Safety of intra-amniotic digoxin administration before late second-trimester abortion by dilation and evacuation

Society of Family Planning Clinical Recommendation: Induction of fetal asystole before abortion Jointly developed with the Society for Maternal-Fetal Medicine

This document serves as a revision to the Society of Family Planning's 2010 guidelines, integrating literature on new techniques and research and addressing the clinical, medical, and sociolegal questions surrounding the induction of fetal asystole. Insufficient evidence exists to recommend routine induction of fetal asystole before previable medication and procedural abortion. However, at periviable gestations and after fetal viability, inducing fetal asystole before abortion prevents the infrequent but serious occurrence of unanticipated expulsion of a fetus with cardiorespiratory activity (Best Practice). Defining viability is complicated as it represents a physiological continuum impacted by gestational duration along with multiple other individual clinical factors and circumstances; therefore, the exact gestational duration to offer fetal asystole will depend on the setting and clinical circumstances. If induction of fetal asystole before abortion is available, we recommend engaging in patient-centered counseling regarding the risks and benefits of induction of fetal asystole in the setting of each unique pregnancy scenario and the patient's beliefs and priorities (Best Practice). We recommend that clinicians identify the optimal pharmacologic agent to administer for a given clinical scenario based on factors such as availability of each agent; the time frame in which fetal asystole needs to be established; and clinicians' technical ability, preferences, and practice (Best Practice). Potassium chloride, lidocaine, and digoxin are all acceptable pharmaceutical agents to induce fetal asystole before abortion. To establish asystole rapidly, we suggest the use of potassium chloride (via intracardiac or intrafunic injection) or lidocaine (via intracardiac or intrafunic injection) (GRADE 2C), although intrathoracic administration of lidocaine may be acceptable. We recommend potassium chloride not be used if intracardiac or intrafunic location cannot be achieved to avoid the risk of accidental administration to the pregnant individual and because insufficient data support its efficacy via other intrafetal locations (GRADE 1C). When using digoxin, we recommend intrafetal administration (GRADE 1C), although intraamniotic administration may be acceptable depending on a clinician's technical ability and setting. Because digoxin may take several hours to induce asystole, an alternative agent should be considered in settings where fetal asystole must be confirmed rapidly.

Society of Family Planning Clinical Recommendation: Induction of fetal asystole before abortion Jointly developed with the Society for Maternal-Fetal Medicine☆,☆☆

This document serves as a revision to the Society of Family Planning's 2010 guidelines, integrating literature on new techniques and research and addressing the clinical, medical, and sociolegal questions surrounding the induction of fetal asystole. Insufficient evidence exists to recommend routine induction of fetal asystole before previable medication and procedural abortion. However, at periviable gestations and after fetal viability, inducing fetal asystole before abortion prevents the infrequent but serious occurrence of unanticipated expulsion of a fetus with cardiorespiratory activity (Best Practice). Defining viability is complicated as it represents a physiological continuum impacted by gestational duration along with multiple other individual clinical factors and circumstances; therefore, the exact gestational duration to offer fetal asystole will depend on the setting and clinical circumstances. If induction of fetal asystole before abortion is available, we recommend engaging in patient-centered counseling regarding the risks and benefits of induction of fetal asystole in the setting of each unique pregnancy scenario and the patient's beliefs and priorities (Best Practice). We recommend that clinicians identify the optimal pharmacologic agent to administer for a given clinical scenario based on factors such as availability of each agent; the time frame in which fetal asystole needs to be established; and clinicians' technical ability, preferences, and practice (Best Practice). Potassium chloride, lidocaine, and digoxin are all acceptable pharmaceutical agents to induce fetal asystole before abortion. To establish asystole rapidly, we suggest the use of potassium chloride (via intracardiac or intrafunic injection) or lidocaine (via intracardiac or intrafunic injection) (GRADE 2C), although intrathoracic administration of lidocaine may be acceptable. We recommend potassium chloride not be used if intracardiac or intrafunic location cannot be achieved to avoid the risk of accidental administration to the pregnant individual and because insufficient data support its efficacy via other intrafetal locations (GRADE 1C). When using digoxin, we recommend intrafetal administration (GRADE 1C), although intraamniotic administration may be acceptable depending on a clinician's technical ability and setting. Because digoxin may take several hours to induce asystole, an alternative agent should be considered in settings where fetal asystole must be confirmed rapidly.

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.

Maternal outcome of selective feticide due to fetal anomaly in late trimester: A retrospective 10 years' experience in Taiwan

BACKGROUND

Feticide was suggested to avoid delivering children with abnormalities. Recently, twin pregnancies have increased. Selective feticide was proposed to achieve a good outcome of pregnancy. This study aimed to evaluate the performance of feticide in twin pregnancy with fetal anomaly.

METHODS

This was a retrospective study enrolled from 2009 to 2018. A total of 68 pregnancies with fetal anomalies received feticide. Potassium chloride was injected into the left ventricle to induce fetal asystole. Maternal and fetal characteristics of 16 dichorionic twins were documented to compare before and after 24th gestational week.

RESULTS

All pregnant women received feticide without any maternal or fetal complication. The reasons for choosing feticide were divided into four groups, including morphologic defect (61.8%), genetic-chromosomal abnormality (30.9%), obstetrical complication (5.9%), and maternal request (1.5%). Mean gestational age at delivery was significantly higher in dichorionic twins who underwent selective feticide before than after 24th gestational week (36.7 vs 33.4, p = 0.04).

CONCLUSION

Intracardiac injection of potassium chloride was effective for feticide and safe for mothers and fetuses. Selective feticide served as an alternative approach for twin pregnancy with fetal anomaly after sufficient discussion.

Feasibility of intra-amniotic digoxin administration by obstetrics and gynecology trainees to induce fetal demise prior to medical abortion beyond 20 weeks

BACKGROUND

Transient fetal survival is one issue that providers may face while managing late second-trimester abortion. Induction of fetal demise using digoxin and other means has been widely performed by maternal-fetal medicine and family planning subspecialists worldwide. However, there are no data available in Ethiopia as regards preventing transient fetal survival in late second-trimester medical termination of pregnancy.

OBJECTIVE

The objective of the study was to document the feasibility of intra-amniotic digoxin administration for inducing fetal demise prior to medical abortion beyond 20 weeks of gestational age. Additionally, we aimed to demonstrate that this skill could be transferred to obstetrics and gynaecology residents at St Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia.

METHODS

A retrospective cross-sectional study design was conducted to document the feasibility, safety and effectiveness of intra-amniotic digoxin. A structured questionnaire was used to collect selected sociodemographic data and clinical characteristics. Data were entered and analysed using SPSS statistical package version 20.

RESULTS

During the study period, 49 women received intra-amniotic digoxin. The success rate of intra-amniotic digoxin in this study was 95.9%. Thirty-seven (75.5%) procedures were performed by obstetrics and gynaecology residents and 12 (24.5%) were performed by family planning faculties. There were two out of hospital expulsions with no signs of life, and no other serious maternal complications were observed.

CONCLUSION

It is feasible for obstetrics and gynaecology trainees in Ethiopia to learn how to safely administer intra-amniotic digoxin to induce fetal demise for induced medical terminations.

[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.

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.

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.

Clinical guidelines. Labor induction abortion in the second trimester

Labor induction abortion is effective throughout the second trimester. Patterns of use and gestational age limits vary by locality. Earlier gestations (typically 12 to 20 weeks) have shorter abortion times than later gestational ages, but differences in complication rates within the second trimester according to gestational age have not been demonstrated. The combination of mifepristone and misoprostol is the most effective and fastest regimen. Typically, mifepristone 200 mg is followed by use of misoprostol 24-48 h later. Ninety-five percent of abortions are complete within 24 h of misoprostol administration. Compared with misoprostol alone, the combined regimen results in a clinically significant reduction of 40% to 50% in time to abortion and can be used at all gestational ages. However, mifepristone is not widely available. Accordingly, prostaglandin analogues without mifepristone (most commonly misoprostol or gemeprost) or high-dose oxytocin are used. Misoprostol is more widely used because it is inexpensive and stable at room temperature. Misoprostol alone is best used vaginally or sublingually, and doses of 400 mcg are generally superior to 200 mcg or less. Dosing every 3 h is superior to less frequent dosing, although intervals of up to 12 h are effective when using higher doses (600 or 800 mcg) of misoprostol. Abortion rates at 24 h are approximately 80%-85%. Although gemeprost has similar outcomes as compared to misoprostol, it has higher cost, requires refrigeration, and can only be used vaginally. High-dose oxytocin can be used in circumstances when prostaglandins are not available or are contraindicated. Osmotic dilators do not shorten induction times when inserted at the same time as misoprostol; however, their use prior to induction using misoprostol has not been studied. Preprocedure-induced fetal demise has not been studied systematically for possible effects on time to abortion. While isolated case reports and retrospective reviews document uterine rupture during second-trimester induction with misoprostol, the magnitude of the risk is not known. The relationship of individual uterotonic agents to uterine rupture is not clear. Based on existing evidence, the Society of Family Planning recommends that, when labor induction abortion is performed in the second trimester, combined use of mifepristone and misoprostol is the ideal regimen to effect abortion quickly and completely. The Society of Family Planning further recommends that alternative regimens, primarily misoprostol alone, should only be used when mifepristone is not available.

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

BACKGROUND

Digoxin is commonly used to facilitate second-trimester surgical abortion despite limited data regarding its safety and effectiveness for this indication. We conducted a pilot study to determine the incidence of side effects after digoxin administration and whether effectiveness can be improved with variations in dose and technique.

STUDY DESIGN

Fifty-two women presenting for elective termination of pregnancy between 18 and 24 weeks' gestation were randomized to one of four digoxin treatment groups: 1.0 mg intraamniotic (1.0 IA), 1.0 mg intrafetal (1.0 IF), 1.5 mg intraamniotic (1.5 IA) or 1.5 mg intrafetal (1.5 IF). Ultrasound was used to assess for the presence of fetal cardiac activity prior to the abortion procedure. Data on the presence and severity of pain, nausea and other potential side effects were collected before digoxin injection, immediately following digoxin injection and on the day after digoxin injection.

RESULTS

Digoxin effectively induced fetal death in 87% of women. The failure rate did not vary by route of administration (IA or IF) and was not lowered by increasing the dose from 1.0 to 1.5 mg. IF injections induced fetal death more rapidly than IA injections. Digoxin administration did not result in increased pain or nausea.

CONCLUSIONS

IA or IF injection of digoxin is safe and effective for inducing fetal death prior to second-trimester surgical abortion. Doses greater than 1.0 mg may not be necessary.

Effectiveness and safety of digoxin to induce fetal demise prior to second-trimester abortion

BACKGROUND

The study was conducted to assess the effectiveness in inducing fetal demise through digoxin injection given 1 day prior to second-trimester pregnancy termination and to evaluate related maternal safety.

STUDY DESIGN

A retrospective cohort analysis of 1795 pregnant women between 17 and 24 weeks' gestation who received varying doses of digoxin by transabdominal intrafetal or intra-amniotic injection at the time of laminaria placement was conducted. Fetal heart activity documented by M-mode Doppler sonography on the subsequent day was considered failure. Digoxin dosages started at 1.0 mg for intrafetal and 0.5 mg for intra-amniotic injections and were progressively decreased based on best clinical judgment.

RESULTS

The overall rate of failure to achieve fetal demise was 6.6% (95% CI, 5.5-7.9). Failure rates varied according to route of administration and dosage. There were no failures using a 1.0-mg intrafetal dose, but failures occurred with lower doses. Failure rates were higher with 0.5 mg for intra-amniotic (8.3%) than intrafetal administration (3.6%). There were no adverse maternal events at any of the doses in this study.

CONCLUSION

Intrafetal digoxin injection at a dose of 1.0 mg is safe and effective for fetal demise prior to pregnancy termination in the second trimester. Significantly lower doses are effective in most cases. Additional doses merit further testing.

Methods for Induced Abortion

We describe present methods for induced abortion used in the United States. The most common procedure is first-trimester vacuum curettage. Analgesia is usually provided with a paracervical block and is not completely effective. Pretreatment with nonsteroidal analgesics and conscious sedation augment analgesia but only to a modest extent. Cervical dilation is accomplished with conventional tapered dilators, hygroscopic dilators, or misoprostol. Manual vacuum curettage is as safe and effective as the electric uterine aspirator for procedures through 10 weeks of gestation. Common complications and their management are presented. Early abortion with mifepristone/misoprostol combinations is replacing some surgical abortions. Two mifepristone/misoprostol regimens are used. The rare serious complications of medical abortion are described. Twelve percent of abortions are performed in the second trimester, the majority of these by dilation and evacuation (D&E) after laminaria dilation of the cervix. Uterine evacuation is accomplished with heavy ovum forceps augmented by 14-16 mm vacuum cannula systems. Cervical injection of dilute vasopressin reduces blood loss. Operative ultrasonography is reported to reduce perforation risk of D&E. Dilation and evacuation procedures have evolved to include intact D&E and combination methods for more advanced gestations. Vaginal misoprostol is as effective as dinoprostone for second-trimester labor-induction abortion and appears to be replacing older methods. Mifepristone/misoprostol combinations appear more effective than misoprostol alone. Uterine rupture has been reported in women with uterine scars with misoprostol abortion in the second trimester. Fetal intracardiac injection to reduce multiple pregnancies or selectively abort an anomalous twin is accepted therapy. Outcomes for the remaining pregnancy have improved with experience.