Inclusion Criteria:  Aged 14 years or older Voluntarily requesting surgical pregnancy termination Intrauterine pregnancy up to 13 weeks 6 days by transabdominal or transvaginal ultrasound performed on day of procedure Eligible for suction curettage English or Spanish speaking Able and willing to give informed consent and agree to terms of the study  Exclusion Criteria:  Age less than 14 years Reaspiration procedure or failed medication abortion Early pregnancy loss Alcohol use disorder or acute alcohol intoxication Currently incarcerated Gestational age 14 weeks or more Requesting a specific pain regimen Premedication with misoprostol Contraindications or allergies to ketamine or fentanyl