RhIG is ideally given at the time of mifepristone, but many give it up to 72 hours afterwards.

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2. A person complains of nausea and “feeling faint” while completing an early uterine aspiration procedure using local cervical anesthesia and ibuprofen only. They are pale and sweaty, and their blood pressure is 90/50 with a pulse of 48.
   1. What is the differential diagnosis?
      • This appears to be a classic vasovagal reaction, with low pulse, hypotension, and sweating. Vasovagal reflex is caused by stimulation of the parasympathetic nervous system, and occurs often with cervical dilation, fear and other emotions. An individual who is overheated, dehydrated, hypoglycemic, or over-medicated may also be predisposed to syncope.
      • Differential Diagnosis: Vasovagal, hemorrhage, low blood sugar, or an inadvertent intravascular –caine injection.

      Vasovagal Reflex	Hemorrhage	Low Blood Sugar	Intravascular -caine
      Slow pulse (< 50) Low BP Pallor Cool clammy skin +/- N/V +/- Abdominal Cramps	Rapid Pulse Late low BP Pallor, Cool clammy skin +/- N/V +/- Uterine cramps	Normal / late rapid Late low BP Pallor, Cool clammy skin +/- N/V +/- Abdominal Cramps	Slow pulse (<50) Tinnitus Perioral tingling Metallic taste Irregular pulse
      Rare: Syncope, Seizure-like activity	Rare: Syncope	Rare: Syncope, Seizures	Rare: seizure, ventricular arrhythmias, cardiac arrest
      Not orthostatic	Becomes orthostatic	Not orthostatic	Not orthostatic

   2. How might you prevent this reaction?
      • To help prevent vasovagal reactions, emphasize hydration, keeping cool (i.e. be careful about being overheated from walking to the health center in hot temperatures), staying calm, and remaining supine for a few minutes after a uterine procedure. Isometric extremity contractions may also help prevent vasovagal (see below).
      • Avoid stimulation of the cervix for 1-2 minutes if someone experiences systemic symptoms from lidocaine or has mild vasovagal symptoms. Cervical stimulation can exacerbate or cause vasovagal reaction.
   3. How would you manage this patient?
      • Vasovagal Management
        • Airway / Positioning: supine or Trendelenburg, head to side if vomiting
        • Cool cloth on head or neck
        • Sniffing alcohol swab or ammonia capsule
        • Vasovagal reflex may be aborted by isometric contractions of the extremities (gripping the arm, hand, leg and foot muscles) (Cason 2014). These maneuvers also activate the skeletal-muscle pump to augment venous return.
        • Prolonged vasovagal, consider:
          • Atropine, IV Fluids, oxygen, evaluation for other potential causes (hemorrhage, etc
          • Record events, and transfer as needed.