Society of Family Planning clinical recommendations: Pain control in surgical abortion part 2 - Moderate sedation, deep sedation, and general anesthesia

Contraception 104 (2021) 583–592

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Contraception

journal homepage: www.elsevier.com/locate/contraception

Original research article

Society of Family Planning clinical recommendations: Pain control in

surgical abortion part 2 – Moderate sedation, deep sedation, and

general anesthesia

Catherine Cansino

a , ∗

, Colleen Denny

, A. Sue Carlisle

, Phillip Stubbleﬁeld

Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States

Department of Obstetrics and Gynecology, New York University, New York, NY, United States

Department of Anesthesia, University of California, San Francisco, CA, United States

Department of Obstetrics and Gynecology, Boston University, Boston, MA, United States

a r t i c l e i n f o

Article history:

Received 10 May 2021

Received in revised form 3 August 2021

Accepted 7 August 2021

Keywords:

Moderate sedation

Deep sedation

General anesthesia

Pain relief for surgical abortion

a b s t r a c t

Analgesic options for surgical abortion (also called procedural abortion) beyond local anesthesia and min-

imal sedation include moderate sedation, deep sedation and general anesthesia. These clinical recom-

mendations review the effectiveness of various moderate sedation, deep sedation, and general anesthesia

regimens for pain control during abortion; medication regimens used to induce analgesia and anesthesia;

patient factors affecting anesthesia safety; preoperative and intraoperative protocols to reduce anesthesia

risks; personnel qualiﬁcations for administration; recommended patient monitoring protocols; and gen-

eral risks of anesthesia in the context of abortion care. The scope of these recommendations is based on

limited available evidence and considerably relies on existing professional society guidelines and recom-

mendations developed by content experts and reviewers. Further research to compare the eﬃcacy and

safety of different regimens is needed.

1. Background

Both surgical (also called procedural) and medication abortions

are associated with some pain, and the intensity of pain varies.

With use of verbal support and minimal sedation, discussed in a

separate clinical guideline [1] , Duros et al. [2] report that 46% of

women undergoing surgical abortion experience pain reported as

“severe pain” deﬁned as level 7 and above on a visual analogue

scale. An increasing number of options for moderate sedation, deep

sedation, and general anesthesia to address pain related to surgi-

cal abortion are available [ 3 , 4 ]. In separate national surveys of ﬁrst-

and second-trimester abortion providers, 79% of ﬁrst-trimester sur-

gical abortion providers preferred using either a combination of lo-

cal anesthesia and intravenous moderate sedation, deep sedation,

or general anesthesia, and most clinics that offered these options

employed these analgesic options for > 80% of their patients [ 3 , 4 ].

Table 1 provides a general overview of the different levels of

sedation; however, individual patients can experience varying anal-

gesic effects throughout their treatment course (intraoperative and

postoperative), and these effects may differ from the intended re-

∗

Corresponding author.

E-mail addresses: cansino@ucdavis.edu , [email protected] (C. Cansino).

sults [5] . Providing safe anesthetic regimens requires attention to

patient selection, whether it is the identiﬁcation of which pa-

tients may receive sedation or which regimen is appropriate for a

given patient, and ensuring that providers and staff are adequately

trained to provide and manage complications of speciﬁc anesthetic

regimens. Staff training, adequate monitoring, and preparation for

emergencies are essential to ensure that staff and practice set-

tings are prepared to respond to over-sedation or other anesthesia-

related complications.

In these recommendations, we address several questions about

moderate and deep sedation and general anesthesia for surgical

abortion provided in both out-of-hospital and in-hospital settings.

In developing these recommendations, a search of the medical lit-

erature was performed using the PubMed program of the National

Library of Medicine and the Cochrane Library of Clinical Trials from

the beginning of the databases through April 5, 2021. Search terms

include but were not limited to analgesia, anesthesia, and sedation,

in combination with abortion, gynecology, obstetrics, pregnancy,

and termination. Publications and relevant statements of the Amer-

ican Association of Nurse Anesthetists (AANA), American College

of Obstetricians and Gynecologists (ACOG), the American Society

of Anesthesiologists (ASA), the European Society of Anaesthesiol-

ogy (ESA), the National Abortion Federation (NAF), Planned Par-

enthood Federation of America (PPFA), the Royal College of Obste-

https://doi.org/10.1016/j.contraception.2021.08.007

C. Cansino et al. Contraception 104 (2021) 583–592

Table 1

Continuum of depth of sedation (adapted from ASA continuum of depth of sedation: deﬁnition of general anesthesia and levels of sedation/analgesia, 2014) [5] .

Levels of sedation DEFINITION drug induced state where:

Minimal sedation (anxiolysis) Patients respond normally to verbal commands. Cognitive function and coordination may be impaired, but

ventilator and cardiovascular (CV) functions are unaffected.

Moderate sedation/analgesia (conscious sedation) Patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No

interventions are required to maintain a patient airway,

and spontaneous ventilation is adequate. CV function

is usually maintained.

Deep sedation/analgesia Patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The

ability to independently maintain ventilatory function may be impaired. Patients may require assistance in

maintaining a patent airway, and spontaneous ventilation may be inadequate.

CV function is usually

maintained.

General anesthesia Patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory

function is often impaired. Patients often require assistance in maintaining a patent airway, and positive

pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced

depression of neuromuscular

function. CV function may be impaired.

Table 2

Recommended dosing for commonly used medications for moderate sedation (National Abortion Federation, 2018) [7] .

Drugs Usual initial dose Maximum initial dose Usual incremental dose Maximum incremental dose

Fentanyl (opioid analgesic) 50 −100 mcg 200 mcg 50 −100 mcg 100 mcg

Midazolam (benzodiazepine sedative) 1 −3 mg 4 mg 1 −2 mg 2 mg

tricians and Gynaecologists (RCOG), and regulatory guidance from

The Joint Commission were reviewed. These organizations’ publica-

tions were primarily referenced when applicable since their guide-

lines are highly relevant to abortion practice and peer reviewed.

Many clinical settings for abortion services also follow guidelines

issued by these professional organizations.

While some questions have been addressed by well-designed

studies, there are important gaps in the literature; for some ques-

tions, the only available answers come from the standards and

policies of professional organizations or there is limited clear guid-

ance. We have speciﬁed these evidence gaps throughout the docu-

ment when applicable.

2. Clinical questions

2.1. What medication regimens are used for moderate sedation, deep

sedation, or general anesthesia?

Different medication regimens may be used to induce seda-

tion (depression of awareness), analgesia (insensibility to pain)

and/or anesthesia (loss of sensation, with or without loss of con-

sciousness). On the ASA continuum of depth of sedation, mod-

erate sedation is not deﬁned by the exact medication used, but

rather by the level of responsiveness and cardiopulmonary func-

tion of each individual patient resulting from a particular regi-

men (speciﬁc medication and dose) ( Table 1 ) [ 5 , 6 ]. Typical med-

ications used for moderate sedation include analgesics which may

be given in combination with sedatives to induce varying degrees

of analgesia, sedation, anxiolysis, and amnesia. Doses are titrated

as needed to achieve the desired level of sedation and anesthesia

[ 5 , 6 ]. This desired effect is deﬁned based on agreement between

the provider and patient that incorporates both parties’ expecta-

tions with regard to immobility and analgesia, ultimately lead-

ing to a safe and complete procedure. There is no clear guidance

that prescribes speciﬁc regimens for patient-related factors such as

body mass index (BMI), medical comorbidities, sedation goals, an-

ticipated procedure-related pain, and planned procedure length to

determine which regimen to use.

Tables 2 and 3 list common intravenous drugs used to pro-

vide minimal to moderate sedation, respectively outlined by NAF

and PPFA [ 7 , 8 ]. Both NAF and PPFA have policies that regulate

the use and dosing schedules of speciﬁc medications used, in-

cluding both the initial dose and recommended intervals for in-

creased titration if the effect is insuﬃcient. There is limited in-

formation comparing these agents based on the speciﬁc medica-

tions and doses. Braaten et al. [9] studied the safety and eﬃcacy

of a speciﬁc dosing algorithm of intravenous fentanyl and mida-

zolam to standard weight-based dosing per clinic standard, noting

no differences in pain scores. Their algorithm was created based

on the subject’s weight, BMI, airway concerns, drug and alcohol

use, and anxiety scores. Several factors, including but not limited

to medication cost, time of onset of desired effect, duration of

effect and anticipated duration of the procedure, need for exact

titration (e.g., use of an infusion pump for remifentanil admin-

istration), provider preference, and patient-related factors, affect

the chosen drug regimen for administration of moderate sedation

(GRADE 1C) [ 7 , 8 ].

PPFA lists propofol, ketamine, and methohexital as medications

used to induce deeper sedation [8] . The ASA guidelines summa-

rize that methohexital offers satisfactory deep sedation and can be

administered by nonanesthesiologists [6] . However, the guidelines

do not provide detailed information regarding speciﬁc dosing regi-

mens for methohexital use [6] . Chestnut’s Obstetric Anesthesia, the

classic textbook on this topic, indicates that propofol is used to in-

duce sedation for monitored anesthesia care as an alternative to

midazolam in surgical abortion [10] . Several cohort studies involv-

ing a total of 64,980 subjects reviewed safe use of deep sedation,

often with propofol [ 11 −13 ]. Ketamine can be used as an adjunct

to parenteral opioid analgesia, and concerns for neonatal depres-

sion would not be applicable when used in surgical abortion cases

[10] .

There is limited evidence regarding recommended medications

for general anesthesia speciﬁcally for surgical abortion. Williams’

Obstetrics recommends a rapid sequence induction with an in-

travenous anesthetic; either propofol, etomidate or remifentanil;

and rapid-onset muscle relaxant such as ketamine, succinylcholine,

or rocuronium [14] . Wu et al. conducted a randomized controlled

study of women undergoing ﬁrst-trimester surgical abortion under

general anesthesia with 6 arms: propofol alone, propofol with fen-

tanyl, propofol with fentanyl and midazolam, etomidate alone, eto-

midate with fentanyl, and etomidate with fentanyl and midazolam

[15] . They reported that propofol, compared to etomidate, causes a

584

C. Cansino et al. Contraception 104 (2021) 583–592

Table 3

Commonly used medications for moderate sedation (Planned Parenthood Federation of America, 2018) [8] .

Drugs Maximum recommended

single dose

Onset of action Duration Comments

Fentanyl (opioid analgesic) 1 −2 mcg/kg IV Almost immediate 0.5 −1 h May be repeated once

Nalbuphine (opioid analgesic) 10 −20 mg IV/IM 2 −3 min IV < 15 min IM 3 −6 h

- May be repeated once

Allow 3 −4 min between doses to assess effect

previously administered dose

- Do not use following other narcotic analgesics

(includes maintenance therapies such as

methadone or suspected narcotic use) – will

reverse effect of nalbuphine and can induce

symptoms of opioid withdrawal

Meperidine (opioid analgesic) 50 −100 mg IM/SQ 10 −15 min 2 −4 h

- May

give every 3 −4 h

- Avoid concomitant use with benzodiazepines

or other CNS depressants

Midazolam (benzodiazepine

sedative)

2.5 mg 3 −5 min < 2h Initial dose 1 −2.5 mg

Administer slowly with 2 −3 min between doses

to assess effect of previously administered dose.

May repeat in

1 mg doses not to exceed a total of

5 mg to maintain desired depth of sedation

PPFA aﬃliates are directed to develop their own local formulary.

greater decrease in mean arterial pressure and pulse oxygen satu-

ration during induction. Side effects such as myoclonus and post-

operative nausea and vomiting were less likely to occur among

those who received propofol compared to etomidate. Among those

who received etomidate, subjects who received a decreased dose

of etomidate and supplemented with fentanyl and midazolam, the

side effects were less likely to occur. In separate studies, Lazenby

[16] and Micks [17] note that general anesthesia in surgical abor-

tion may include intravenous fentanyl, intravenous midazolam, in-

haled nitrous oxide, intravenous propofol, and/or inhaled anesthet-

ics. Chestnut’s Obstetric Anesthesia states that general anesthesia

for dilation and evacuation is commonly administered with propo-

fol infusion and an opioid; ketamine may be preferred in patients

with signiﬁcant bleeding [10] .

2.2. How effective are moderate sedation, deep sedation, and general

anesthesia for pain control during abortion procedures?

Moderate sedation, deep sedation, and general anesthesia are

effective in controlling pain during abortion procedures. Analgesic

options for ﬁrst- and second-trimester surgical abortion are similar

based on patient preference and comorbidities, regardless of gesta-

tional age [ 3 , 4 , 18 ]. Most published research on the eﬃcacy of anal-

gesic options beyond minimal sedation has focused on moderate

sedation for ﬁrst-trimester abortions. Allen et al. [19] conducted a

randomized controlled trial with an equivalence design noting that

oral sedation with 10 mg of oxycodone and 1 mg of lorazepam is

not equivalent to intravenous sedation with 100 mcg of fentanyl

and 2 mg of midazolam. The National Guidance Alliance hosted by

RCOG completed a comprehensive review of the literature and rec-

ommends intravenous over oral administration if “conscious” se-

dation is used [18] . While moderate sedation, deep sedation, and

general anesthesia are more commonly used for second-trimester

than for ﬁrst-trimester surgical abortion [20] , we could ﬁnd no

randomized trials of moderate sedation in second-trimester surgi-

cal abortion to assess comparative effectiveness of different anes-

thetic regimens or against placebo. There are limited data compar-

ing the eﬃcacy of deep sedation vs general anesthesia for surgical

abortion at speciﬁc gestational ages.

A combination of fentanyl and midazolam is effective in reduc-

ing pain associated with ﬁrst-trimester surgical abortion (GRADE

1B) [ 21 −24 ]. According to a systematic review by Renner et al.

[21] that only included randomized trials, moderate sedation de-

creases procedure-related and postoperative pain in ﬁrst-trimester

surgical abortion. In 2001, Rawling and Wiebe [22] compared in-

travenous fentanyl 50–100 mcg to intravenous placebo (normal

saline) in women undergoing ﬁrst-trimester surgical abortion who

also received cervical anesthesia and sublingual lorazepam and to

women who received no intravenous treatment at all. Women who

received fentanyl had lower pain scores than those who received

placebo (mean 4.3 vs 5.3 on a 10-point scale, with a mean differ-

ence of 1.0, 95% CI 0.4, 1.6). Wong et al. [23] studied the analgesic

effects of sedation using intravenous midazolam 2 mg and fentanyl

25 mcg compared with placebo among women undergoing ﬁrst-

trimester surgical abortion. They found no signiﬁcant difference in

pain between groups, but those who received IV sedation reported

better satisfaction (50% IV sedation vs 20% placebo reported satis-

factory or excellent satisfaction, p = 0.003).

A study by Allen et al. [24] was not included in the above-

mentioned systematic review because it was not randomized. In

this study, 330 women undergoing ﬁrst-trimester surgical abortion

chose among 3 options for pain management: cervical anesthe-

sia alone ( n = 105), cervical anesthesia plus sublingual lorazepam

(0.5–1.0 mg orally 20 minutes before surgery) ( n = 106), or cer-

vical anesthesia plus intravenous sedation with fentanyl (doses of

50–125 mcg) and midazolam (1–2 mg) ( n = 119). The investigators

reported that subjects who received the combination of cervical

anesthesia and intravenous sedation with fentanyl and midazolam

had the lowest pain scores (reduction in pain score of 0.86, 95%

CI 0.25 −1.46). They found no signiﬁcant difference in mean pain

scores between those who received cervical anesthesia with sub-

lingual lorazepam compared to those who received cervical anes-

thesia alone (6.78 vs 6.22). When they divided the intravenous se-

dation group into low-dose (50 mcg fentanyl and 1 mg midazo-

lam) and moderate-dose (75–125 mcg fentanyl and/or 1.5–2.0 mg

midazolam) groups, mean pain scores from those who received the

moderate dose were signiﬁcantly lower compared to those who re-

ceived the low-dose regimen (4.93 vs 6.18, p ≤ 0.001).

2.3. What preprocedure patient evaluation or patient preparation is

necessary for moderate sedation, deep sedation, or general

anesthesia?

Patient evaluation and preparation for the intended level of se-

dation is primarily based on the patient’s surgical risk and the fa-

cility’s ability to manage anesthesia-related complications, includ-

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C. Cansino et al. Contraception 104 (2021) 583–592

ing unintended depth of sedation. Given the multifactorial interac-

tion of medical comorbidities and anesthesia complications, rec-

ommendations for appropriate preprocedure evaluation are pri-

marily derived from expert opinion rather than high-quality trials.

While there is no clear consensus on speciﬁc preprocedure patient

evaluation or patient preparation that is necessary prior to moder-

ate sedation, deep sedation, or general anesthesia, professional so-

cieties do recommend that an assessment be performed, especially

among patients with co-morbidities (Grade 1C) [ 7 , 8 , 25 −27 ].

There is suggestive evidence that some preexisting medical con-

ditions may be related to adverse outcomes in patients receiving

either moderate or deep sedation analgesia [27] . Consultants to

the ASA Task Force, considered experts in preanesthesia evalua-

tion, noted that a preanesthetic history and physical examination

is “essential,” citing beneﬁts that include but are not limited to

the safety of perioperative care, optimal resource use, improved

outcomes, and patient satisfaction. However, an ASA Task Force

of anesthesiologists and methodologists from the ASA Committee

on Standards and Practice Parameters concluded that there is in-

suﬃcient published evidence to evaluate the relationship between

sedation-analgesia outcomes and the performance of a preproce-

dure evaluation.

The recommendations of the Task Force include “being familiar

with the sedation-oriented aspects of the patient’s medical history,

and a focused physical examination including vital signs, auscul-

tation of the heart and lungs, and evaluation of the airway” [27] .

Common comorbidities that may inﬂuence anesthesia safety in-

clude hypertension, particularly systolic blood pressure over 200

mm Hg [28] ; pulmonary disease, including smoking, obstructive

sleep apnea [29] , and poorly controlled asthma [30] ; poorly con-

trolled diabetes [31] ; renal disease [32] ; and anemia [33] , particu-

larly in procedures with higher risk of blood loss and transfusion

[33] . Substance use may also inﬂuence the recommended anes-

thesia regimen [34] . Several studies report safe use of moderate

or deep sedation among obese women (combined total 5517 sub-

jects with BMI ≥ 40kg/m

, 871 of who have BMI ≥ 40 kg/m

)

[35,36] . In addition to auscultation of the heart and lungs during

the preoperative examination, the patient’s airway should be as-

sessed for features associated with possible diﬃcult airway man-

agement, including obstructive sleep apnea, previous head/neck ra-

diation, surgery or trauma, small mouth opening, dysmorphic fa-

cial features, lack of teeth, or BMI > 26 kg/m

[ 8 , 27 , 37 ]. The Mal-

lampati classiﬁcation system is 1 standardized way of evaluating

the airway of patients receiving moderate/deep sedation or gen-

eral anesthesia to identify patients in whom tracheal intubation

would be diﬃcult, serving as the most accurate precautionary as-

sessment of patients who are more likely to require rescue intuba-

tion [ 38 , 39 ]. However, we found no articles speciﬁcally describing

its use to screen patients for safe out-of-hospital ambulatory sur-

gical abortions; hence, neither NAF nor PPFA make a speciﬁc rec-

ommendation on how airway assessment is conducted [ 7 , 8 ].

No speciﬁc standard preprocedure laboratory tests were ad-

vised, but the Task Force recommended that preprocedure labora-

tory tests be guided by the patient’s underlying medical condition

and the likelihood that the results will affect the management of

sedation/analgesia. ACOG guidelines similarly recommend a preop-

erative medical history, a physical examination, and a patient as-

sessment using the ASA continuum of depth of sedation; no dis-

tinction between inpatient vs outpatient or ambulatory care set-

ting was described [25] . Both NAF and PPFA clinical guidelines for

moderate sedation require a presedation evaluation of the patient

to include relevant history and review of systems, medication re-

view, last food intake, baseline vital signs, and targeted exam of

the heart, lungs, and airway (GRADE 1C) [ 7 , 8 ].

2.4. Which patients are typically not appropriate for management in

out-of-hospital ambulatory care facilities with moderate sedation,

deep sedation, or general anesthesia? Which patient factors inﬂuence

patient safety during anesthesia?

For individuals who want or need pain control during surgical

abortion, the risks of anesthesia administration must be weighed

against the analgesic beneﬁts. Several factors may inﬂuence the

decision of whether a patient is an appropriate candidate for out-

of-hospital anesthesia, including provider preference (whether the

surgeon or anesthesia provider), distance from nearest hospital

that can accommodate postabortion complications, and most im-

portantly, the patient’s surgical risk based on their comorbidi-

ties and the facility’s ability to manage potential complications

secondary to these comorbidities (GRADE 1C) [ 7 , 8 ]. There is no

evidence-based standard regarding patient selection for abortion

care in out-of-hospital ambulatory care facilities based on appro-

priateness for level of intended sedation. However, the NAF Clini-

cal Policy Guidelines do stipulate that patients who have an “atyp-

ical airway assessment” or categorized as ASA Class III or greater

should be offered “a reduced level of sedation, an alternate abor-

tion procedure, or provision of care by an anesthesia professional”

[7]

The ASA physical status classiﬁcation system can be used as a

guide to assess a patient’s procedure-related risk (GRADE 2C) [40] .

Classiﬁcations range from completely healthy patients (ASA Class l)

to brain-dead (ASA Class VI) ( Table 4 ). Pregnancy of any duration

is suﬃcient to place the patient in ASA Class II, which includes

patients with mild systemic disease, due to associated physiologic

changes in pregnancy such as relative hypoxia and other metabolic

changes that may alter responses to medications. However, the ASA

classiﬁcation system by itself cannot adequately describe patient

risk from surgery because it does not specify type of anesthesia

and lacks a risk index for the surgery itself. Anesthesia risk and

surgical risks may be additive and should be evaluated together

(GRADE 2B) [41] .

To assess risk in relation to care setting, Guiahi et al. [42] eval-

uated whether women with 1 or more chronic medical conditions

[asthma (45%); hypertension (19%); hypothyroidism (7%); epilepsy

(6%); diabetes, HIV, hematologic disorders ( < 5% combined); BMI

> 40 ( < 1%)] who were seeking ﬁrst-trimester surgical abortion

were at greater risk for complications in the oﬃce setting com-

pared to their healthy peers. These patients were classiﬁed as ASA

class II, with the addition of 16 patients classiﬁed as ASA Class III

only for BMI > 40 kg/m

. No difference in anesthetic-related com-

plications was noted in the 2 groups (0 complications in either

group, with a total of 176 who received moderate sedation).

Thirty-nine patients in the study were managed in the inpa-

tient setting for classiﬁcation as ASA class III or IV or for whom

the abortion provider was concerned about increased risk for com-

plications based on pregnancy characteristics or reproductive his-

tories. Four of these 39 patients who had inpatient abortions had a

complication, none of these complications were anesthesia-related,

and the authors found that patients who underwent inpatient pro-

cedures with comorbidities that met classiﬁcation criteria for ASA

Class III or IV were not more likely to experience a complica-

tion than those without comorbidities. Results from Guiahi’s study

imply that most women classiﬁed as ASA II for comorbidities in

addition to pregnancy can safely undergo ﬁrst-trimester abortion

in an ambulatory care setting. The authors also concluded that

providers in the study were able to appropriately identify patients

who should be managed in an inpatient setting based either on

medical history or pregnancy-related factors.

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C. Cansino et al. Contraception 104 (2021) 583–592

Table 4

ASA physical status classiﬁcation current deﬁnitions and examples

∗

[40] .

ASA physical status

classiﬁcation

Deﬁnition Examples, including, but not limited to:

ASA I A normal healthy patient Healthy, nonsmoking, no or minimal alcohol use

ASA II A patient with mild systemic Disease Mild diseases only without substantive functional limitations. Examples include (but

are not limited to): current smoker, social alcohol drinker, pregnancy, obesity

(30 < BMI < 40), well- controlled diabetes (DM)/hypertension

(HTN), mild lung

disease

ASA III A patient with severe systemic disease Substantive functional limitations; 1 or more moderate to severe diseases. Examples

include (but are not limited to): poorly controlled DM or HTN, chronic obstructive

pulmonary disease (COPD), morbid obesity (BMI ≥40), active hepatitis, alcohol

dependence or abuse, implanted pacemaker, moderate reduction of ejection

fraction, end-stage renal disease (ESRD)

undergoing regularly scheduled dialysis,

premature infant postconceptual age < 60 weeks, history ( > 3 months) of

myocardial infarction (MI), cerebrovascular accident (CVA), transient ischemic

attack (TIA), or coronary artery disease (CAD)/stents.

ASA IV A patient with severe systemic disease that is

a constant threat to life

Examples include (but

are not limited to): recent ( < 3 months) MI, CVA, TIA, or

CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction

of ejection fraction, sepsis, disseminated intravascular coagulation, acute

respiratory distress or ESRD not undergoing regularly scheduled dialysis.

ASA V A moribund patient who is not expected to

survive

without the operation

Examples include (but are not limited to): ruptured abdominal/thoracic aneurysm,

massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of

signiﬁcant cardiac pathology or multiple organ/system dysfunction.

ASA VI A declared brain-dead patient whose organs

are being removed for donor purposes

∗

The addition of “E” denotes emergency surgery. (An emergency is deﬁned as existing when delay in treatment of the patient would lead to a signiﬁcant increase in the

threat to life or body part.)

Table 5

Types of anesthesia providers.

Anesthesia professional – includes anesthesiologist, certiﬁed registered nurse anesthetist (CRNA) or anesthesiologist assistant (AA).

Nonanesthesiologist sedation practitioners - licensed physicians who have not completed postgraduate training in anesthesiology but are speciﬁcally trained to

administer moderate sedation.

Supervised sedation professionals – includes licensed registered nurses, advanced practice nurses, and physician assistants.

2.5. What qualiﬁcations must providers have to safely administer

moderate sedation, deep sedation, and general anesthesia? What

policies and standards are available?

Employing qualiﬁed personnel and ensuring continued com-

petency to administer the planned anesthetic regimen is imper-

ative for providing safe care. There are several types of health

care providers who may be involved in providing anesthesia care

( Table 5 ). The ASA recommends that health care organizations re-

quire nonanesthesiologist sedation practitioners to meet speciﬁc

standards before granting privileges to administer moderate seda-

tion through education, training, and licensure (GRADE 1C) [43] .

These requirements include: (1) satisfactory completion of formal

education and training on administration of moderation sedation

and rescue from over-sedation referring to a state beyond the in-

tended effect, (2) current active medical licensure, (3) evaluation

of the practitioner’s practice pattern, and (4) active participation

in a program for performance improvement. The ASA does not fur-

ther specify any particular evaluation process or program for per-

formance improvement.

Supervised sedation professionals can administer and monitor

moderate sedation when under the supervision of an anesthesia

professional or nonanesthesiologist sedation practitioner. These su-

pervised sedation professionals must meet similar licensing and

competency-training requirements. Methods to assess competency

can be individualized for each organization, ensuring satisfactory

completion of a program that teaches the safe administration of

medications used to establish a level of moderate sedation and the

rescue of patients who exhibit a level of sedation that is deeper

than intended.

Certiﬁed registered nurse anesthetists are independently li-

censed anesthesia professionals who plan and deliver anesthesia,

including moderate sedation, deep sedation, and general anesthe-

sia [ 44 , 45 ]. The medical and nursing practice of CRNAs is further

governed by institutional, state, and federal restrictions with re-

gard to the required level of supervision needed, if any [45] . Given

the continuum of depth of sedation, nonanesthesiologist physi-

cians who administer deep sedation must be qualiﬁed and trained

speciﬁcally in providing this level of sedation. In addition, they

should be similarly qualiﬁed to recognize the need for rescue and

be adept at rescuing a patient from unintended general anesthe-

sia. They can neither delegate the administration or monitoring

of deep sedation to individuals who are not similarly qualiﬁed,

nor supervise such individuals in performing the administration or

monitoring of deep sedation. Furthermore, they must be dedicated

solely to administering and monitoring deep sedation; they cannot

participate in or perform the diagnostic or therapeutic procedure

for which the sedation is being administered (GRADE 1C) [ 46 , 47 ].

Among individuals whose deep sedation progresses to unin-

tended general anesthesia, such care should be provided, medically

directed, or supervised by an anesthesiologist, the operating practi-

tioner, or another licensed physician with speciﬁc training in seda-

tion, anesthesia, and rescue techniques related to general anesthe-

sia (GRADE 1C) [46] . Otherwise, routine general anesthesia should

only be administered by anesthesia professionals (i.e., anesthesiol-

ogists, nurse anesthetists, and certiﬁed anesthesiologist assistants)

(GRADE 1C).

Most institutional policies follow ASA personnel standards [ 7 , 8 ].

Abortion care practices must adopt pertinent policies that are con-

sistent with the care setting, whether they are hospital-based or

free-standing sites. These policies frequently align with those set

by NAF or PPFA [ 7 , 8 ]. In addition, state laws may regulate whether

or not authorization from an accrediting body such as The Joint

Commission must be obtained to secure permission for health care

organizations to provide such sedation and analgesia procedures.

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C. Cansino et al. Contraception 104 (2021) 583–592

2.6. What monitoring is required for moderate sedation, deep

sedation, or general anesthesia?

The ASA recommends monitoring the patient’s level of con-

sciousness for both moderate and deep sedation. While there is

no clear evidence on whether monitoring improves patient out-

comes or decreases risk, Task Force consultants who authored ASA

guidelines “strongly agree that monitoring level of consciousness

reduces risks for both moderate and deep sedation” (GRADE 1C)

[6] .

The ASA requires that all patients undergoing sedation or anal-

gesia be monitored by pulse oximetry with appropriate alarms in

order to detect “oxygen desaturation and hypoxemia in patients

who are administered sedatives/analgesics” (GRADE 1C) [6] .Inad-

dition, ventilatory function should be continually monitored by ob-

servation or auscultation. Pulse oximetry detects hypoxia, but not

hypercarbia; hypercarbia is an earlier sign of inadequate ventila-

tion compared to hypoxia (GRADE 1C) [6] . The ASA also recom-

mends that monitoring of exhaled carbon dioxide should be con-

sidered for all patients receiving deep sedation and for patients

receiving moderate sedation whose ventilation cannot be directly

observed (GRADE 1C).

In addition, the Task Force recommends that vital signs

are monitored at 5-minute intervals “once a stable level of

sedation is established” during moderate and deep sedation

However, Wilson et al. [48] reported no anesthesia-related com-

plications when monitoring patients at 10-minute intervals, sug-

gesting that a longer interval between measurements may be suf-

ﬁcient among low-risk surgical patients. Electrocardiographic mon-

itoring should be used for all undergoing deep sedation and se-

lect patients undergoing moderate sedation, such as those with

signiﬁcant cardiovascular disease or a history of dysrhythmia [6] .

ASA recommends that the frequency of recording the patient’s

functional status (level of consciousness, ventilator and oxygena-

tion status, and hemodynamic parameters) depends on the type

and amount of medication administered, procedure length, and the

general condition of the patient. Minimum time points of assess-

ment include: (1) before the procedure, (2) after administration

of sedatives/analgesics, (3) regular intervals during the procedure,

(4) during initial recovery, (5) prior to discharge from the facility

(GRADE 1C).

2.7. What are the anesthesia-related side effects and risks associated

with moderate/deep sedation and general anesthesia? What

equipment is necessary to manage these risks?

Side effects associated with anesthesia regimens range from

mild to life-threatening. Nausea and vomiting are common side ef-

fects from several anesthesia medications; pruritus is commonly

associated with opioid use; and paradoxical agitation can occur

with benzodiazepine use, even with recommended doses.

More serious adverse events are also possible with speciﬁc

anesthesia agents. When opioids and benzodiazepines are used

in combination, their sedative effects may be additive [6] . Older

halogenated agents, such as halothane or isoﬂurane, are associated

with increased blood loss due to uterine relaxation and a higher

risk of blood transfusion when used for general anesthesia during

cesarean delivery [ 49 −52 ]. However, these inhaled agents are now

rarely used. Micks et al. [17] studied the effects of sevoﬂurane, a

newer halogenated agent, among women undergoing surgical abor-

tion with general anesthesia and did not ﬁnd an increased risk of

interventions to address bleeding; however, the study was under-

powered to detect clinically important differences and no clear rec-

ommendation can be made regarding the safety proﬁle of newer

halogenated agents. RCOG recommends use of a short-acting opi-

oid in addition to propofol for general anesthesia rather than in-

halational agents [18] . It does not distinguish sevoﬂurane from

other inhalational agents since all of these agents cause uterine re-

laxation which is the likely cause of increased blood loss.

In addition to increased bleeding and the inadvertent adminis-

tration of a greater depth of anesthesia than intended, other signif-

icant anesthesia-related complications associated with the admin-

istration of moderate/deep sedation and general anesthesia include

cardiovascular decompensation, cerebral hypoxia and death

. The

Centers for Disease Control and Prevention reported anesthesia-

related abortion mortality in the United States for 1998 to 2010,

though no information on clinical setting was provided [53] . With

approximately 16.1 million abortion procedures, 108 deaths oc-

curred (mortality rate of 0.7 per 10 0,0 0 0 procedures), with 22

deaths (20% of the total) attributed to anesthesia complications.

Among 28 deaths after surgical abortion at 13 weeks’ gestation

or less, anesthesia complications were the most common cause

( n = 13). Rates of death with different types of anesthesia were not

reported, so it is not possible to estimate whether death was more

likely with sedation or general anesthesia than with local anesthe-

sia only. In the systematic review of ﬁrst-trimester surgical abor-

tion by White et al., the authors noted 0.02% anesthesia-related

complications among procedures that occurred in oﬃce-based set-

tings and < 0.5% of procedures that occurred in surgical centers and

hospitals; no deaths were reported [54] .

The ASA Task Force and consultants agree that ready availabil-

ity of appropriately sized emergency equipment reduces the risks

of both moderate and deep sedation ( Table 6 ) [6] . The ASA does

not specify any distinction in medications or equipment necessary

for moderate sedation, and deep sedation, or general anesthesia. It

does advise that for moderate sedation, a deﬁbrillator should be

immediately available for patients with mild (e.g., hypertension) or

severe cardiovascular disease (e.g., ischemia, congestive failure). A

deﬁbrillator should be available for all patients receiving deep se-

dation (Grade 1C).

The ASA states that the literature supports the use of sup-

plemental oxygen during moderate sedation and suggests that it

should be used during deep sedation to reduce the frequency of

hypoxia (GRADE 1C) [6] . If hypoxemia is anticipated or develops

during sedation or analgesia, supplemental oxygen should be ad-

ministered. The ASA concludes that “supplemental oxygen should

be considered for moderate sedation and should be administered

during deep sedation unless speciﬁcally contraindicated for a par-

ticular patient or procedure.”

NAF

requires functioning equipment and current medications to

be available on-site for medical emergencies, including an oxygen

delivery system, oral airways, epinephrine, antihistamines, appro-

priate antagonists for benzodiazepines and opioids (if used), bron-

chodilators, and bag-valve masks capable of delivering supplemen-

tal oxygen [7] . An automatic external deﬁbrillator should be avail-

able at sites where deep sedation and general anesthesia are used.

NAF guidelines require the use of supplemental oxygen with deep

sedation and general anesthesia.

2.8. What postsedation care is needed for moderate sedation, deep

sedation, or general anesthesia?

Anesthesia-related complications and deaths may result from

inadequate postanesthesia monitoring, emphasizing the impor-

tance of vigilant postanesthesia care [ 55 , 56 ]. The ASA recommends

that “all patients should be observed in an appropriately staffed

and equipped area ( Table 6 ) until they are near their baseline

level of consciousness and are no longer at increased risk for car-

diorespiratory depression” (GRADE 1C) [6] . Clinical question #5

and Table 6 respectively review suggested and required staﬃng

and equipment. Postsedation goals and monitoring are similar for

patients receiving moderate sedation, deep sedation, and general

588

C. Cansino et al. Contraception 104 (2021) 583–592

Table 6

Recommended emergency equipment for sedation and analgesia [6] .

Intravenous equipment Gloves

Tourniquets

Alcohol wipes

Sterile gauze pads

Intravenous catheters

Intravenous tubing

Intravenous ﬂuid

Assorted needles for drug aspiration, intramuscular injection

Appropriately sized syringes

Tape

Basic airway management equipment Source of compressed oxygen (tank with regulator or pipeline supply with ﬂowmeter)

Source of suction

Suction catheters

Yankauer-type suction

Face masks

Self-inﬂating breathing bag-valve set

Oral and nasal airways

Lubricant

Advanced airway management equipment

(for practitioners with intubation skills)

Laryngeal mask airways

Laryngoscope handles

Laryngoscope blades

Endotracheal tubes (cuffed 6.0, 7.0, 8.0 mm ID)

Stylet (appropriately sized for endotracheal tubes)

Pharmacologic antagonists Naloxone

Flumazenil

Emergency medications Epinephrine

Ephedrine

Vasopressin

Atropine

Nitroglycerin

(tablets or spray)

Amiodarone

Lidocaine

Glucose, 50%

Diphenhydramine

Hydrocortisone, methylprednisolone or dexamethasone

Diazepam or midazolam

Appropriate medications and equipment, including a deﬁbrillator, should be available whenever drug regimens to induce cardiorespira-

tory depression are administered. The list is a guide that can be tailored to individual practice needs.

anesthesia (GRADE 1C). Until subjects return to their baseline level

of consciousness, oxygenation should be monitored periodically

during this period when they continue to be at risk for hypoxemia.

Ventilation and circulation should be monitored at regular inter-

vals until patients are suitable for discharge.” There are no further

details available regarding recommended expertise among recovery

room staff, staﬃng ratios, or equipment, and the Task Force con-

cluded that there was insuﬃcient literature to examine the impact

of postprocedure monitoring on patient outcomes.

2.9. Does deep sedation or general anesthesia during abortion

procedures require routine endotracheal intubation?

Given concerns about a theoretically increased risk of aspiration

in pregnant patients, there have been a number of studies investi-

gating whether endotracheal intubation is necessary for safety dur-

ing surgical abortion. These descriptive studies note that low-risk

patients who undergo ﬁrst and second-trimester surgical abortion

may safely receive moderate or deep sedation without routine en-

dotracheal intubation (GRADE 1C) [ 11 , 12 , 36 ]. We could ﬁnd no spe-

ciﬁc ASA recommendation of routine intubation of patients in the

ﬁrst or second trimester for deep sedation or general anesthesia.

Mancuso et al. [13] performed a retrospective chart review of

deep sedation, most commonly using propofol and fentanyl, among

women undergoing surgical abortion between 15- and 24-weeks’

gestation in an operating room setting. Among 332 subjects, 9

(2.7%) were routinely intubated and 5 (1.5%) were converted intra-

operatively. The majority of subjects either maintained their natu-

ral airway ( n = 313, 94.3%) or were supported by laryngeal mask

( n = 5, 1.5%). There were no reported cases of pulmonary aspira-

tion.

A retrospective study conducted by Dean et al. [12] examined

the safety of deep sedation without intubation in a free-standing

abortion clinic by reporting on the experience of 62,125 patients,

including 11,0 39 having an abortion in the second trimester up to

24 0/7 weeks’ gestation. Potential subjects were excluded based

on the following criteria: BMI > 40 kg/m

, uncontrolled hyper-

thyroidism, poorly controlled diabetes, hypertension suggestive of

imminent stroke, acute active hepatitis, poorly controlled seizure

disorders, known respiratory compromise or poorly controlled

asthma, or other acute or chronic medical conditions “judged to

pose signiﬁcant or life-threatening risk.” Subjects were also ex-

cluded if they had eaten solid food less than 8 hours before

surgery or clear liquids less than 2 hours before surgery. There

were no cases of pulmonary aspiration identiﬁed; only 1 case was

converted to endotracheal intubation. Sixteen subjects were trans-

ferred to the hospital, but none were transferred for anesthesia-

related problems. Based on the upper 95% conﬁdence interval for

their sample, the authors calculate the theoretical risk for aspira-

tion at up to 1 in 21,0 0 0 abortions overall, and up to 1 in 3,700

second-trimester procedures.

While Dean et al. excluded obese women, Gokhale et al. [36] re-

ported their experience in providing IV moderate and deep se-

dation without endotracheal intubation in the outpatient setting

among 5,579 obese and nonobese women undergoing ﬁrst- and

second-trimester abortion up to 22 6/7 weeks’ gestation. Subjects

elected their anesthetic regimen which included IV fentanyl and

midazolam or IV propofol with or without fentanyl or midazo-

lam; methohexital or meperidine were administered in rare cir-

589

C. Cansino et al. Contraception 104 (2021) 583–592

cumstances when other drugs were temporarily unavailable or in

short supply. All women undergoing IV sedation without propo-

fol were restricted from solid food for 8 hours prior to the proce-

dure and from all oral intake for 4 hours prior to the procedure;

those who received propofol were advised against all oral intake

starting at midnight before the procedure. Intra- and postopera-

tive monitoring were performed based on ASA guidelines. There

were no patients who experienced any pulmonary complications

or anesthesia-related adverse events. Based on the upper 95% CI

for the sample size, the authors calculated the maximal risk of an

anesthesia-related complication is 1 in 1860 procedures.

2.10. Is fasting necessary before moderate or deep sedation for

abortion in ambulatory care settings?

Fasting is traditionally recommended for a speciﬁed interval be-

fore elective surgical procedures to reduce the risk of aspiration of

gastric contents. The ASA recommends fasting for at least 2 hours

after intake of clear liquids before elective procedures requiring

general anesthesia, regional anesthesia, or procedural sedation or

analgesia, as well as fasting for at least 6 hours after a light meal,

and fasting for 8 hours or longer after a meal that includes fried

foods, fatty foods or meat [26] . No distinction is made between

moderate sedation, deep sedation, or general anesthesia. The ESA

recommends fasting for at least 2 hours from clear liquids and 6

hours from solid food [57] . Despite ASA and ESA recommendations

regarding fasting guidelines for the general surgical population, ob-

servational studies on women undergoing surgical abortion suggest

no risk of aspiration among nonfasting patients [ 48 , 58 ].

A Cochrane review found 38 randomized comparisons in 22

published trials, primarily in healthy nonpregnant adults not con-

sidered at increased risk of aspiration [59] . These studies compared

the standard fasting protocol of nil per os (NPO) from midnight

until surgery vs drinking water, clear liquid, or isotonic drinks un-

til 90–180 minutes before anesthesia. The multiple studies investi-

gated gastric volume and acidity as surrogate markers for aspira-

tion, since more reliable measures are not available and aspiration

is a rare occurrence. There was no difference in outcomes between

the fasting group and those allowed to drink any of the liquids, ex-

cept gastric volume was less among the group permitted to drink

water. Given the mass effect of the gravid uterus and the effect

of progesterone on the smooth muscle of the gastrointestinal tract,

there is theoretical concern about the increased risk of aspiration

in pregnant individuals given changes in gastric volume. To explore

whether pregnancy is associated with increased gastric volume,

Aksel et al. [60] used ultrasound to measure the cross-sectional

area of the gastric antrum in nonpregnant women compared to

those in the second trimester and third trimester of pregnancy; the

fasting status of subjects were not stated. They concluded that the

observed differences in residual gastric volume were unlikely to be

great enough to cause aspiration.

Two cohort studies have speciﬁcally addressed whether allow-

ing oral intake before sedation for surgical abortion conferred in-

creased risk for aspiration. Wilson et al. [48] report a retrospec-

tive review of 1,433 patients who had a surgical abortion at up

to 18 weeks’ gestation with intravenous fentanyl with or with-

out midazolam. Although the investigators excluded women with

active cardiac or respiratory disease, they did not exclude those

who were obese or were considered to have a diﬃcult airway.

Oral intake was not restricted before or after the procedure, and

women were intentionally encouraged to eat to prevent nausea

and vomiting with the preoperative oral antibiotic. There were no

cases of aspiration. Four adverse events were recorded, none re-

lated to sedation. Wiebe et al. [58] completed a retrospective chart

review of 47,748 women who had a surgical abortion up to 18

weeks’ gestation (mean 8.8 weeks) at 1 of 2 free-standing abor-

tion clinics between 2003 and 2010. The clinics routinely asked

patients to eat a light meal, such as toast, before coming to the

clinic. The patients all received intravenous fentanyl and midazo-

lam with cervical anesthesia. The investigators reported no imme-

diate anesthesia-related complications.

Based on these 3 studies by each of the research teams of Ak-

sel, Wilson and Wiebe, NAF recommends that “[f]or patients re-

ceiving moderation sedation who are not at increased risk of as-

piration, time from last meal should not limit access to abortion

care”; no speciﬁc recommendations are provided [7] . Based on the

Wiebe study, PPFA recommends fasting from solid food (including

pulp juices and milk products) for at least at 6 hours and clear liq-

uids for at least at 2 hours prior to sedation [8] . RCOG guidance

on anesthesia and sedation for surgical abortion speciﬁcally opted

against making recommendations related to fasting requirements

and simply acknowledge existence of the 2011 guidance from ESA

[18] . Although research on aspiration risk in pregnancy and during

abortion procedures continues to evolve, there is currently insuf-

ﬁcient direct evidence to universally recommend or forgo fasting

guidelines prior to abortion procedures.

3. Clinical recommendations

Please see Appendix 1 for a key to interpreting GRADE.

The following recommendations are based primarily on

moderate- or low-quality scientiﬁc evidence:

• A combination of intravenous fentanyl and midazolam is ef-

fective in reducing pain associated with ﬁrst-trimester surgical

abortion (GRADE 1B).

• Patients receiving sedation and analgesia should be monitored

by pulse oximetry both during and after surgery to detect oxy-

gen desaturation and hypoxemia (GRADE 1C).

• The ventilatory function of patients receiving sedation and

analgesia should be continually monitored by observation or

auscultation (GRADE 1C).

• The ASA classiﬁcation system can be used as a guide to assess

a patient’s procedure-related risk (GRADE 2C).

• Supplemental oxygen should be used to decrease the frequency

of hypoxia. Its use should be considered when administering

moderate sedation and recommended when administering deep

sedation unless speciﬁcally contraindicated for a particular pa-

tient (GRADE 1C).

• Low-risk patients undergoing surgical abortion in the ﬁrst and

second trimester may safely receive moderate or deep sedation

without routine endotracheal intubation (GRADE 1C).

The following recommendations are based primarily on consen-

sus and expert opinion.

• General anesthesia for dilation and evacuation is commonly ad-

ministered with a propofol infusion and an opioid (GRADE 1C).

• Preoperative assessment should include a review of the preop-

erative medical history; review of systems; physical examina-

tion with measurement of vital signs, airway assessment, and

cardiovascular exam; patient’s analgesic and sedation goals cor-

responding to the anticipated procedure-related pain (GRADE

1C).

• Several factors may inﬂuence the decision of whether a patient

is an appropriate candidate for out-of-hospital anesthesia, in-

cluding provider preference (whether the surgeon or anesthesia

provider), distance from nearest hospital that can accommodate

postabortion complications, and most importantly, the patient’s

surgical risk based on her comorbidities and the facility’s ability

to manage potential complications secondary to these comor-

bidities (GRADE 1C).

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C. Cansino et al. Contraception 104 (2021) 583–592

• Among individuals whose deep sedation progresses to unin-

tended general anesthesia, such care should be provided, med-

ically directed, or supervised by an anesthesiologist, the oper-

ating practitioner, or another licensed physician with speciﬁc

training in sedation, anesthesia, and rescue techniques related

to general anesthesia (GRADE 1C). Otherwise, routine general

anesthesia should only be administered by anesthesia profes-

sionals (i.e., anesthesiologists, nurse anesthetists, and certiﬁed

anesthesiologist assistants) (GRADE 1C).

• Postsedation care requires patient monitoring until the patient

resumes near baseline level of consciousness (GRADE 1C).

4. Recommendations for future research

• Comparative eﬃcacy of medication regimens in ﬁrst- and

second-trimester surgical abortion, especially in light of drug

shortages.

• Comparative safety of medication regimens with regard to in-

ducing deeper sedation than intended and adverse events such

as pulmonary aspiration, unanticipated intubation, and hospital

transfer.

• Bleeding parameters associated with administration of newer

halogenated agents used for general anesthesia.

• Eﬃcacy and safety of analgesic options for obese individuals

and patients with other signiﬁcant medical comorbidities.

5. Sources

A series of clinical questions was developed by the authors and

reviewed by the Executive Board of the Society of Family Plan-

ning and Clinical Affairs Subcommittee. A search of the medical

literature was performed using the PubMed program of the Na-

tional Library of Medicine and the Cochrane Library of Clinical Tri-

als from the beginning of the databases through October 16, 2019.

Search terms include but were not limited to analgesia, anesthesia,

and sedation, in combination with abortion, gynecology, obstetrics,

pregnancy, and termination. Publications and relevant statements

of the American Society of Anesthesiologists, the American College

of Obstetricians and Gynecologists, the European Society of Anaes-

thesiology, the National Abortion Federation, Planned Parenthood

Federation of America, and the Royal College of Obstetricians and

Gynaecologists, and regulatory guidance from The Joint Commis-

sion were reviewed. A comprehensive systematic review was not

performed.

6. Intended audience

Providers of abortion services in ambulatory settings. This

set of recommendations should guide clinicians in their medical

decision-making, although it is not intended to dictate clinical care.

Author Contributions

These recommendations were prepared by Catherine Cansino,

MD, MPH; Phillip Stubbleﬁeld, MD; Colleen Denny, MD; and Sue

Carlisle, PhD, MD, and were reviewed and approved by the Board

of the Society of Family Planning.

Declaration of Competing Interest

The authors and SFP board members have no conﬂicts of in-

terest to report. The Society of Family Planning receives no direct

support from pharmaceutical companies or other industries for the

production of clinical recommendations.

Funding

This research did not receive any speciﬁc grant from funding

agencies in the public, commercial, or not-for-proﬁt sectors.

Supplementary materials

Supplementary material associated with this article can be

found, in the online version, at doi: 10.1016/j.contraception.2021.08.

007 .

Appendix A. Key for Recommendations Summary

Recommendations key.

Symbol Meaning

1 Strong recommendation

2 Weaker recommendation

A High quality evidence

B Moderate quality evidence

C Low quality evidence, clinical experience, or expert consensus

a Society of Family Planning clinical recommendations use a modiﬁed

GRADE system. The GRADE system is described in several publications, with a

comprehensive set of articles in the Journal of Clinical Epidemiology (J Clin Epi-

demiology, (2011) 64:383-394, 64:395-400, 64:401-406, 64:407-415, 64:1277-

1282, 64:1283-1293, 64:1294-1302, 64:1303-1312, 64:1311-1316, (2013) 66:140-

150,

66:151-157, 66:158-172. 66:173-183, 66:719-725, 66:726-735).

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