Inspired by Ng et al 2021.
EA – electroacupuncturekey to acronyms
ToP – termination of pregnancy
IVF – invitro fertilisation
RCT – randomised controlled trial
SE – suction evacuation
IM – intramuscular
AA – auricular acupuncture
This paper was published online in Acupuncture in Medicine last month and comes from a well-known research group led by Ernest Ng. Ernest has helped me out with information for this blog in the past, in particular with data concerning the use of acupuncture and sham acupuncture around IVF: see Acupuncture and IVF.
This is the first RCT of EA for pain relief during surgical termination of first trimester pregnancy by SE under local analgesia. 60 nulliparous women were randomised to one of three parallel groups: control, acupuncture and combined groups. All three groups received 400μg misoprostol vaginally for cervical priming 3–6 hours before SE, and 5mg of oral diazepam 30 minutes before SE. The control and the combined groups also received an IM injection of pethidine (1mg/kg body weight) 15 minutes prior to SE. The acupuncture group received an IM injection of saline.
EA was performed in both the acupuncture and the combined groups from 10 minutes prior to the SE until the end of the procedure. The points used were LI4 and PC6 and the EA was applied at 2Hz using the Ito ES160 device. The longest procedure was 11 minutes so there was no risk of exceeding the time window for optimal surgical analgesia (roughly 20 to 40 minutes). I assume had the EA was applied on both sides and that LI4 was connected to PC6 on each side. We are told that the intensity was adjusted to the same level in all women, which is a little unusual, so I will ask for clarification.
The other thing that raised my eyebrows a little was that the trial was conducted 10 years ago, but I am sure there is a perfectly good explanation. I remember asking authors about delays in publication before and on one occasion the data was held by a statistician who had a psychotic breakdown and another time the reply was “Well Mike, you know it has been really hot here!”
The results show a significantly lower pain score during the SE procedure for the groups receiving EA and the trend appears to be in favour of EA alone rather than the combined group, although this is not significant. On the subject of significance testing, I cannot see any mention of statistical correction for multiple tests, but the number of tests were not particularly excessive.
The women, acupuncturist and surgeons were not blind to the application of EA but the women in the acupuncture groups clearly did not know whether they had pethidine or saline injected IM before the procedure. This suggests that the pharmacological effects of IM pethidine at a dose of 1mg/kg add nothing to the effect of EA alone; however, the study was not powered for this comparison so we must be careful not to overinterpret these results.
This is not the first trial of acupuncture in first trimester abortion, but it is the first to use EA. The previous study from the US and published in 2019 used AA as the intervention (n=153). AA with indwelling Pyonex needles (5 points in each ear) was compared with a non-penetrating sham control (just the adhesive plaster) and a usual care control in 3 parallel arms. Unfortunately, around ¾ of the participants in the AA (78%) and sham (73%) groups correctly guessed their treatment allocation.
In this study all groups received 800mg ibuprofen prior to the procedure and local anaesthesia with a paracervical block. The real AA group had significantly less pain and anxiety than either of the other two groups.
1 Ng DYT, Lo A, So EWS, et al. A randomized controlled study of acupuncture for pain relief during first trimester surgical termination of pregnancy performed under local analgesia. Acupunct Med Published Online First: 11 December 2021. doi:10.1177/09645284211057567
2 Ndubisi C, Danvers A, Gold MA, et al. Auricular acupuncture as an adjunct for pain management during first trimester abortion: a randomized, double-blinded, three arm trial. Contraception 2019;99:143–7. doi:10.1016/j.contraception.2018.11.016