A randomized pilot study on the effectiveness and side-effect profiles of two doses of digoxin as fetocide when administered intraamniotically or intrafetally prior to second-trimester surgical abortion

Intraamniotic digoxin administration versus intracardiac or funic potassium chloride administration to induce foetal demise before termination of pregnancy: a prospective study

Different foeticide techniques and pharmacological agents have been used to achieve foetal asystole. This study aimed to compare the success of intraamniotic digoxin, intracardiac potassium chloride (KCl), and funic KCl in achieving foetal asystole and discuss procedural difficulties for physicians and clinical outcomes. This prospective observational study included 124 patients who received foeticide at 22-31 weeks of gestation. All procedures were performed transabdominally, and 1 mg of intraamniotic digoxin, funic KCl, or intracardiac KCl was administered. Procedure times, procedural difficulty scores, patient pain scores, decrease in haematocrit levels, induction and hospitalisation times, and the presence of chorioamnionitis were recorded. The foeticide success rates were 93.0, 95.1, and 97.5% for intraamniotic digoxin, intracardiac KCl, and funic KCl, respectively. Intraamniotic digoxin was associated with shorter procedure times, lower procedural difficulty scores, and lower patient pain scores (p < 0.001). Decreases in haematocrit, induction times, and chorioamnionitis were similar in all three procedures. Success rates and clinical results were similar for all three procedures. Foeticide with intra-amniotic digoxin has a high success rate, the procedure is easier to perform, and patients experience less procedural pain.IMPACT STATEMENTWhat is already known on this subject? Different foeticide techniques and pharmacological agents have been used to achieve foetal asystole. Pharmacological agents used in the foeticide procedure can be injected as intracardiac, funic, intrafetal, or intraamniotic, and the most commonly used are potassium chloride (KCl), digoxin, and lidocaine.What do the results of this study add? The success rates and clinical outcomes in achieving foetal asystole are similar for intracardiac KCl, funic KCl, and intra-amniotic digoxin procedures. Foeticide with intra-amniotic digoxin is less difficult to perform, and patients experience less pain associated with the procedure. All three techniques appear to be safe and have similar short-term obstetric outcomes.What are the implications of these findings for clinical practice and/or further research? Physicians may prefer foeticide with intra-amniotic digoxin as the procedure is technically simpler and has similar success rates to intracardiac or funic KCl administration. A prospective randomised study could better compare the advantages and limitations of the foeticide techniques.

Intra-cardiac lidocaine administration to induce fetal demise before late second-trimester abortion: Retrospective review

OBJECTIVE

To determine the efficacy and safety of intra-cardiac lidocaine administration to induce fetal demise before second-trimester medication abortion in a teaching hospital in Addis Ababa, Ethiopia.

METHODS

We performed a retrospective chart review to collect selected sociodemographic and clinical information. All patients who received fetal intra-cardiac lidocaine between January 1, 2019 and April 30, 2019 were included in the study. Fetal demise was considered successful if achieved within 24 hours after fetal intra-cardiac lidocaine administration. We analyzed the data using SPSS version 20. We used frequency tables to describe the data and performed a multivariable analysis to determine associations between variables.

RESULTS

A total of 80 fetuses were given intra-cardiac lidocaine.The mean gestational age was 23⁺¹  weeks (range 21⁺⁰ -27⁺⁵  weeks). Twenty-four hours after lidocaine administration 76 (95%) pregnancies showed negative fetal cardiac activity. Fetuses at gestational ages of 21-23⁺⁶  weeks were five times more likely to have negative cardiac activity compared with those with gestational ages between 24 and 28 weeks (P=0.001). Two women developed nausea, vomiting, and a metallic taste, but no serious adverse events were reported.

CONCLUSIONS

Intra-cardiac lidocaine is effective at inducing fetal demise before late second-trimester medication abortion with no associated serious adverse events or complications.

Drugs used to induce fetal demise prior to abortion: a systematic review

Clinicians have used feticidal agents prior to second trimester abortion for many years. Despite the widespread use of various agents to induce fetal demise, a comprehensive or systematic review of the evidence is lacking on the safety, effectiveness, and most effective routes of administration.

Objectives

To evaluate the existing drugs and routes of administration used in inducing fetal demise prior to abortion, and to determine the safety, effectiveness, and acceptability of these feticidal agents.

Methods

We searched PubMed, EMBASE, CINAHL, POPLINE, and Global Index Medicus to identify studies describing pharmacologic agents used to induce fetal demise prior to termination of pregnancy. We included randomized controlled trials and observational studies comparing digoxin, potassium chloride (KCL), and lidocaine to induce fetal demise. We included studies that evaluated the primary outcomes of safety and effectiveness, including success in achieving fetal demise, induction to expulsion time for medical abortion, dilation and evacuation time, as well as maternal side effects and complications. Two authors independently screened abstracts and full texts. One reviewer extracted data from the included studies, which was counterchecked by a second reviewer.

Results

We identified eight studies that met inclusion criteria: three randomized controlled trials, and five observational studies. A total of 4505 women received drugs to induce fetal demise at 17 to 38 weeks' gestation, including digoxin (n = 4174), KCL (n = 324), and lidocaine (n = 7). Intra-fetal digoxin was superior to intra-amniotic digoxin in achieving fetal demise (OR 3.51, 95% CI 1.60, 7.78). Intracardiac KCL 15% 2–3 mL reduced induction to expulsion time by 320 min (p <.006).

Similarly, intracardiac KCL 15% 1–3 ml reduced dilation and evacuation time from 16.1 ± 7.9 min to 12.7 ± 5 min (p < 0.001). Intracardiac lidocaine 2% 10 mL was more effective at achieving fetal demise than intracardiac KCL 6 mmol (85.7% vs. 57.9%). Intra-amniotic and intra-fetal digoxin 1 mg, as compared to no feticidal agent, led to greater pre-procedure expulsion, hospital readmission, and the presence of one or more signs of infection.

Conclusions

Evidence from included cohort studies demonstrates that digoxin, KCL, and lidocaine are all effective in inducing fetal demise. Intra-fetal administration of digoxin is superior to intra-amniotic digoxin administration. Administration of feticide using intracardiac KCL may shorten the abortion experience. Limited data from observational studies also supports an increase in maternal side effects and/or complications related to the administration of digoxin.

Implications

Intra-fetal administration of digoxin is more effective in achieving fetal demise when compared to intra-amniotic administration. There is a knowledge gap in determining the single best drug for inducing fetal demise prior to abortion. Additional research is needed to compare different feticidal agents in terms of safety and effectiveness.

[Feticide procedures in second and third trimesters terminations of pregnancy]

Performing a feticide as part of termination of late pregnancy is recommended in many countries. Feticide avoids a live birth of a severely affected premature newborn and prevents fetal pain. There are limited data on feticide procedures since only a few countries in the world authorize late termination of pregnancy. The objective of this review was to assess the most appropriate feticide procedure based on published data during the last thirty years. Administration of an initial fetal analgesia followed by a lethal lidocaine injection through the umbilical cord, under ultrasound guidance, appears to be the most effective, safe and ethical way to perform feticide. According to the current knowledge regarding the risk of fetal pain and survival of extremely preterm infants, a feticide should be discussed as early as 20-22 weeks of gestation.

No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

OBJECTIVE

This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.

INTENDED USERS

Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.

TARGET POPULATION

Women with an unintended or abnormal first or second trimester pregnancy.

EVIDENCE

PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.

VALUES

The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.

Intra-amniotic digoxin for feticide between 21 and 30 weeks of gestation: a prospective study

OBJECTIVE

Intra-amniotic injection of digoxin is a well-known method for feticide before inducing a termination of pregnancy (TOP) at 17-24 weeks of gestation. Information on its effectiveness when administered after 24 weeks of gestation is limited. This study evaluated the efficacy of intra-amniotic digoxin injection for inducing fetal demise within 18-24 hours, at 21-30 weeks of gestation, and its safety.

DESIGN

Prospective cohort study.

SETTING

Tertiary university medical centre.

POPULATION

Women at 21-30 weeks of gestation with a singleton pregnancy, admitted for TOP.

METHODS

Intra-amniotic injection of 2 mg of digoxin was performed 1 day before medical TOP. Fetal heart activity was evaluated by ultrasound for 18-24 hours after the injection. Serum digoxin level and maternal electrocardiogram (ECG) were evaluated 6, 10, and 20 hours after injection.

MAIN OUTCOME MEASURE

Frequency of successful fetal demise.

RESULTS

Fifty-nine women participated in the study. The mean gestational age was 24⁺²  weeks (range 21⁺⁰ -30⁺⁰ ), with 29 (49.2%) beyond 24⁺⁰  weeks of gestation. Fetal cardiac activity arrest was achieved in 55/59 cases (93.2%). Normal maternal ECG recordings were noted in all cases. Mean serum digoxin levels 6 and 10 hours after injection were in the therapeutic range (1.3 ± 0.7 ng/l and 1.24 ± 0.49 ng/l, respectively) and below the toxic level (2 ng/l). Extramural delivery following digoxin did not occur. There were no cases of chorioamnionitis.

CONCLUSION

Intra-amniotic digoxin for feticide at 21-30 weeks of gestation in a singleton pregnancy appears effective and safe before TOP at advanced gestational ages.

TWEETABLE ABSTRACT

This study shows that feticide by intra-amniotic digoxin injection at 21-30 weeks of gestation appears effective and safe.

Outcomes of dilation and evacuation with and without feticide by intra-cardiac potassium chloride injection: a service evaluation

OBJECTIVE

To compare procedure duration, complications, and acceptability of dilation and evacuation (D&E) with and without feticide by intra-cardiac potassium chloride (KCL) injection.

STUDY DESIGN

We evaluated outcomes with D&E at 18-24 weeks of gestation in the 6 months before and 6 months after removing feticide with KCL from the guidelines of a national British abortion provider. We extracted demographic and procedure-related data from medical records and electronic databases. We surveyed women undergoing D&E in both time periods about acceptability and side effects.

RESULTS

We analyzed 291 cases with and 257 cases without KCL. Unadjusted mean procedure duration was shorter with KCL than without (12.7 vs. 16.1 min, respectively, p<.001). After adjustment for age, parity, Cesarean deliveries, gestational age, body mass index, surgeon, and number or duration of osmotic dilators used, KCL remained associated with a 3.5 min (95% CI 2.4-4.6) reduction in D&E duration. Uterine atony was more common with KCL than without (3% vs. 0%, respectively, p=.004), despite more frequent administration of prophylactic utero-tonics to women who received KCL (82% KCL vs. 73% no-KCL, p=.001). Women who had KCL reported more pain in the period between feticide and dilator placement and the evacuation than women who had not received feticide (49% vs. 25%, respectively, p<.001). Most women in both groups found their procedure very acceptable or acceptable (79% KCL vs. 87% no-KCL, p=.2).

CONCLUSIONS

Feticide with intra-cardiac KCL reduced D&E procedure duration, but was associated with more pain and uterine atony. Treatment acceptability was high with and without feticide.

IMPLICATIONS

Inducing fetal demise before dilation and evacuation with intra-cardiac potassium chloride may result in shorter operative times but does not appear to improve safety or acceptability. Level I evidence remains needed to support the use of feticide before surgical abortion.

A qualitative study of digoxin injection before dilation and evacuation

OBJECTIVE

We sought to qualitatively understand patients' experiences with digoxin as a step before dilation and evacuation (D&E).

STUDY DESIGN

We recruited English-speaking women from one abortion health center where digoxin is routinely used before D&E. We interviewed participants one to three weeks after the D&E about physical and emotional experiences with digoxin and understanding of its purpose. Using grounded theory, we analyzed transcripts iteratively, identifying themes from interviews; we stopped recruitment when we reached thematic saturation.

RESULTS

We conducted 20 interviews and participants described mixed experiences. Three overarching themes from the qualitative interviews were: (1) physical and emotional discomfort; (2) varied understanding of digoxin's purpose and effects; and (3) reassurance. Most participants described significantly negative experiences with digoxin; however, many participants also described positive aspects of the injection intermingled with those negative experiences.

CONCLUSIONS

Participants' experiences with digoxin before D&E were both polarized and nuanced. While participants were largely clear about digoxin's action, they were much less clear about the reason for its use.

IMPLICATIONS

Both the clinical purpose for and patients' experiences with digoxin before D&E are complicated. Providers who continue to use digoxin should consider patient preferences in how they offer digoxin, and consider tools to ensure patient understanding.

Intra-fetal Compared With Intra-amniotic Digoxin Before Dilation and Evacuation: A Randomized Controlled Trial

OBJECTIVE

To compare the effectiveness of 1.0 mg intra-fetal or intra-amniotic digoxin to achieve fetal asystole before second-trimester surgical pregnancy termination.

METHODS

In a randomized trial, women received 1.0 mg transabdominal intra-fetal or intra-amniotic digoxin on the day of laminaria placement before dilation and evacuation between 20 and 24 weeks of gestation. The primary outcome was incidence of fetal asystole, documented immediately before dilation and evacuation. We planned to analyze the primary outcome by original group assignment as well as by as-treated and per-protocol populations. A sample size of 270 was needed to detect an 8% difference in failure rates between groups. Prespecified secondary outcomes included the incidence of adverse events, side effects, and procedural differences.

RESULTS

Between January 2012 and January 2013, we screened 381 women and randomized 270 women to receive intra-fetal (n=136) or intra-amniotic (n=134) digoxin. Characteristics were similar across groups; the mean gestational age was 21.6 weeks (standard deviation 1.2). The proportion of fetal asystole was higher in the intra-fetal group (128/135 [94.8%]) than the intra-amniotic group (107/130, 82.3%; relative risk of failure to achieve asystole 3.41, 95% confidence interval 1.52-7.68). Results were similar in the as-treated and per-protocol populations. There were no significant differences in adverse events or side effects and no differences in injection duration, operative time, or estimated blood loss.

CONCLUSION

Administration of intra-fetal injection of digoxin led to a higher proportion of participants achieving fetal asystole within 24 hours than intra-amniotic injection.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT01047748.

Induction of fetal demise before pregnancy termination: practices of family planning providers

OBJECTIVES

Our survey aimed to characterize the practice of inducing fetal demise before pregnancy termination among abortion providers, including its technical aspects and why providers have chosen to adopt it.

STUDY DESIGN

We conducted a survey of Family Planning Fellowship-trained or Fellowship-affiliated Family Planning (FP) subspecialists about their practice of inducing fetal demise, including questions regarding the circumstances in which they would induce demise, techniques used and rationales for choosing whether to adopt this practice.

RESULTS

Of the 169 FP subspecialists we surveyed, 105 (62%) responded. About half (52%) of respondents indicated that they routinely induced fetal demise before terminations in the second trimester. Providers' practices varied in the gestations at which they started inducing demise as well as the techniques used. Respondents provided legal, technical and psychological reasons for their decisions to induce demise.

CONCLUSION

Inducing fetal demise before second-trimester abortions is common among US FP specialists for multiple reasons. The absence of professional guidelines or robust data may contribute to the variance in the current practice patterns of inducing demise.

IMPLICATIONS

Our study documents the widespread practice of inducing fetal demise before second-trimester abortion and further describes wide variation in providers' methods and rationales for inducing demise. It is important for abortion providers as a professional group to come to a formal consensus on the appropriate use of these techniques and to determine whether such practices should be encouraged, tolerated or even permitted.

Feasibility, effectiveness and safety of transvaginal digoxin administration prior to dilation and evacuation

OBJECTIVES

This study evaluates the feasibility, efficacy and safety of transvaginal digoxin administration to induce fetal demise prior to dilation and evacuation.

STUDY DESIGN

This descriptive report from a single center involves a large case series of dilations and evacuations (D&Es) ranging from 18 to 22 weeks of gestation. Transvaginal feticidal injection with digoxin was attempted in 1640 cases; intrafetal, intraamniotic and combined (intrafetal and intraamniotic) injections were administered. Digoxin dosage ranged from 0.5 to 3.0 mg, with the majority receiving 1.0 mg. Cases were reviewed to determine feasibility, efficacy and adverse events.

RESULTS

Successful completion of transvaginal injection occurred in 98.5% (1637/1662) of eligible cases, and 1596 cases were evaluable for fetal demise. Demise occurred by the time of D&E in 99.4% of all cases; 99.7% of intrafetal injections resulted in fetal demise. Doses ≥1 mg were equally effective (98.1%-99.6%) regardless of injection site (intraamniotic, combined intrafetal/intraamniotic or intrafetal). Doses <1.0 mg were less successful at inducing demise if not administered intrafetally (p<.001). Rates of ruptured membranes (4.1%), chorioamnionitis (0.49%) and extramural deliveries (0.12%) were low. Patients who experienced complications were more likely to be of greater gestational age and have had a previous cesarean section.

CONCLUSIONS

Transvaginal digoxin administration is feasible, effective and safe.

IMPLICATION STATEMENT

This study demonstrates the feasibility, effectiveness and safety of transvaginal digoxin administration in a large clinical cohort. Future studies will be needed to determine if this method of administration improves patient satisfaction and outcomes when compared to transabdominal feticidal injections.

Transvaginal administration of intraamniotic digoxin prior to dilation and evacuation

BACKGROUND

Transabdominal injection of digoxin into the amniotic fluid or fetus to induce fetal demise before dilation and evacuation (D&E) abortion has become common practice since the passage of the Partial-Birth Abortion Ban Act in 2007.

STUDY DESIGN

We performed a prospective study to assess the feasibility of transvaginal administration of intraamniotic digoxin the day before D&E. All women between 18 0/7 and 23 5/7 weeks of gestation seeking termination from December 2009 to May 2011 were approached for study participation. Women who declined participation were asked to identify their primary rationale. For women declining study participation, transection of the umbilical cord during D&E was performed to meet the requirements of the ban.

RESULTS

Over 18 months, 134 women met study entry criteria and 108 (81%) declined to participate. Of the 26 women who enrolled, 1.0 mg undiluted digoxin was successfully administered transvaginally in 24 (92%, 95% confidence interval 75%-99%). The most common reasons for declining participation were discomfort with preoperatively inducing fetal demise (37%) and desire to avoid a medically unnecessary medication (36%).

CONCLUSIONS

Transvaginal administration of digoxin is a feasible alternative to transabdominal administration to induce preoperative fetal demise. The majority of women decline digoxin administration when an alternative is available.

Safety of digoxin for fetal demise before second-trimester abortion by dilation and evacuation

BACKGROUND

Digoxin is used to induce fetal demise before dilation and evacuation (D&E) abortion. Published data on the safety of digoxin in abortion care are limited.

STUDY DESIGN

We conducted a retrospective cohort study with historical controls at a large family planning center. We reviewed the records of patients at 18 to 24 weeks' gestation who received digoxin before D&E from May 15, 2007 (date the center initiated digoxin use), through March 31, 2008. We also reviewed the records of patients who presented for D&E without digoxin from February 22, 2006, through May 12, 2007. We compared the rates of immediate complications.

RESULTS

We included 566 digoxin patients and 513 controls. Eleven spontaneous abortions occurred in the digoxin cohort; none occurred among controls (p<.001). We found 19 cases of infection in the digoxin cohort and three among controls (odds ratio 5.91; 95% confidence interval 1.74-20.07). Eleven digoxin patients were admitted to a hospital after the preoperative visit; no controls were admitted (p<.001).

CONCLUSIONS

Patients who received digoxin before D&E were more likely to experience spontaneous abortion, infection and hospital admission than controls who underwent D&E without digoxin.