Potential of ketofol to provide adequate sedation and analgesia in women undergoing manual vacuum aspiration in emergency department at the University Teaching Hospitals, Lusaka, Zambia

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Nsofwa, Nsunge
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The University of Zambia
Diagnosis of abortion in Zambia relies on clinical findings coupled with ultrasound examination. The treatment of choice in the first trimester is manual vacuum aspiration (MVA). Reducing the physical pain and anxiety during MVA is the ultimate goal of management for which, several drugs have been used solely or in combination to try to alleviate the pain associated with the procedure with variable results. However, the aspect of anxiety, which is a crucial aspect of care, is not adequately taken care of and perhaps raises ethical issues around performing MVA under local anaesthesia in emotionally vulnerable miscarrying women. A previous study done at University Teaching Hospital (UTH), Lusaka, Zambia showed that more than 90% of women undergoing MVA experience severe pain, despite receiving preoperative analgesics such as Paracetamol, Ibuprofen and Morphine. Ketofol sedation has not been tried in MVA in our setting in spite of successfully producing adequate sedation action for many short painful procedures. A pre-post interventional study with historical controls was conducted as a quality improvement study at UTH in the Department of Gynaecology to explore the potential of Ketofol sedation to provide adequate sedation and analgesia in women undergoing MVA. Pain scores were recorded using a Faces Pain Scale during the procedure (reported immediately after the procedure), at 10 minutes and at 60 minutes. During the procedure, sedation scores were determined using Ramsay Sedation Scale as well measuring heart rates and oxygen saturation. Time to discharge was also measured. A total of 94 women were studied; 54 patients who received UTH standard care in the previous study (oral Paracetamol 1g, Ibuprofen 400mg and Morphine 30mg) and 40 patients who received Ketofol sedation in addition to the UTH standard care which the patients in the historical group also received. Data from 2015 included 54 (57.4%) women who received UTH standard care (oral Paracetamol, Ibuprofen and Morphine). In the current study Ketofol sedation was administered in addition to standard care to 40 women during MVA. There was no statistical difference in all baseline characteristics of participants in both groups; p value >0.05. Pain scores were measured during the procedure (reported immediately afterwards), at 10 minutes and 60 minutes after the procedure. Women in the standard care group reported significantly higher pain scores, median 10 (IQR,8-10) compared to women in the Ketofol group median 2 (IQR 0–2); p<0.001 during the procedure, and also reported more pain at 10 minutes after the procedure however, there was no statistically significant difference in pain recorded at 60 minutes after the procedure. It was further noted that patients in the Ketofol group had significantly lower heart rates during the procedure. addition to this, it was noted, contrary to expectations, that the time to discharge was reduced in the Ketofol group compared to the standard care group, potentially due to reduced pain experienced. In conclusion, the results suggest that addition of Ketofol sedation to the current UTH standard of care reduced procedural pain experienced during MVA compared to standard care alone as well as producing effective sedation and rapid recovery. Keywords: Miscarriage, Manual Vacuum Aspiration, Sedation, Ketofol
Fetal death--Zambia , Miscarriages--Complications--Treatment--Zambia , Abortion--Zambia