High-quality care for termination of pregnancy (TOP) requires pain to be effectively managed; however, practices differ, and the available guidelines do not specify optimal strategies.
To guide providers in effective pain management for second-trimester medical and surgical TOP.
We searched PubMed, Cochrane and Embase databases, and the US National Library of Medicine clinical trials registry, from inception to the end of June 2019, and hand-searched reference lists.
Trials comparing pain management strategies with no treatment, placebo or active interventions during induced medical or surgical TOP, occurring between 13 and 24 weeks of gestation, and reporting direct or indirect measures of pain.
Both authors summarised and systematically assessed the evidence and risk of bias using standard tools.
We included seven medical and four surgical TOP studies, with 453 and 349 participants, respectively. The heterogeneity of interventions and outcomes prevented pooled analyses. Medical TOP: women receiving routine or continuous epidural analgesia experienced mild pain. The prophylactic use of nonsteroidal anti-inflammatory drugs (NSAIDs) decreased pain (mean difference -0.5, P < 0.001) and additional opioid requirements (3.5 versus 7 mg, P = 0.04) compared with placebo/other treatment. Paracervical block was ineffective. No studies assessed intramuscular (IM)/intravenous (IV) opioid or nonpharmacological treatment. Surgical TOP: general anaesthesia/deep IV sedation alleviated pain. Nitrous oxide was ineffective. No studies assessed moderate IV sedation, IV/IM opioid, paracervical block without sedation, NSAID or nonpharmacological treatment.
Based on limited data, regional analgesia and NSAIDs mitigated second-trimester medical TOP pain; general anaesthesia/deep IV sedation alleviated surgical TOP pain.
Although women experience intense pain during second-trimester termination of pregnancy, few data are available to inform their treatment.

Women are increasingly presenting for abortion at very early gestation. However, providers may be reluctant to conduct abortion at this stage as they may be concerned that they cannot exclude an ectopic pregnancy or that they may terminate a non-viable pregnancy, or may be concerned that both medical and surgical methods may be less effective at this stage of gestation. This provider concern may result in delays in the abortion as additional investigations may be required until an intrauterine pregnancy can be confirmed. Additional unnecessary visits may be distressing for women and waste health service resources. The objective of this systematic review was to determine whether it is safe and effective to initiate abortion before there is ultrasound evidence of an intrauterine pregnancy.
We searched Embase Classic, Embase; Ovid MEDLINE® Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE® Daily, Ovid MEDLINE®; and Cochrane Library on 25 October 2019. Eligible studies were randomized and non-randomized comparative studies, published in English from 1985, comparing initiation of abortion before there is definitive evidence of an intrauterine pregnancy with initiation afterwards. We assessed risk-of-bias using the Newcastle-Ottowa scale. All outcomes were analyzed as risk ratios (RR) and meta-analyzed using the Mantel-Haenszel method. The quality of the evidence was assessed using GRADE.
Two non-randomized studies (n = 3785) showed no differences in \"missed ectopic pregnancy\" (RR = 0.26, 95% CI 0.03-2.12), \"ongoing pregnancy\" (RR = 1.06, 95% CI 0.34-3.34), or \"complete abortion without surgical intervention\" (RR = 1, 95% CI 0.98-1.02) between initiation of medical abortion before or after ultrasound evidence of an intrauterine pregnancy. A third non-randomized study (n = 1530) showed no differences between initiation of surgical abortion before or after ultrasound evidence of an intrauterine pregnancy in \"missed ectopic pregnancy\" (no events), \"ongoing pregnancy\" (RR = 0.56, 95% CI 0.03-11.59) or \"complete abortion without repeat surgical intervention\" (RR = 1, 95% CI 0.99-1.01). The quality of evidence was very low.
Initiation of abortion before there is definitive ultrasound evidence of an intrauterine pregnancy in women without signs or symptoms of an ectopic pregnancy should be considered.

To compare the effectiveness, safety, and acceptability of in-clinic and remote/self-assessment, as well as different remote/self-assessments, for confirming the success of medical abortion at ≤10+0 weeks\' gestation.
Ovid Embase Classic and Embase; Ovid MEDLINE(R) and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations and Daily; and the Cochrane Library. We also consulted experts in this field for any ongoing or missed trials.
Randomized controlled trials published in English from 2000 onward, comparing in-clinic assessment with ultrasound to remote or self-assessment or comparing different remote or self-assessment strategies to confirm the success of medical abortion of pregnancies up to and including 10+0 weeks gestation, reporting any of the following outcomes: \"missed ongoing pregnancy,\" \"correct implementation of the follow-up strategy,\" patient satisfaction/preference, \"adherence to follow-up strategy,\" \"unscheduled visits/telephone calls to the abortion service,\" and surgical intervention.
One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for randomized controlled trials. All outcomes were analyzed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel-Haenszel statistical method and a fixed effect model. The overall quality of the evidence was assessed using GRADE.
Four randomized controlled trials (n = 5761) compared in-clinic to remote self-assessment and found no clinically significant differences apart from higher preference rates for remote follow-up, especially in the remote follow-up groups. The quality of this evidence was compromised by attrition, no blinding, inconsistency, indirectness, and low event rates. Two randomized controlled trials (n = 1125) compared different remote assessment strategies (using urine pregnancy tests) and also found no clinically significant differences apart from a clinically significantly lower rate of unscheduled visits to the abortion service in the remote follow-up group using a multilevel urine pregnancy test compared to remote follow-up using a high-sensitivity urine pregnancy test. The quality of this evidence was compromised by small event rates, lack of blinding, indirectness and high attrition rates.
The published data support offering women who have had a medical abortion up to and including 10+0 weeks\' gestation the choice of self-assessment, remote assessment, or clinic follow-up.

BACKGROUND: Previous systematic reviews have concluded that medical termination of pregnancy (TOP) performed by non-doctor providers may be as effective and safe as when provided by doctors. Medical treatment of incomplete miscarriage by non-doctor providers and the treated women\'s acceptance of non-doctor providers of TOP has not previously been reviewed.
OBJECTIVE: To review the effectiveness, safety, and acceptability of first-trimester medical TOP, including medical treatment for incomplete miscarriage, by trained non-doctor providers.
METHODS: A search strategy using appropriate medical subject headings was developed. Electronic databases (PubMed, Popline, Cochrane, CINAHL, Embase, and ClinicalTrials.gov) were searched from inception through April 2016. Randomised controlled trials and comparative observational studies were included.
METHODS: Meta-analyses were performed for included randomised controlled trials regarding the outcomes of effectiveness and acceptability to women. Certainty of evidence was established using the GRADE approach assessing study limitations, consistency of effect, imprecision, indirectness and publication bias.
RESULTS: Six papers were included. Medical TOP and medical treatment of incomplete miscarriage is probably equally effective when performed by non-doctor providers as when performed by doctors (RR 1.00; 95% CI 0.99-1.01). Women\'s acceptance, reported as overall satisfaction with the allocated provider, is probably equally high between groups (RR 1.00; 95% CI 1.00-1.01).
CONCLUSIONS: Medical TOP and medical treatment of incomplete miscarriage provided by trained non-doctor providers is probably equally as effective and acceptable to women as when provided by doctors.
CONCLUSIONS: Medical termination of pregnancy performed by doctors and non-doctors can be equally effective and acceptable.