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& Gynecology and Reproductive Biology 154 (2011) 9–15 Contents lists available at ScienceDirect European

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and Reproductive Biology

journal homepage: www.els evier.com/locate/ejogrb

Biology journal homepage: www.els evier.com/locate/ejogrb Review Pain relief in outpatient hysteroscopy: a survey of

Review

Pain relief in outpatient hysteroscopy: a survey of current UK clinical practice

Helena O’Flynn a , Lauren L. Murphy a , Gaity Ahmad b , Andrew J.S. Watson c , *

a University of Manchester Medical School, Manchester, UK b Department of Obstetrics and Gynaecology, Pennine Acute Trust, Greater Manchester, UK c Department of Obstetrics and Gynaecology, Tameside General Hospital, Fountain Street, Ashton-under-Lyne, Lancashire OL6 9RW, UK

ARTICLE INFO

Article history:

Received 28 February 2010 Received in revised form 7 August 2010 Accepted 25 August 2010

Keywords:

Outpatient hysteroscopy

Pain relief

Analgesia

Local anaesthesia

Contents

ABSTRACT

Background: Outpatient hysteroscopy is increasingly being used as a cost-effective alternative to in- patient hysteroscopy under general anaesthesia. Like other outpatient gynaecological procedures, however, it has the potential to cause pain severe enough for the procedure to be abandoned. There are no national guidelines on pain relief for outpatient hysteroscopy. Methods: A postal survey of UK gynaecologists was carried out to evaluate current clinical practice regarding methods of pain relief used during office hysteroscopy. A total of 250 questionnaires were sent out and 115 responses received. Results: Outpatient hysteroscopy was offered by 76.5% of respondents. Respondents reported a wide variation in the use of routine and rescue analgesia, and also in the nature of the analgesia used. One- quarter of those offering outpatient hysteroscopy used no form of analgesia. Conclusion: The results showed that whilst there is no consensus on the type of analgesia provided, rescue analgesia is commonly being used, particularly in the form of intracervical blocks. 2010 Published by Elsevier Ireland Ltd.

1. Introduction

 

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Method

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3. Results

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3.1. Routine

premedication

 

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3.2. Non-routine premedication

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4. Discussion

 

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4.1. Oral

analgesia

 

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4.2. Local anaesthesia

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4.3. Paracervical

block

 

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4.4. Intracervical anaesthesia

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4.5. Topical anaesthesia

 

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4.6. Intrauterine

anaesthesia

 

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5. Conclusions

 

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13

References

 

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15

1. Introduction

Hysteroscopy is increasingly being used in the office setting, as it is well tolerated by many women, even without the use of

* Corresponding author. Tel.: +44 161 331 6158. E-mail addresses: andy.watson@tgh.nhs.uk , watsoaj3@doctors.net.uk (Andrew J.S. Watson).

0301-2115/$ – see front matter 2010 Published by Elsevier Ireland Ltd. doi: 10.1016/j.ejogrb.2010.08.015

anaesthesia [1] . It can, however, still be a painful experience for some and there is no consensus on the use of analgesia. The rate of successful completion of hysteroscopy varies from 77% to 97.2% [2–5] . Various methods of pain relief have been described, including paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac and mefenamic acid, opioid analgesics, and local anaesthesia including intracervical blocks, paracervical blocks and topical cervical or intrauterine anaesthesia.

[ ( F i g 1 ) T D $ F I G

]

10

H. O’Flynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 9–15

& Gynecology and Reproductive Biology 154 (2011) 9–15 Fig. 1. Proportion of routine premedications used. Of

Fig. 1. Proportion of routine premedications used. Of the respondents using routine premedication, the majority (13 (41%)) offered a combination of oral analgesics (paracetamol and/or NSAID) and local anaesthesia.

Outpatient hysteroscopy (OPH) is a well tolerated procedure and many women find it acceptable. Its benefits over hysteroscopy under general anaesthetic include reduced costs, shorter hospital stay and faster recovery and return to work times [6] . A survey was carried out to explore current UK clinical practice with regard to the use of analgesia for OPH.

2. Method

A list of gynaecologists regularly performing laparoscopic surgery was derived using the British Society for Gynaecological Endoscopy senior membership list and an internet search. Each UK healthcare trust’s website was searched using the following keywords: laparoscopic surgeries; endoscopies; minimal access surgery and reproductive medicine. An anonymous questionnaire ( Appendix A ) was sent to the identified parties; excluding trainees and specialist nurses. Data were collected on a number of items relating to the method of pain relief, if any, routinely chosen for hysteroscopy, and the time prior to the procedure at which it was administered. Demographic information relating to the year the gynaecologist answering the questionnaire became a consultant, and also the grade of persons in the department (consultants, trainees or nurse practitioners) performing hysteroscopy, was also collected. A self- addressed envelope was provided for the questionnaire to be returned. The data were collated using Microsoft Access.

[ ( F i g 2 ) T D $ F I G

]

3. Results

A total of 250 postal questionnaires were sent out, to which 115

recipients responded (46%). OPH was offered by 88 (76.5%) respondents. Of those offering OPH, 32 (36.4%) offered routine premedication with either oral analgesia (paracetamol or NSAID) or local anaesthesia; 55 (62.5%) did not offer pain relief routinely, and one (1.1%) was unsure of what was used. Opioid analgesia was not offered by any respondent.

3.1. Routine premedication

Oral analgesics (paracetamol and NSAIDs) and local anaes- thetics were used for routine premedication, and were offered by 32 respondents (27.8%) ( Fig. 1 ). Local anaesthesia accounted for 21 (65.6%) of routine premedication offered. Twenty-four (75%) respondents gave oral analgesia, and 11 (34.4%) used it as their only form of routine pain relief prior to the procedure. The use of local anaesthesia in conjunction with oral analgesics was described by 13 (40.6%) of those offering routine premedication ( Fig. 2 ). The wide variety in the timing of routine oral premedication is displayed in Fig. 3 . Oral premedication is offered by 24 respondents. One gynaecologist mentioned use of paracetamol and an NSAID at both 30 min to 1 h, and 1–2 h pre-procedure, accounting for the total of 25 uses in Fig. 3 . The most common form of routine oral premedication was the use of NSAIDs at 30 min to 1 h pre-procedure (7 uses (21.9%)), but a combination of paracetamol and NSAID (6 uses (18.8%)), or NSAID alone (5 uses (15.6%)) at 1–2 h pre-procedure were also utilised.

3.2. Non-routine premedication

The majority of units do not routinely offer premedication (55, 62.5%) but an extra six (6.8%) respondents reported the use of ‘rescue’ local anaesthesia in addition to analgesic premedication they already offer, taking the total to 61 (69.3%). This rescue analgesia was used when pain prevented a full examination. Local anaesthesia was far more likely than oral analgesics to be used as

rescue analgesia during hysteroscopy—37 (42.0%) ( Fig. 4 ). Only three respondents (3.4%), however, offered oral analgesia on a rescue basis, in each case in conjunction with an intracervical block.

A total of 22 (25.0%) gynaecologists offering OPH used no form

of premedication, whilst one (1.1%) gave post-procedure paracet- amol or NSAID, and one other gave post-procedure analgesia on an ‘‘as required’’ basis.

6 5 4 3 2 1 0
6
5
4
3
2
1
0

No additional drugson an ‘‘as required’’ basis. 6 5 4 3 2 1 0 With Paracetamol With NSAID

With Paracetamolbasis. 6 5 4 3 2 1 0 No additional drugs With NSAID With Paracetamol &

With NSAID6 5 4 3 2 1 0 No additional drugs With Paracetamol With Paracetamol & NSAID

With Paracetamol & NSAID3 2 1 0 No additional drugs With Paracetamol With NSAID Fig. 2. Use of routine

Fig. 2. Use of routine local anaesthesia alone and in combination with pharmacological analgesia.

[ ( F i g 3 ) T D $ F I G

]

[ ( F i g 4 ) T D $ F I G

]

H. O’Flynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 9–15

11

14 12 10 8 6 4 2 0 30 minutes pre procedure 30 minutes to
14
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10
8
6
4
2
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procedure
30 minutes to 1 hour
pre procedure
1 hour to 2 hours pre
procedure
Over 2 hours pre
procedure

ligament, thus explaining how paracervical block can relieve pain arising from cervical dilatation and uterine distension [10] . It has also been suggested that certain patient attributes act as risk factors for the experience of significant pain [4] :

Paracetamol & NSAIDrisk factors for the experience of significant pain [4] : Extremes of age; NSAID Anxiety; Previous

Extremes of age; Extremes of age;

NSAID

Anxiety; Previous painful experience of hysteroscopy; Cervical stenosis. Anxiety; Previous painful experience of hysteroscopy; Cervical stenosis.

Paracetamol

Our survey investigated the use of pain relief in OPH. A total of 250 questionnaires were sent, with 115 responses, of which 88 respondents perform the procedure. A source of bias exists in that those who offer pain relief would be more likely to respond positively to the questionnaire: hence this survey represents the clinical practice of those more concerned in the issue of the patient’s pain experience during hysteroscopy. It is acknowledged that the small sample size (250) of our review may also act as a source of bias. Two Cochrane reviews have been carried out analysing pain relief

in hysterosalpingography [11], and the use of paracervical block in

cervical dilatation and uterine distension [12]. Both of these

procedures carry similar risks for pain as OPH, including cervical instrumentation, uterine distension, and potential for spillage of the distension medium into the peritoneal cavity. Neither review was able to conclude with a recommended method of pain relief. This postal survey supports the findings of these reviews. OPH can be a painful procedure for some women, but others state that pain experienced during the procedure is less than they would normally experience during menstruation [6] . A retrospec- tive study also found that it was feasible for OPH to be performed without anaesthesia as it was well tolerated, even in postmeno- pausal women [1] . OPH is also more acceptable in women when a hysteroscope of a smaller diameter is employed [13,14] . Numerous studies have reported outcomes for various methods of pain relief during OPH and other office gynaecological procedures and investigations, but there is no consensus on effective pain relief during OPH. Here, only the methods of pain relief utilised by study participants are reviewed in detail.

Timing of Premedication

Fig. 3. Timing of routine oral premedication with paracetamol and/or NSAID.

20 18 16 14 12 No additional drugs 10 With NSAID 8 With Paracetamol &
20
18
16
14
12
No additional drugs
10
With NSAID
8
With Paracetamol & NSAID
6
4
2
0

Fig. 4. Use of rescue local analgesia alone and in combination with oral analgesics (paracetamol and/or NSAID).

4. Discussion

Diagnostic hysteroscopy is increasingly being performed in the outpatient setting. It has replaced dilatation and curettage as a means of investigating abnormal uterine bleeding [7] . The results and findings obtained through OPH also compare well with those from in-patient hysteroscopy, for many women negating the risks involved with a general anaesthetic, and for the healthcare provider reducing the associated costs and theatre time [8] . Pain occurs at several points during OPH and endometrial biopsy procedures, due to the necessary instrumentation [9] :

Insertion of a speculum; Cervical manipulation; At the insertion of the hysteroscope; At uterine distension; During endometrial biopsy/sampling; At spillage of the distension medium into the peritoneal cavity occurs.

Innervation of the vagina, cervix and lower uterus arises from the Frankenha¨ user plexus, running with the parasympathetic nerve supply from S2 to S4. Innervation of the uterine fundus travels via sympathetic nerves from the ovarian plexus, part of the pelvic splanchnic nerves that originate in the lower thoracic spinal cord, and which go on to cross the infundibulopelvic ligament. These nerves all travel together as the uterovaginal nerve plexus, following the course of the uterine artery at the junction of the base of the broad ligament and the superior transverse cervical

4.1. Oral analgesia

Uterine pain during office gynaecological procedures may be due to excessive prostaglandin concentrations occurring around the uterus, with high levels having been found in endometrial curettings [15] . Prostaglandins are derived from arachidonic acid by the cyclo-oxygenase enzymes COX-1, COX-2 and to a lesser extent COX-3. They are involved in physiological responses, particularly the stimulation of inflammation [16] . The methods of oral analgesia chosen by respondents in our survey were paracetamol or unspecified NSAIDs. Both of these act to inhibit the production of prostaglandins. NSAIDs directly inhibit the COX enzymes, but each isoenzyme to a different degree, thereby preventing the synthesis of prostaglandins. NSAIDs are commonly used in the treatment of primary dysmenorrhoea and have been studied in the context of pain relief in OPH, with drugs such as ibuprofen, diclofenac, dexketoprofen and mefenamic acid being chosen [15,17,18] . When given as a single 50 mg oral dose, maximum peak plasma concentrations of 3.8 m mol/L of diclofenac are achieved between 20 and 60 min after administration, indicating that this would be the best time for routine premedication with this drug [19] . However, NSAIDs are not suitable for all, and may precipitate asthma due to diversion of arachidonic acid into the leukotriene synthesis pathway. They are also contraindicated in those with gastric ulceration, and severe heart failure [20] .

12

H. O’Flynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 9–15

Paracetamol (acetaminophen) has a different mechanism of action. During the metabolism of arachidonic acid by COX isoenzymes, hydroperoxides are created, which exert a positive feedback control on the activity of COX. It is believed that paracetamol mainly acts by blocking the feedback mechanism,

although it also has some inhibitory effect on COX-3 in the central nervous system. It is classified as a simple analgesic, and has no anti- inflammatory properties [21]. The peak analgesic effect of a standard 1 g dose of paracetamol is reached 2 h after administration [22]. Opioid analgesics are not used in office gynaecological procedures as they have common side effects of nausea, vomiting and drowsiness, especially when used for acute pain. They also have no anti-inflammatory effects [23] .

A total of six respondents (5.2%) co-administered paracetamol

and an unspecified NSAID for premedication. Co-administration of paracetamol and NSAIDs can be of great benefit in procedures such as OPH. Both drugs are deemed to be simple analgesics on the World

Health Organisation ‘analgesic ladder’ that was initially created for relief of pain in cancer [24]. Together, they can be used in the treatment of minor acute pain, with paracetamol providing a peripherally acting analgesic, and NSAID playing an anti-inflamma- tory and anti-prostaglandin role [21]. This is of great use in gynaecological procedures, where instrumentation of the female reproductive organs will result in pain and release of inflammatory mediators, as previously described. Merry et al. demonstrated that the analgesic effects of a combination of paracetamol and ibuprofen were superior to either drug alone, and also that the time to peak plasma concentration of paracetamol was reduced, but that of ibuprofen increased when in combination ( Table 1 ) [25]. For the purpose of OPH, co-administration of paracetamol and ibuprofen would be best between 30 min and 1 h 30 min prior to the procedure. In summary, the times to achieve peak analgesic effect for paracetamol, NSAID and a combination of the two are 2 h, 20– 60 min and 30 min to 1 h 30 min, respectively. Oral analgesia is only suitable for use as pre-medication, due to the time taken to reach peak analgesic effect. This could cause unacceptable delays in the clinic should a woman require rescue analgesia, leading to unnecessary expense and time losses. A total of 24 out of 88 (27.3%) gynaecologists offering OPH in our survey gave patients instruc- tions to take oral analgesia, though this does not truly reflect how many patients may choose to take premedication.

A benefit of using paracetamol and/or NSAID for OPH is that

they are cheap, readily available drugs, to which the woman is likely to have access already. NSAIDs are commonly used drugs for menstrual disorders, providing both analgesia and a reduction in menstrual blood loss [26] . Even if prescription-only NSAIDs are not accessible to the woman, ibuprofen can be bought over the counter. The advantages here are that women can be given instructions to self medicate at home before attending for OPH, saving both cost and time as the women do not need to have medication prescribed in hospital prior to the procedure.

4.2. Local anaesthesia

Effective pain relief from local anaesthesia requires a suitable drug at a suitable concentration, the most advantageous route of administration, and a sufficient time interval between its

administration and the commencement of the procedure. Several different methods of local anaesthesia for OPH have been investigated:

Paracervical block; Intracervical anaesthesia; Topical anaesthesia, e.g. sprays and gels; Intrauterine anaesthesia.

The injection of any local anaesthetic carries a risk of accidental intravasation, which can lead to cardiovascular compromise due to systemic vasodilation, and also central nervous system effects such as light-headedness and even sedation [27] . Local anaesthesia lends itself more to use in the non-routine setting, with a shorter time to peak anaesthetic effect. As the need for this is unlikely to be known before starting the procedure, this is likely to account for the reason why in our survey, of the 88 respondents offering OPH, 27 (30.7%) used intracervical blocks as rescue anaesthesia, and only 9 (10.2%) used them routinely.

4.3. Paracervical block

A recent systematic review analysing the use of local anaesthesia in outpatient hysteroscopy concluded that paracervi- cal local anaesthetic injection is superior to other methods of local anaesthesia [28] . That review, however, did not include studies analysing oral analgesia as a method of pain relief. Paracervical block was found to be beneficial in studies by Giorda et al. and Cicinelli et al. [14,29] , although those studies examined only its use in postmenopausal women. Both were randomised controlled trials and it is possible that as postmenopausal women tend to have a greater likelihood of cervical stenosis, they will feel more pain, hence exaggerating the difference between the anaesthetised and placebo arms of the studies. In premenopausal women, OPH seems to be a more acceptable procedure even without the use of pain relief, with local anaesthesia required significantly less often [30] . Paracervical block is not without its problems. In Giorda’s study, 22 of 121 women receiving a paracervical block (18.2%) found the injection itself painful, although the results of their study seem to indicate that such a block is effective, compared to hysteroscopy without local anaesthesia. However, they did not have a placebo control arm to this group [14] . Lau et al. question the effectiveness of paracervical anaesthesia as injection of paracervical local anaesthetic is painful in itself [9] . Their study demonstrated that paracervical anaesthesia failed to significantly block the pain arising from uterine distension, and therefore they concluded that its use in OPH cannot be justified. Chudnoff et al. also demonstrated that paracervical anaesthesia significantly reduced pain caused by cervical manipulation but failed to reduce pain arising from uterine/tubal manipulation during hysteroscopic sterilisation [31] . Revisiting the innervation of the uterus, however, it has been demonstrated that innervation to the cervix, lower uterus and fundus meets and travels together as the uterovaginal nerve plexus, following the course of the uterine artery at the junction of the base of the broad ligament and the superior transverse cervical ligament [10] . With a paracervical block, theoretically pain signals from both the cervix and uterus should

Table 1 Mean (SD) pharmacokinetic properties of paracetamol and ibuprofen alone and in combination. C max : maximum concentration; T max : time to achieve C max . Taken from Merry et al. [25] .

 

Paracetamol alone

Paracetamol in combination

Ibuprofen alone

Ibuprofen in combination

T max (h) C max (mg/L)

1.09 (1.12)

0.64 (0.31)

1.16 (0.90)

1.44 (0.93)

15.8 (6.5)

19.2 (6.4)

30.8 (8.3)

19.1 (7.8)

H. O’Flynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 9–15

13

be blocked. This was confirmed by the studies of Giorda and Cicinelli [14,29] . Giorda et al. also state that in postmenopausal women a smaller diameter hysteroscope is more effective than a paracervical block to minimise pain [14] , but that a larger diameter hysteroscope may have to be reverted to later in the procedure for a satisfactory examination.

4.4. Intracervical anaesthesia

Broadbent et al. found injection of intracervical anaesthesia to be just as painful as or evenworse than OPH itself, despite the fact that it is a well tolerated form of anaesthesia for other gynaecological procedures [32], and advocate its use only where cervical dilation is required. As the need for cervical dilatation is unlikely to be known before starting the procedure, this is likely to account for the reason why in our survey, of the 88 respondents offering OPH, 27 (30.7%) used intracervical blocks as rescue anaesthesia, and only 9 (10.2%) used them routinely. An issue thatwas raised in a study by Downes is the method by which intracervical anaesthesia is delivered [33]. Broadbent used a 22-gauge needle, whereas Downes used a dental syringe. In other surgical specialties, the use of a dental syringe has been shown to reduce the pain experienced by the patient at injection of local anaesthetics [34].

4.5. Topical anaesthesia

Topical anaesthetics can also be applied in spray, gel and cream form to the cervix. Sprays and creams have been found to be

effective in anaesthetising the cervix, but no studies have proven the effectiveness of lignocaine gel [35,36] .

4.6. Intrauterine anaesthesia

Intrauterine anaesthesia is performed by the instillation of a local anaesthetic into the uterine cavity through the cervical canal, and can be considered to be another form of topical anaesthesia. Whilst in theory the use of this type of anaesthesia should block pain signals from nerve endings in the endometrium, this was not shown in Lau’s study [37] . Anaesthesia of the uterine body is required to block pain signals from the uterine fundus during distension of the uterus.

5. Conclusions

This postal survey demonstrates wide variation in practice regarding the use of oral analgesics or local anaesthetics for pain relief during OPH. The majority of respondents offering OPH (55, 62.5%) did not offer routine analgesia for OPH, and 22 (25%) gave no form of analgesia. Intracervical blocks formed the largest single group of stand-alone rescue anaesthesia, followed by paracervical blocks. Among respondents using routine premedication, oral analgesics are predominately offered. In order to evaluate the efficacy of pain relief in OPH, more high powered, randomised placebo-controlled trials need to be carried out on a wide population, assessing the optimum mode of pain relief and the most appropriate dose.

14

H. O’Flynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 9–15

Appendix A. Questionnaire for pain relief in outpatient hysteroscopy

[ T D $ I N L I N E ]

1) When did you become a Consultant?

2) Out of the following, who performs hysteroscopy outside of theatre in your unit?

All

Consultants.

All Consultants. Selected Consultants. Trainees undertaking specific outpatient hysteroscopy training

Selected

Consultants.

All Consultants. Selected Consultants. Trainees undertaking specific outpatient hysteroscopy training

Trainees undertaking specific outpatient hysteroscopy training

Trainees undertaking specific outpatient hysteroscopy training
Trainees undertaking specific outpatient hysteroscopy training

Most trainees.

Nurse Practitioners

hysteroscopy training Most trainees. Nurse Practitioners 3) Do patients receive analgesia for outpatient hysteroscopy

3) Do patients receive analgesia for outpatient hysteroscopy routinely?

Yes No
Yes
No

If yes, please select from the following;

a) Pre procedural

Paracetamol

NSAID

Opioid

the following; a) Pre procedural Paracetamol NSAID Opioid If analgesia is given pre procedure, please indicate

If analgesia is given pre procedure, please indicate the time period in which medication is administered;

30 minutes

30 minutes to

30 minutes to

1 hour to

1 hour to

Over 2 hours

before

procedure

before procedure

1 hour before procedure

2 hours beforebefore procedure

procedure

procedure

b) Intraprocedural

Intracervical block

Paracervical block

Topical anaesthesia

b) Intraprocedural Intracervical block Paracervical block Topical anaesthesia c) Other, please specify; THANK YOU

c) Other, please specify;

THANK YOU

H. O’Flynn et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 9–15

15

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