EXERCISES: MEDICATIONS AND PAIN MANAGEMENT

EXERCISE 5.1

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

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

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

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3. A patient who is 5 weeks by LMP has a history of alcohol and heroin use, and states that they last used heroin yesterday. The patient 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 patient pulls away stating “I can feel everything.”
   1. How would you treat this person’s pain?
   2. How would this change if the patient were on buprenorphine (Suboxone)?
   3. How would this change if the patient disclosed using heroin today?

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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/what information would help you to make a decision in each case?
   1. An 18-year old patient at 5 weeks GA who appears nervous. When you enter the room you can smell marijuana.
   2. A 35 year old patient at 12 weeks GA is on methadone for opioid use disorder. They have been on the same dose for 8 years, and last took their medication this morning.

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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 Rh-D immunoglobulin (RhoGam) suggested in a patient over 12-weeks gestation?
   1. Patient has positive anti-D antibody titre.
   2. Rh-negative patient received RhoGam 4 weeks ago during evaluation for threatened abortion.
   3. Rh-negative patient 4 days post-abortion who did not receive RhoGam at the uterine aspiration visit.

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2. While completing an early uterine aspiration procedure using local cervical anesthesia and ibuprofen only, the patient complains of nausea and “feeling faint”. The patient is pale and sweating. The blood pressure is 90/50 with a pulse of 48.
   1. What is your differential diagnosis?
   2. How might you prevent this reaction?
   3. How would you manage this patient?

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