I have no disclosures Sa ra Whe tsto ne , MD, MHS Unive rsity o f - - PDF document

Gynecology Office Procedures:

Maximizing Efficacy and Pain Control

Sa ra Whe tsto ne , MD, MHS Unive rsity o f Ca lifo rnia , Sa n F ra nc isc o

I have no disclosures

Objectives

Utilize 2 e vide nc e -b a se d stra te g ie s fo r pa in re duc tio n during o ffic e g yne c o lo g ic pro c e d ure s De sc rib e the ste ps fo r 2 c o mmo n g yne c o lo g ic pro c e d ure s (so tha t yo u c a n d o the m in yo ur pra c tic e suc c e ssfully a nd pa inle ssly)

A day in the office… A day in the office…

DAILY SCHEDULE Tuesday Date: 7/3/18 T ime Visit 8:00 AM Fo llo w-up - Pe lvic pa in 8:30 AM Ce rvic a l po lyp re mo va l 8:45 AM IUD re mo va l 9:00 AM E nd o me tria l b io psy 9:30 AM IUD inse rtio n 10:00 AM E to no g e stre l impla nt inse rtio n & re mo va l 10:30 AM Ma nua l ute rine a spira tio n

8AM – Follow-up - Pelvic pain

Innervation of the pelvis Innervation of the pelvis

 Sympathetic fibers (T10-L2) innervate the fundus

 E nte r ute ro sa c ra l lig a me nts via infe rio r hypo g a stric ple xus  E nte r via ne rve s fro m o va ria n ple xuse s a t the c o rnua

 Parasympathetic fibers (S2-S4) innervate the lower uterine segment, cervix, and upper vagina

 Prima rily fro m the F ra nke nha use r ple xus  T ra ve l to the ute rus a nd c e rvix via the c a rd ina l lig a me nts

 Sympathetic fibers (T10-L2) innervate the fundus

 E nte r ute ro sa c ra l lig a me nts via infe rio r hypo g a stric ple xus  E nte r via ne rve s fro m o va ria n ple xuse s a t the c o rnua

 Parasympathetic fibers (S2-S4) innervate the lower uterine segment, cervix, and upper vagina

 Prima rily fro m the F ra nke nha use r ple xus  T ra ve l to the ute rus a nd c e rvix via the c a rd ina l lig a me nts

Additional innervation Additional innervation

 Myo me tria l inne rva tio n fo llo ws b ra nc he s o f the ute rine a rte ry  Ne rve s e xte nd thro ug h myo me trium to e ndo me tria l-myo me tria l inte rfa c e  Ba sa l third o f the e ndo me trium is inne rva te d  Myo me tria l inne rva tio n fo llo ws b ra nc he s o f the ute rine a rte ry  Ne rve s e xte nd thro ug h myo me trium to e ndo me tria l-myo me tria l inte rfa c e  Ba sa l third o f the e ndo me trium is inne rva te d

Nociception ≠ Pain Nociception ≠ Pain

Measuring pain Measuring pain

• Satisfaction
• Recommend to a friend
• Choose again
• % with severe pain
• Pain scales
• Satisfaction
• Recommend to a friend
• Choose again
• % with severe pain
• Pain scales

Strategies for acute pain Strategies for acute pain

MULTIMODAL PAIN MANAGEMENT MULTIMODAL PAIN MANAGEMENT

Definition: Using more than 1 class of meds or analgesic technique Example: Local anesthesia + NSAID + benzodiazepine + nonpharmacologic strategies Definition: Using more than 1 class of meds or analgesic technique Example: Local anesthesia + NSAID + benzodiazepine + nonpharmacologic strategies

PREEMPTIVE ANALGESIA PREEMPTIVE ANALGESIA

Definition: Intervention more effective PRIOR to tissue injury Rationale: Increased pain response to subsequent stimulation (“wind-up”

• r “hyperanalgesia”)

Definition: Intervention more effective PRIOR to tissue injury Rationale: Increased pain response to subsequent stimulation (“wind-up”

• r “hyperanalgesia”)

Crews JC. JAMA 2002

Types of local anesthesia Types of local anesthesia

Cooper NA et al. BMJ, 2010

Comparison of local anesthetics Comparison of local anesthetics

Local anesthetic Potency Onset Duration Bupivic a ine Stro ng Mo de ra te (up to 20 min) L

• ng (3-6h)

Me pivic a ine Me dium F a st (4-7 min) Mo de ra te (3 h) L ido c a ine Me dium F a st (4-7 min) Mo de ra te (1-2h) (~3 h with e pi) Chlo ro pro c a ine We a ke r F a ste st Sho rt (30-60 min)

Prevent local anesthetic toxicity Prevent local anesthetic toxicity

Aspirate for blood prior to injection Monitor total dose Monitor patient

• symptoms. Stop

after partial dose to check symptoms. Use larger volume

• f more dilute soln

Inject multiple sites Prepare for toxic and allergic reactions

Lidocaine toxicity

Carin MA et al. Neoreviews, 2008

Pain and the pelvic exam Pain and the pelvic exam

11-60% o f wo me n re po rt pa in o r disc o mfo rt during pe lvic e xa m 10-80% o f wo me n re po rt fe a r, e mb a rra ssme nt, o r a nxie ty during pe lvic e xa m 3.2 is me a n pa in sc o re fo r disc o mfo rt with pe lvic e xa m 17% o f wo me n re po rte d a pa in sc o re o f 6-10/ 10 with pe lvic e xa m

Risk factors for higher pain scores:

• Ag e < 26
• Pre se nc e o f 1+ me nta l he a lth issue s
• Histo ry o f se xua l a b use
• Ne g a tive e mo tio na l c o nta c t with pro vide r

Blo o mfie ld HE e t a l. Ann o f Int Me d , 2014 Hild e n M e t a l. Ac ta Ob ste t Gyne c o l Sc a nd , 2003

Non- pharmacologic pain management Non- pharmacologic pain management

Pa tie nt c o ntro l: pa rtic ipa tio n in de c isio ns He a t Co unse ling te c hniq ue s Po sitive sug g e stio n, g uide d ima g e ry Music Ac upunc ture Hypno sis “Vo c a l lo c a l”

Akin MD et al. Obstet Gynecol, 2001 Cepeda MS et al. Cochrane Database Syst Review, 2006 Faymonville ME et al. Pain, 1997 Keogh SC et al. BMC Womens Health, 2014 Kotani N et al. Anesth, 2001

Power of language

(“verbocaine”)

Power of language

(“verbocaine”)

Nic ho la s MD e t a l. Pa in ma na g e me nt. I n Pa ul M e t a l. Manage me nt of U ninte nde d and Abnormal Pre gnanc y. Ho b o kne , NJ: Wile y-Bla c kwe ll; 2009

8:30AM – Cervical polyp removal

Cervical Polyp Removal Cervical Polyp Removal

 If yo u a re n’ t c urre ntly d o ing this, yo u sho uld ! Ca n re mo ve c e rvic a l po lyps a nd sma ll (<2c m) e nd o me tria l po lyps

 Equipment:

• 1. Ring fo rc e ps.
• 2. Silve r nitra te stic ks.
• 3. Optio na l: a llis c la mp

 T ypic a lly we ll to le ra te d witho ut a ne sthe sia .

 If yo u a re n’ t c urre ntly d o ing this, yo u sho uld ! Ca n re mo ve c e rvic a l po lyps a nd sma ll (<2c m) e nd o me tria l po lyps

 Equipment:

• 1. Ring fo rc e ps.
• 2. Silve r nitra te stic ks.
• 3. Optio na l: a llis c la mp

 T ypic a lly we ll to le ra te d witho ut a ne sthe sia .

Polyp Removal Polyp Removal

 Cle a n with b e ta dine  I f po lyp o n a sta lk, g ra sp a s hig h a s po ssib le with ring fo rc e ps a nd b e g in to twist in o ne dire c tio n. Whe n me e t re sista nc e in tha t dire c tio n, twist o the r wa y. Do not pull. Co ntinue twisting pro c e ss until po lyp ha s b e e n re mo ve d. Ca ute rize b a se with silve r nitra te (he lps kill re ma ining c e lls)  I f po lyp no t o n a sta lk: Unlike ly tha t ring fo rc e ps will g ra sp it. T ry a llis c la mp to “c ho mp it o ff”. Ca ute rize b a se with silve r nitra te  Se nd to pa tho lo g y.  Cle a n with b e ta dine  I f po lyp o n a sta lk, g ra sp a s hig h a s po ssib le with ring fo rc e ps a nd b e g in to twist in o ne dire c tio n. Whe n me e t re sista nc e in tha t dire c tio n, twist o the r wa y. Do not pull. Co ntinue twisting pro c e ss until po lyp ha s b e e n re mo ve d. Ca ute rize b a se with silve r nitra te (he lps kill re ma ining c e lls)  I f po lyp no t o n a sta lk: Unlike ly tha t ring fo rc e ps will g ra sp it. T ry a llis c la mp to “c ho mp it o ff”. Ca ute rize b a se with silve r nitra te  Se nd to pa tho lo g y.

 Ba c k

8:45AM – IUD Removal

IUD Removal IUD Removal

 No tra ining ne c e ssa ry!  Equipment: Ring fo rc e ps. Cyto lo g y b rush.  No tra ining ne c e ssa ry!  Equipment: Ring fo rc e ps. Cyto lo g y b rush.

IUD Removal IUD Removal

Ask pt to c o ug h a nd pull q uic kly o n string s a s she c o ug hs (this he lps with the visc e ra l fe e ling pt will ha ve yo u re mo ve it)

If strings visible

T ry to te a se the m

• ut b y twisting

c yto lo g y b rush within the e ndo c e rvix.

If strings not visible

Complications: ve ry

ra re . String c a n b re a k o ff o r if I UD e mb e dde d yo u wo n’ t b e a b le to re mo ve it. Oc c a sio na lly it hurts to re mo ve (usua lly no t).

9:00 AM Endometrial biopsy (EMB)

Pain with endometrial biopsy Pain with endometrial biopsy

Predictors of increased pain:

• Nullipa rity
• Po st-me no pa usa l sta tus
• Dysme no rrhe a

Predictors of increased pain:

• Nullipa rity
• Po st-me no pa usa l sta tus
• Dysme no rrhe a

Ha lf o f wo me n de sc rib e E MB a s mo de ra te ly o r se ve re ly pa inful

Dogan E et al. Obstet Gynecol, 2004 Mercier RJ et al. Obstet Gynecol, 2012

Endometrial biopsy steps Endometrial biopsy steps

Preparation for EMB 1 Bimanual exam 2 Speculum placement 3 Cleaning the cervix 4 Tenaculum placement 5 Performing EMB 6 Removal of instruments 7 Post- procedure 8

Premedication with misoprostol Premedication with misoprostol

 Stud ie s e va lua ting pre -me d ic a tio n with miso pro sto l

 Cra ne JM e t a l (2009): no diffe re nc e in pa in c o mpa re d to pla c e b o  T e lli E e t a l (2014): no diffe re nc e in pa in c o mpa re d to re c ta l NSAI D a nd pla c e b o  Pe rro ne e t a l (2002): mo re pa in in wo me n who re c e ive d miso pro sto l

 Mo re unple a sa nt side e ffe c ts re po rte d a mo ng wo me n who re c e ive d miso pro sto l  Stud ie s e va lua ting pre -me d ic a tio n with miso pro sto l

 Cra ne JM e t a l (2009): no diffe re nc e in pa in c o mpa re d to pla c e b o  T e lli E e t a l (2014): no diffe re nc e in pa in c o mpa re d to re c ta l NSAI D a nd pla c e b o  Pe rro ne e t a l (2002): mo re pa in in wo me n who re c e ive d miso pro sto l

 Mo re unple a sa nt side e ffe c ts re po rte d a mo ng wo me n who re c e ive d miso pro sto l

1

Crane JM et al. J Obstet Gynecol Can, 2009 Telli E et al. Gynecol Obstet Invest, 2014 Perrone JF et al. Obstet Gynecol, 2002

5 Tenaculum placement 5 Tenaculum placement

Ra ndo mize d N=188 Witho ut te na c ulum (N=61) Una b le to pe rfo rm (N=3) Me a n sc o re 4.4 + 1.6 I na de q ua te spe c ime n (N=3) With te na c ulum (N=57) Me a n sc o re 7.7 + 1.5 I na de q ua te spe c ime n (N=9)

K uc ukg o z Gule c U e t a l. Arc h Gyne c o l Ob ste t, 2014

The necessity of using tenaculum for endometrial sampling procedure with pipelle: a randomized control study

Without a tenaculum

6 Intrauterine anesthesia 6 Intrauterine anesthesia

 Systematic review of 23 studies  All use flexible catheter  2-3 min pre-procedure  Generally 5mL of 1-2% lidocaine (50-100mg)  Systematic review of 23 studies  All use flexible catheter  2-3 min pre-procedure  Generally 5mL of 1-2% lidocaine (50-100mg)

Mercier RJ et al. Obstet Gynecol, 2012

Author (year) Addt’l meds Pain scores

(intervention vs. placebo)

Significant difference?

Trolice (2000) 4.7 vs. 9.9 ye s Dogan (2004)

• / +NSAI

D 5.9/ 4.6n vs. 7.1 Ye s o nly with lido AND NSAI D Güney (2006) +miso 4.9 vs. 6.2 (pre me no ) 6.7 vs. 6.2 (po stme no ) Ye s b ut o nly fo r pre me no pa usa l wo me n Hui (2006) 2.3 vs. 4.2 ye s Api (2010)

• / +NSAI

D 3.8 vs. 6.5 Ye s, no t supe rio r to NSAI D a lo ne Rattanachaiyonont (2005) +pa ra c e rv 2.3 vs. 4.7 Ye s Kosus (2014) 1.0 vs. 3.0

6 Intrauterine anesthesia: 2% lidocaine 6 Intrauterine anesthesia: 2% lidocaine

Kosus M et al. Pain Res Manag, 2014 Mercier RJ et al. Obstet Gynecol, 2012

6 Intrauterine anesthesia 6 Intrauterine anesthesia

 Good evidence to support use for EMB

 Mo st c o nsiste nt e ffe c t se e n a t 100-200mg o f lid o c a ine  Stud ie s ha ve d e mo nstra te d intra ute rine a ne sthe sia e q uiva le nt to pa ra c e rvic a l b lo c k fo r E MB

 Good evidence to support use for EMB

 Mo st c o nsiste nt e ffe c t se e n a t 100-200mg o f lid o c a ine  Stud ie s ha ve d e mo nstra te d intra ute rine a ne sthe sia e q uiva le nt to pa ra c e rvic a l b lo c k fo r E MB

Ireland LD et al. Obstet Gynecol Survey, 2016 Mercier RJ et al. Obstet Gynecol, 2012

Do NOT ro utine ly g ive miso pro sto l prio r to E MB T ry to pe rfo rm E MB without tenaculum Co nside r intrauterine anesthesia o r pa ra c e rvc ia l b lo c k if pa tie nt a t risk fo r inc re a se d pa in

Summary:

Pa in ma na g e me nt fo r E MB

Summary:

Pa in ma na g e me nt fo r E MB

A Rational Approach to EMB A Rational Approach to EMB

Po st- Me no pa use

AL L wo me n WI T H ANY BL E E DI NG Re c e nt o nse t irre g b ld ing : Co nsid e r tre a ting first a nd if b ld ing no rma lize s, d e fe r E MB

Ag e >50

All wo me n with re c urre nt irregular b le e d ing

Ag e 45-50

Re c urre nt irre g ula r b le e d ing plus >1 risk fa c to r > 6 mo nths

• f irre g ula r

& he a vy b le e d ing

Ag e <45:

L

• ng histo ry
• f

untre a te d anovulatory b le e ding E xc e pt 4-6 mo a fte r sta rting HRT De fe r if pe rio ds a re lig ht a nd spa c ing o ut

F urthe r e va lua tio n ma nd a to ry if: Persistent AUB a fte r ne g a tive E MB a nd/ o r 3-6 mo nths o f me dic a l the ra py

NSAID EMB pipelle 1% lidocaine Tenaculum Fox swabs

Silver nitrate

Endometrial Biopsy: Supplie s

Endometrial Biopsy: STEPS Endometrial Biopsy: STEPS

1. BME to c he c k size , po sitio n o f ute rus 2. Cle a n c e rvix with b e ta dine 3. Attempt passing pipelle without using tenaculum. Pla c e pipe lle just inside o s, she b e a rs do wn while yo u push. If it “po ps” thro ug h the inte rna l o s, g e t yo ur sa mple a s no te d b e lo w. If it do e sn’ t pa ss, yo u’ ll ne e d te na c ulum.

• 4. Always give lidocaine at tenaculum site if you use a tenaculum.
• 5. Tenaculum: 1 c m wide b ite , slo wly c lo se .

6. Pull firmly b a c k o n te na c ulum a s yo u push pipe lle thro ug h o s. T e na c ulum sho uld mo ve a b o ut 2 c m. 1. BME to c he c k size , po sitio n o f ute rus 2. Cle a n c e rvix with b e ta dine 3. Attempt passing pipelle without using tenaculum. Pla c e pipe lle just inside o s, she b e a rs do wn while yo u push. If it “po ps” thro ug h the inte rna l o s, g e t yo ur sa mple a s no te d b e lo w. If it do e sn’ t pa ss, yo u’ ll ne e d te na c ulum.

• 4. Always give lidocaine at tenaculum site if you use a tenaculum.
• 5. Tenaculum: 1 c m wide b ite , slo wly c lo se .

6. Pull firmly b a c k o n te na c ulum a s yo u push pipe lle thro ug h o s. T e na c ulum sho uld mo ve a b o ut 2 c m.

Endometrial Biopsy Endometrial Biopsy

7. Administe r intra ute rine a ne sthe sia , if de sire d (a s de sc rib e d pre vio usly) 8. Onc e pipe lle pa sse s o r “po ps” thro ug h the inte rna l o s, push it gently up to fundus and then back it away from fundus by about 1 cm. Do no t push ha rd a g a inst the

• fundus. Do no t re pe a te dly to uc h the fundus. Touching fundus=painful.

9. Ob ta in suc tio n b y pulling the style t a ll the wa y b a c k

• 10. Mo ve the pipe lle up a nd do wn within the ute rus (b e lo w the fundus) while twisting .
• 11. Ca re fully plung e spe c ime n into spe c ime n c up witho ut to uc hing the pipe lle to the

fo rma lin o r side s o f c up.

• 12. Che c k spe c ime n a de q ua c y b y sha king fo rma lin a nd lo o king fo r tissue pie c e s.
• 13. I

f a de q ua te a nd ute rus g ritty: do ne . I f no t g ritty o r ina de q ua te : do a no the r pa ss. 7. Administe r intra ute rine a ne sthe sia , if de sire d (a s de sc rib e d pre vio usly) 8. Onc e pipe lle pa sse s o r “po ps” thro ug h the inte rna l o s, push it gently up to fundus and then back it away from fundus by about 1 cm. Do no t push ha rd a g a inst the

• fundus. Do no t re pe a te dly to uc h the fundus. Touching fundus=painful.

9. Ob ta in suc tio n b y pulling the style t a ll the wa y b a c k

• 10. Mo ve the pipe lle up a nd do wn within the ute rus (b e lo w the fundus) while twisting .
• 11. Ca re fully plung e spe c ime n into spe c ime n c up witho ut to uc hing the pipe lle to the

fo rma lin o r side s o f c up.

• 12. Che c k spe c ime n a de q ua c y b y sha king fo rma lin a nd lo o king fo r tissue pie c e s.
• 13. I

f a de q ua te a nd ute rus g ritty: do ne . I f no t g ritty o r ina de q ua te : do a no the r pa ss.

EMB Tips EMB Tips

Help her with breathing.

Count to 10 -- Give s he r c o ntro l a nd a time fra me . I f ne e d to do a no the r pa ss, a sk pe rmissio n

If she c a n’ t to le ra te , ST OP.

Offe r a no the r visit with a tiva n,

• r pro c e d ure und e r se d a tio n,
• r ultra so und if po st-

me no pa usa l

 If trouble passing pipelle, use different vectors of traction on the tenaculum (up, down, right, left).  I f still c a n’ t pa ss it a nd she c a n to le ra te , c o nside r pa ra c e rvic a l b lo c k Ca n a lso try o s finde r, sma ll dila to rs o r ultra so und g uida nc e .  If known to be anxious or if attempt and fail, give ativan for next attempt (if pt willing).  I f una b le to e nte r e ndo me trium c a vity, g ive miso pro sto l o r o the r pre me dic a tio n  If trouble passing pipelle, use different vectors of traction on the tenaculum (up, down, right, left).  I f still c a n’ t pa ss it a nd she c a n to le ra te , c o nside r pa ra c e rvic a l b lo c k Ca n a lso try o s finde r, sma ll dila to rs o r ultra so und g uida nc e .  If known to be anxious or if attempt and fail, give ativan for next attempt (if pt willing).  I f una b le to e nte r e ndo me trium c a vity, g ive miso pro sto l o r o the r pre me dic a tio n

EMB Tips EMB Tips

9:30 AM IUD insertion

Pain with IUD insertion Pain with IUD insertion

Predictors of increased pain:

• Nullipa rity
• Re mo te fro m la st d e live ry
• Ag e > 30 ye a rs
• Dysme no rrhe a

Predictors of increased pain:

• Nullipa rity
• Re mo te fro m la st d e live ry
• Ag e > 30 ye a rs
• Dysme no rrhe a

I UD inse rtio n a sso c ia te d with mild to mo de ra te pa in

Mercier RJ et al. Obstet Gynecol, 2012

IUD insertion steps IUD insertion steps

Preparation for IUD insertion 1 Bimanual exam 2 Speculum placement 3 Cleaning the cervix 4 Tenaculum placement 5 Sounding uterine cavity 6 Inserting the IUD 7 Removal

• f

instruments 8 Post- procedure 9

1 Premedication with NSAIDs 1 Premedication with NSAIDs

Ibuprofen

• Multiple studie s

sho we d no b e ne fit fo r inse rtio n pro c e d ure

Naproxen

• Infe rio r to tra ma d o l

b ut supe rio r to pla c e b o

Ketorolac (IM)

• In RCT

, no sig nific a nt d iffe re nc e in pa in with IUD inse rtio n

• ve ra ll, lo we r pa in in

nullipa ro us wo me n

• L
• we r pa in sc o re s

a fte r inse rtio n

L

• pe z L

M e t a l. Co c hra ne Syste mic Re vie ws, 2015 Ng o e t a l. Ob ste t Gyne c o l, 2015

Premedication with misoprostol Premedication with misoprostol

 Pa in sc o re hig he r in miso pro sto l g ro up during a nd a fte r IUD inse rtio n  Cra mping mo re like ly with miso pro sto l (OR 2.64, 95% CI 1.46-4.76)

 I n o ne tria l o f nullipa ro us wo me n, wo me n g ive n miso pro sto l we re le ss like ly to re po rt mo de ra te o r se ve re pa in  I n a no the r tria l, miso pro sto l g ro up le ss like ly to re c o mme nd tre a tme nt

 Pa in sc o re hig he r in miso pro sto l g ro up during a nd a fte r IUD inse rtio n  Cra mping mo re like ly with miso pro sto l (OR 2.64, 95% CI 1.46-4.76)

 I n o ne tria l o f nullipa ro us wo me n, wo me n g ive n miso pro sto l we re le ss like ly to re po rt mo de ra te o r se ve re pa in  I n a no the r tria l, miso pro sto l g ro up le ss like ly to re c o mme nd tre a tme nt

1

L

• pe z L

M e t a l. Co c hra ne Syste mic Re vie ws, 2015

Tenaculum Placement Tenaculum Placement

Co mpa re d to pla c e b o :

 2% lid o c a ine g e l (to pic a l): no diffe re nc e in pa in  1% lid o c a ine inje c tio n: lo we r pa in  Othe r fo rmula tio ns: lo we r pa in

 E ML A c re a m (2.5% lido c a ine & 2.5% prilo c a ine )  4% lido c a ine g e l  10% lido c a ine spra y  2% lido c a ine g e l pla c e d va g ina lly Co mpa re d to pla c e b o :

 2% lid o c a ine g e l (to pic a l): no diffe re nc e in pa in  1% lid o c a ine inje c tio n: lo we r pa in  Othe r fo rmula tio ns: lo we r pa in

 E ML A c re a m (2.5% lido c a ine & 2.5% prilo c a ine )  4% lido c a ine g e l  10% lido c a ine spra y  2% lido c a ine g e l pla c e d va g ina lly

L

• pe z L

M e t a l. Co c hra ne Syste mic Re vie ws, 2015

5 7 Insertion of IUD with local anesthesia 7 Insertion of IUD with local anesthesia

Topical lidocaine gel

• No diffe re nc e in pa in with

I UD inse rtio n (N=3 studie s)

1

Intracervical lidocaine gel or block

• No diffe re nc e in pa in with

I UD inse rtio n

2

Paracervical block

• No diffe re nc e in pa in with

I UD inse rtio n (N=2 studie s)

3

L

• pe z L

M e t a l. Co c hra ne Syste mic Re vie ws, 2015

Paracervical block Paracervical block

• A. Vid a e ff 2016
• B. Ma nn WJ, Sto va ll T
• G. 1996

Summary:

Pain management for IUD insertion

Summary:

Pain management for IUD insertion

”No pro phyla c tic pha rma c o lo g ic inte rve ntio n ha s b e e n a d e q ua te ly e va lua te d to suppo rt its routine use fo r re duc tio n o f pa in during o r a fte r IUD inse rtio n.” ”No pro phyla c tic pha rma c o lo g ic inte rve ntio n ha s b e e n a d e q ua te ly e va lua te d to suppo rt its routine use fo r re duc tio n o f pa in during o r a fte r IUD inse rtio n.”

• F
• r pa tie nts at greater risk of

pain, c a n c o nside r:

• Pre me d ic a tio n with PO na pro xe n
• r IM ke to ro la c
• Pa ra c e rvic a l b lo c k with 1%

lid o c a ine

• Inc lud ing a d ministra tio n a t

te na c ulum site

• F
• r pa tie nts at greater risk of

pain, c a n c o nside r:

• Pre me d ic a tio n with PO na pro xe n
• r IM ke to ro la c
• Pa ra c e rvic a l b lo c k with 1%

lid o c a ine

• Inc lud ing a d ministra tio n a t

te na c ulum site

Gemzell-Danielsson K et al. Hum Reprod Update, 2013 Ireland LD et al. Obstet Gynecol Survey, 2016

Resource

• n LARC

Resource

• n LARC

http:/ / inno va ting - e duc a tio n.o rg / c o urse / la rc - inse rtio n-se rie s/ LARC Insertion and Removal Series I nno va ting E duc a tio n in Re pro duc tive He a lth

IUD Insertion: Cu-IUC vs LNG-IUS IUD Insertion: Cu-IUC vs LNG-IUS

 Bo th re q uire te na c ulum  So unding re c o mme nde d b e fo re inse rtio n

 Prefer EMB pipelle

 L e vo no rg e stre l I US c a n b e pla c e d witho ut ste rile g lo ve s  Co ppe r I UC ha s to b e lo a de d ste rile ly  Bo th re q uire te na c ulum  So unding re c o mme nde d b e fo re inse rtio n

 Prefer EMB pipelle

 L e vo no rg e stre l I US c a n b e pla c e d witho ut ste rile g lo ve s  Co ppe r I UC ha s to b e lo a de d ste rile ly

IUC Insertion Supplies IUC Insertion Supplies

 IUD  Spe c ulum  Be ta dine swa b s  1% lido c a ine fo r 12:00 te na c ulum site  E MB pipe lle (to so und)  T e na c ulum  Sc isso rs to c ut string s  Ste rile g lo ve s to lo a d Cu-IUC  IUD  Spe c ulum  Be ta dine swa b s  1% lido c a ine fo r 12:00 te na c ulum site  E MB pipe lle (to so und)  T e na c ulum  Sc isso rs to c ut string s  Ste rile g lo ve s to lo a d Cu-IUC

• 1. Prepare
• 1. Prepare

 Ge t a ll supplie s se t up (d o n’ t fo rg e t sc isso rs, do n’ t o pe n the IUD ye t)  Pre pa re the pa tie nt:  BME to c he c k ute rine po sitio n a nd size  Be ta d ine to c e rvix  1% lid o c a ine a t 12:00 a nte rio r c e rvix  Tenaculum: 1 c m wid e b ite , slo wly c lo se . YES, you must use a tenaculum! T e ne c ulum stra ig hte ns o ut the e nd o me tria l c a na l. Witho ut it, inc re a se d c ha nc e o f pe rfo ra tio n o r o f pla c ing IUD b e lo w the fundus.  Ge t a ll supplie s se t up (d o n’ t fo rg e t sc isso rs, do n’ t o pe n the IUD ye t)  Pre pa re the pa tie nt:  BME to c he c k ute rine po sitio n a nd size  Be ta d ine to c e rvix  1% lid o c a ine a t 12:00 a nte rio r c e rvix  Tenaculum: 1 c m wid e b ite , slo wly c lo se . YES, you must use a tenaculum! T e ne c ulum stra ig hte ns o ut the e nd o me tria l c a na l. Witho ut it, inc re a se d c ha nc e o f pe rfo ra tio n o r o f pla c ing IUD b e lo w the fundus.

• 2. Sound the uterus
• 2. Sound the uterus

Pre fe r E MB pipe lle Why so und?

• 1. Me a sure de pth o f the ute rus

Che c k its po sitio n (re tro , mid, a nte fle xe d)

• 2. Mo st impo rta nt: to e nsure

tha t the I UD will pa ss thro ug h the c e rvix

Pre fe r E MB pipe lle Why so und?

• 1. Me a sure de pth o f the ute rus

Che c k its po sitio n (re tro , mid, a nte fle xe d)

• 2. Mo st impo rta nt: to e nsure

tha t the I UD will pa ss thro ug h the c e rvix

Initial steps the same for all IUDs Initial steps the same for all IUDs

Copper IUD insertion

• 3. Load the

Cu-IUC

• 3. Load the

Cu-IUC

1. F ully pe e l b a c k pa c ka g e so IUD is sitting o n to p. 2. Put o n ste rile g lo ve s. 3. Pla c e the white plung e r ro d in the c le a r inse rtio n tub e - use c are no t to plunge the I U D o ut the to p o f the tube ! 4. Push e nds o f the a rms o f the T do wnwa rd into the inse rtio n tub e . Ho ld the white plung e r in pla c e while yo u do this. 1. F ully pe e l b a c k pa c ka g e so IUD is sitting o n to p. 2. Put o n ste rile g lo ve s. 3. Pla c e the white plung e r ro d in the c le a r inse rtio n tub e - use c are no t to plunge the I U D o ut the to p o f the tube ! 4. Push e nds o f the a rms o f the T do wnwa rd into the inse rtio n tub e . Ho ld the white plung e r in pla c e while yo u do this.

• 4. Advance

IUD into Uterus

• 4. Advance

IUD into Uterus

 Ge ntly a dva nc e the lo a de d IUD into the ute rine c a vity.  ST OP whe n the b lue de pth-g a ug e c o me s in c o nta c t with the c e rvix o r whe n yo u re a c h fundus (lig ht re sista nc e is fe lt)  Ge ntly a dva nc e the lo a de d IUD into the ute rine c a vity.  ST OP whe n the b lue de pth-g a ug e c o me s in c o nta c t with the c e rvix o r whe n yo u re a c h fundus (lig ht re sista nc e is fe lt)

• 5. Release Arms
• f Cu-IUC
• 5. Release Arms
• f Cu-IUC

Ho ld the te na c ulum a nd white plunger rod stationary, while partially withdrawing the insertion tube. T his re le a se s the a rm Ho ld the te na c ulum a nd white plunger rod stationary, while partially withdrawing the insertion tube. T his re le a se s the a rm

Arms a re d o wn whe n insid e inse rte r. Withd ra wing tub e while ho ld ing inse rte r still a llo ws a rms to po p up a nd o ut. Unlike Mire na , this is d o ne a t fund us b / c a rms swing la te ra l a nd up.

• 6. Gently push insertion tube to

position IUD at fundus

• 6. Gently push insertion tube to

position IUD at fundus

 Ge ntly push the insertion tube up until yo u fe e l a slig ht re sista nc e .  Ho ld the white plung e r ro d sta tio na ry  T his ste p e nsure s pla c e me nt hig h in the ute rus  Ge ntly push the insertion tube up until yo u fe e l a slig ht re sista nc e .  Ho ld the white plung e r ro d sta tio na ry  T his ste p e nsure s pla c e me nt hig h in the ute rus

• 7. Withdraw Inserter
• 7. Withdraw Inserter

 Ge ntly a nd slo wly withdra w the inse rte r tub e a nd white inse rtio n ro d fro m the c e rvic a l c a na l until string s c a n b e se e n pro truding fro m the c e rvic a l o pe ning .  Ca re fully trim string s to 3 c m using lo ng sc isso rs  Ge ntly a nd slo wly withdra w the inse rte r tub e a nd white inse rtio n ro d fro m the c e rvic a l c a na l until string s c a n b e se e n pro truding fro m the c e rvic a l o pe ning .  Ca re fully trim string s to 3 c m using lo ng sc isso rs

Levonorgestrel IUS insertion

• 1. Pull on the nylon strings until the arms of the

IUD are inside the insertion tube

• 1. Pull on the nylon strings until the arms of the

IUD are inside the insertion tube

Position blue flange at the sounded length

• 2. Position the flange to the length as

measured by the sound

• 2. Position the flange to the length as

measured by the sound

• 3. Insert the IUD and tube until the flange

is 1-2 cm from cervical os

• 3. Insert the IUD and tube until the flange

is 1-2 cm from cervical os

Alternatively: Push IUD up to fundus then withdraw 1.5 cm

• 4. Release IUD arms by pulling back on the blue tab to

the white marker Count to 10 to allow arms to fully extend

• 4. Release IUD arms by pulling back on the blue tab to

the white marker Count to 10 to allow arms to fully extend

Arms a re up while insid e inse rte r. Pulling b a c k b lue ta b re le a se s the a rms so the y a re initia lly stra ig ht up a nd the n o pe n la te ra lly. Ne e d spa c e fo r this to o c c ur whic h is why yo u ne e d to b e 1-2 c m b e lo w the fund us.

• 5. Push the IUD to the fundus (flange at the os.
• 5. Push the IUD to the fundus (flange at the os.

T he d e vic e ha s “me mo ry” a nd if it ha s b e e n insid e the inse rte r to o lo ng , the a rms te nd to sta y uprig ht inste a d o f b e nd ing la te ra lly. Co unting to 10 g ive s time fo r the m to b e nd la te ra lly a nd sta y tha t wa y (pre ve nts ina d ve rte nt re mo va l o f d e vic e a s yo u withd ra w inse rte r)

• 6. Release the IUD by pulling the blue tab all

the way back

• 6. Release the IUD by pulling the blue tab all

the way back

• 7. Withdraw inserter and cut strings to 3cm with

long scissors

• 7. Withdraw inserter and cut strings to 3cm with

long scissors

Re turn

10:00AM – ETG Implant Insertion & Removal

Betadine 1% lidocaine Implant Steri-strips Gauze

Implant insertion Supplie s Steps to Implant Insertion Steps to Implant Insertion

• 1. Po sitio n pa tie nt, with he r no n-d o mina nt a rm fle xe d a t the e lb o w
• 2. Id e ntify the inse rtio n site (8-10 c m a b o ve the me d ia l e pic o nd yle o f the

hume rus)

• 3. Cle a n the a re a with b e ta d ine
• 4. Ane sthe tize the inse rtio n a re a with 1% lid o c a ine
• 5. Stre tc h the skin a ro und the inse rtio n site with thumb a nd ind e x fing e r
• 1. Po sitio n pa tie nt, with he r no n-d o mina nt a rm fle xe d a t the e lb o w
• 2. Id e ntify the inse rtio n site (8-10 c m a b o ve the me d ia l e pic o nd yle o f the

hume rus)

• 3. Cle a n the a re a with b e ta d ine
• 4. Ane sthe tize the inse rtio n a re a with 1% lid o c a ine
• 5. Stre tc h the skin a ro und the inse rtio n site with thumb a nd ind e x fing e r

Steps to Implant Insertion (cont) Steps to Implant Insertion (cont)

• 6. Punc ture the skin with the tip o f the ne e dle slig htly a ng le d le ss tha n 30
• 7. L
• we r the a pplic a to r to a ho rizo nta l po sitio n. While lifting the skin with the

tip o f the a pplic a to r. Slide the ne e dle to its full le ng th.

• 8. Mo ve the slide r fully b a c k until it sto ps. T

he impla nt is no w in its fina l sub de rma l po sitio n

• 9. Pa lpa te impla nt to ve rify the pre se nc e imme dia te ly a fte r inse rtio n

10.Pla c e b a nda g e o ve r the inse rtio n site . Ha ve the wo ma n pa lpa te the impla nt. 11.Apply a pre ssure b a nda g e with ste rile g a uze to minimize b ruising .

• 6. Punc ture the skin with the tip o f the ne e dle slig htly a ng le d le ss tha n 30
• 7. L
• we r the a pplic a to r to a ho rizo nta l po sitio n. While lifting the skin with the

tip o f the a pplic a to r. Slide the ne e dle to its full le ng th.

• 8. Mo ve the slide r fully b a c k until it sto ps. T

he impla nt is no w in its fina l sub de rma l po sitio n

• 9. Pa lpa te impla nt to ve rify the pre se nc e imme dia te ly a fte r inse rtio n

10.Pla c e b a nda g e o ve r the inse rtio n site . Ha ve the wo ma n pa lpa te the impla nt. 11.Apply a pre ssure b a nda g e with ste rile g a uze to minimize b ruising .

Implant Removal Supplies Implant Removal Supplies

Be ta dine swa b s L

• c a l a ne sthe tic

Sc a lpe l Ste rile g lo ve s Mo sq uito c la mps Ste ri-strips Ba nda g e Ga uze fo r a rm Be ta dine swa b s L

• c a l a ne sthe tic

Sc a lpe l Ste rile g lo ve s Mo sq uito c la mps Ste ri-strips Ba nda g e Ga uze fo r a rm

Implant Localization Implant Localization

 I f una b le to pa lpa te the impla nt prio r to re mo val, do not a tte mpt re mo va l  L

• c a lize with ultra so und o r MRI

 Co nside r re fe rra l to lo c a l e xpe rt fo r re mo va l  Atte mpt re mo va l only a fte r lo c a liza tio n and depth have been confirmed by ultrasound/MRI  Ne xpla no n is ra dio pa q ue a nd c a n b e lo c a te d b y x-ra y o r c o mpute d to mo g ra phic sc a n, b ut Ne xpla no n c a n.  I f una b le to pa lpa te the impla nt prio r to re mo val, do not a tte mpt re mo va l  L

• c a lize with ultra so und o r MRI

 Co nside r re fe rra l to lo c a l e xpe rt fo r re mo va l  Atte mpt re mo va l only a fte r lo c a liza tio n and depth have been confirmed by ultrasound/MRI  Ne xpla no n is ra dio pa q ue a nd c a n b e lo c a te d b y x-ra y o r c o mpute d to mo g ra phic sc a n, b ut Ne xpla no n c a n. Rule o ut a lle rg ie s, a ne sthe tize the a rm (i.e . with 0.5 to 1 c c 1% lido c a ine ) a t the site whe re the inc isio n will b e ma de (ne a r the tip o f the impla nt tha t is c lo se st to the e lb o w) Strive to inje c t the lo c a l a ne sthe tic under the impla nt to ke e p the impla nt c lo se to the skin surfa c e Rule o ut a lle rg ie s, a ne sthe tize the a rm (i.e . with 0.5 to 1 c c 1% lido c a ine ) a t the site whe re the inc isio n will b e ma de (ne a r the tip o f the impla nt tha t is c lo se st to the e lb o w) Strive to inje c t the lo c a l a ne sthe tic under the impla nt to ke e p the impla nt c lo se to the skin surfa c e

Implant Removal Implant Removal

74 .

Implant Removal Implant Removal

I nje c t I nc ise Pre ss pro xima l tip I nc ise c a psule Gra sp impla nt

Uterine Aspiration Uterine Aspiration

Sa fe wa y o f re mo ving ute rine c o nte nts Ca n b e use d fo r e nd o me tria l b io psy, e a rly pre g na nc y lo ss, a b o rtio n, a nd ma na g e me nt o f se ptic a b o rtio n Hig hly e ffe c tive Ca n b e d o ne in o utpa tie nt / E D se tting T he re is g e ne ra lly no ne e d to d o sha rp c ure tta g e a fte r Sa fe wa y o f re mo ving ute rine c o nte nts Ca n b e use d fo r e nd o me tria l b io psy, e a rly pre g na nc y lo ss, a b o rtio n, a nd ma na g e me nt o f se ptic a b o rtio n Hig hly e ffe c tive Ca n b e d o ne in o utpa tie nt / E D se tting T he re is g e ne ra lly no ne e d to d o sha rp c ure tta g e a fte r

7 Insertion of IUD with local anesthesia 7 Insertion of IUD with local anesthesia

• Mody SK e t a t a l (2012): no

sig nific a nt d iffe re nc e in pa in sc o re with inse rtio n o r po st-pro c e d ure

• Mody SK e t a t a l (2012): no

sig nific a nt d iffe re nc e in pa in sc o re with inse rtio n o r po st-pro c e d ure

• Cirik DA e t a l (2013): sig nific a nt

d iffe re nc e in me d ia n pa in sc o re s a t IUD inse rtio n a nd po st-pro c e d ure

• Cirik DA e t a l (2013): sig nific a nt

d iffe re nc e in me d ia n pa in sc o re s a t IUD inse rtio n a nd po st-pro c e d ure

Paracervical block with 1% lidocaine (10mL) c o mpa re d to no intervention or placebo

l p p l

Cirik DA e t a l. I nt J Re pro d Co ntra c e pt Ob ste t Gyne c o l, 2013 Mo d y SK e t a l. Co ntra c e ptio n, 2012

Uterine Aspiration Supplies Uterine Aspiration Supplies

 Be ta dine  L

• c a l a ne sthe tic

 Dila to rs  Ma nua l ute rine a spira tio n e q uipme nt  Ultra so und (o ptio na l)  Be ta dine  L

• c a l a ne sthe tic

 Dila to rs  Ma nua l ute rine a spira tio n e q uipme nt  Ultra so und (o ptio na l)

First-Trimester Uterine Aspiration First-Trimester Uterine Aspiration Steps of uterine aspiration Steps of uterine aspiration

1) Pre pa re the pa tie nt – info rme d c o nse nt, e nha nc e c o mfo rt, do rsa l litho to my, b ima nua l e xa m 2) Pre pa re the a spira to r (se e ne xt slide ) 3) Pre pa re the c e rvix 4) Pe rfo rm the pa ra c e rvic a l b lo c k 5) Dila te the c e rvix 6) I nse rt the c a nnula (size o f c a nnula a ppro xima te ly numb e r o f we e ks g e sta tio n) 7) Suc tio n ute rine c o nte nts 8) Pe rfo rm a ny c o nc urre nt pro c e dure s (na me ly I UD inse rtio n 9) Che c k fo r pro duc ts o f c o nc e ptio n 1) Pre pa re the pa tie nt – info rme d c o nse nt, e nha nc e c o mfo rt, do rsa l litho to my, b ima nua l e xa m 2) Pre pa re the a spira to r (se e ne xt slide ) 3) Pre pa re the c e rvix 4) Pe rfo rm the pa ra c e rvic a l b lo c k 5) Dila te the c e rvix 6) I nse rt the c a nnula (size o f c a nnula a ppro xima te ly numb e r o f we e ks g e sta tio n) 7) Suc tio n ute rine c o nte nts 8) Pe rfo rm a ny c o nc urre nt pro c e dure s (na me ly I UD inse rtio n 9) Che c k fo r pro duc ts o f c o nc e ptio n

Preparing the aspirator Preparing the aspirator Summary Summary

 Strive to d o mo re pro c e d ure s in the o ffic e !  Cha lle ng e yo urse lf to ma ke

• ffic e pro c e dure s pa inle ss!

 Co nside r:

 No n-pha rma c o lo g ic a ppro a c he s  Additio na l pro c e dura l stra te g ie s tha t re duc e pa in  I ndic a tio ns a nd te c hniq ue fo r intra ute rine , pa ra - a nd intra -c e rvic a l b lo c ks

 Strive to d o mo re pro c e d ure s in the o ffic e !  Cha lle ng e yo urse lf to ma ke

• ffic e pro c e dure s pa inle ss!

 Co nside r:

 No n-pha rma c o lo g ic a ppro a c he s  Additio na l pro c e dura l stra te g ie s tha t re duc e pa in  I ndic a tio ns a nd te c hniq ue fo r intra ute rine , pa ra - a nd intra -c e rvic a l b lo c ks