Elsevier

Contraception

Volume 81, Issue 6, June 2010, Pages 462-473
Contraception

Clinical Guidelines
Induction of fetal demise before abortion

https://doi.org/10.1016/j.contraception.2010.01.018Get rights and content

Abstract

For decades, the induction of fetal demise has been used before both surgical and medical second-trimester abortion. Intracardiac potassium chloride and intrafetal or intra-amniotic digoxin injections are the pharmacologic agents used most often to induce fetal demise. In the last several years, induction of fetal demise has become more common before second-trimester abortion. The only randomized, placebo-controlled trial of induced fetal demise before surgical abortion used a 1 mg injection of intra-amniotic digoxin before surgical abortion at 20–23 weeks' gestation and found no difference in procedure duration, difficulty, estimated blood loss, pain scores or complications between groups. Inducing demise before induction terminations at near viable gestational ages to avoid signs of life at delivery is practiced widely. The role of inducing demise before dilation and evacuation (D&E) remains unclear, except for legal considerations in the United States when an intact delivery is intended. There is a discrepancy between the one published randomized trial that used 1 mg intra-amniotic digoxin that showed no improvement in D&E outcomes and observational studies using different routes, doses and pre-abortion intervals that have made claims for its use. Additional randomized trials might provide clearer evidence upon which to make further recommendations about any role of inducing demise before surgical abortion. At the current time, the Society of Family Planning recommends that pharmacokinetic studies followed by randomized controlled trials be conducted to assess the safety and efficacy of feticidal agents to improve abortion safety.

Section snippets

Background

Induced abortion is the second most common surgery for reproductive-aged women in the United States, after cesarean delivery [1], [2]. The safety of this common procedure is well-established [3]. Surgical and medical methods of abortion can be performed safely in the second trimester, and even in the third trimester when pregnancy termination usually is completed by medical induction for lethal fetal anomalies or other significant medical conditions affecting the pregnant woman [4].

During the

Outside of legal concerns, what are the medical reasons providers induce fetal demise before abortion?

The most commonly reported use of feticidal agents is for selective termination and multifetal pregnancy reduction [71]. Since the advent of ovulation stimulation, IVF and GIFT, many women treated for infertility get pregnant with multiple gestations. There have been no randomized controlled trials (RCTs) comparing pregnancy reduction to carrying multiple gestations to delivery with respect to any fetal or maternal outcomes. The reduction of higher-order gestations to twins — or twins to a

Conclusions and recommendations

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A: Recommendations are based primarily on good and consistent scientific evidence.

  • One milligram of intra-amniotic digoxin is no better than placebo to decrease procedure time or provider-reported technical difficulty. Patients have increased vomiting after intra-amniotic digoxin injections.

Level B: Recommendations are based primarily on limited or

Important questions to be answered

Although we have primarily observational data about the safety and effectiveness of feticidal injections, there is a paucity of the highest level of evidence — RCTs — about the effect of inducing fetal demise on the safety, speed and risks of the abortion procedure itself, before either D&E or induction termination. We currently have inadequate data to recommend this intervention to increase the safety of D&E. In order to study the safety and absorption of digoxin and KCl, we need more

Acknowledgments

The authors would like to thank Erin Cassad Schultz, JD, and Jennifer Templeton Dunn, JD, for their assistance in addressing the medicolegal issues surrounding the use of feticidal agents.

References (102)

  • BrandesJ.M.

    Reduction of the number of embryos in a multiple pregnancy: quintuplet to triplet

    Fertil Steril

    (1987)
  • BerkowitzR.L. et al.

    One hundred consecutive cases of selective termination of an abnormal fetus in a multifetal gestation

    Obstet Gynecol

    (1997)
  • EddlemanK.A.

    Selective termination of anomalous fetuses in multifetal pregnancies: two hundred cases at a single center

    Am J Obstet Gynecol

    (2002)
  • ElimianA. et al.

    Effect of causing fetal cardiac asystole on second-trimester abortion

    Obstet Gynecol

    (1999)
  • EvansM.I.

    Selective termination for structural, chromosomal, and mendelian anomalies: international experience

    Am J Obstet Gynecol

    (1999)
  • Timor-TritschI.E.

    Multifetal pregnancy reduction by transvaginal puncture: evaluation of the technique used in 134 cases

    Am J Obstet Gynecol

    (1993)
  • WapnerR.J.

    Selective reduction of multifetal pregnancies

    Lancet

    (1990)
  • DonnerC. et al.

    Multifetal pregnancy reduction: comparison of obstetrical results with spontaneous twin gestations

    Eur J Obstet Gynecol Reprod Biol

    (1992)
  • DreyE.A.

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

    Am J Obstet Gynecol

    (2000)
  • HernW.M.

    Laminaria, induced fetal demise and misoprostol in late abortion

    Int J Gynaecol Obstet

    (2001)
  • JacksonR.A.

    Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial

    Obstet Gynecol

    (2001)
  • MolaeiM.

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

    Contraception

    (2008)
  • DavisG. et al.

    Mid-trimester abortion

    Lancet

    (1972)
  • BushM.C. et al.

    Multifetal pregnancy reduction and selective termination

    Clin Perinatol

    (2003)
  • BerkowitzR.L.

    The current status of multifetal pregnancy reduction

    Am J Obstet Gynecol

    (1996)
  • MoiseK.J.

    Radiofrequency ablation for selective reduction in the complicated monochorionic gestation

    Am J Obstet Gynecol

    (2008)
  • PorrecoR.P. et al.

    Occlusion of umbilical artery in acardiac, acephalic twin

    Lancet

    (1991)
  • NicoliniU.

    Complicated monochorionic twin pregnancies: experience with bipolar cord coagulation

    Am J Obstet Gynecol

    (2001)
  • SkellyH.

    Consumptive coagulopathy following fetal death in a triplet pregnancy

    Am J Obstet Gynecol

    (1982)
  • JonesR.K.

    Abortion in the United States: incidence and access to services, 2005

    Perspect Sex Reprod Health

    (2008)
  • MartinJ.A.

    Births: final data for 2005

    Natl Vital Stat Rep

    (2007)
  • BartlettL.A.

    Risk factors for legal induced abortion-related mortality in the United States

    Obstet Gynecol

    (2004)
  • GrimesD.A. et al.

    Morbidity and mortality from second-trimester abortions

    J Reprod Med

    (1985)
  • BeksacM.S.

    Selective feticide in dichorionic pregnancies with intracardiac blood aspiration: report of nine cases

    J Perinat Med

    (2009)
  • BoulotP.

    Multifetal pregnancy reduction: a consecutive series of 61 cases

    Br J Obstet Gynaecol

    (1993)
  • EvansM.I.

    Transabdominal versus transcervical and transvaginal multifetal pregnancy reduction: international collaborative experience of more than one thousand cases

    Am J Obstet Gynecol

    (1994)
  • GolbusM.S.

    Selective termination of multiple gestations

    Am J Med Genet

    (1988)
  • IbericoG.

    Embryo reduction of multifetal pregnancies following assisted reproduction treatment: a modification of the transvaginal ultrasound-guided technique

    Hum Reprod

    (2000)
  • KerenyiT.D. et al.

    Selective birth in twin pregnancy with discordancy for Down's syndrome

    N Engl J Med

    (1981)
  • RedwineF.O. et al.

    Selective birth in a case of twins discordant for Tay Sachs disease

    Acta Genet Med Gemellol (Roma)

    (1984)
  • RodeckC.H.

    Selective feticide of the affected twin by fetoscopic air embolism

    Prenat Diagn

    (1982)
  • ChitkaraU.

    Selective second-trimester termination of the anomalous fetus in twin pregnancies

    Obstet Gynecol

    (1989)
  • PijpersL.

    Selective birth in a dyzygotic twin pregnancy with discordancy for Down's syndrome

    Fetal Ther

    (1989)
  • ShalevE.

    Ultrasound-guided selective feticide of hydrocephalic fetus in triplet pregnancy

    J Clin Ultrasound

    (1988)
  • Li Kim MuiS.V.

    Sepsis due to Clostridium perfringens after pregnancy termination with feticide by cordocentesis: a case report

    Fetal Diagn Ther

    (2002)
  • DommerguesM.

    Twin-to-twin transfusion syndrome: selective feticide by embolization of the hydropic fetus

    Fetal Diagn Ther

    (1995)
  • DumlerE.A. et al.

    Intracardiac fibrin adhesive for selective fetocide in twin pregnancy: report of three cases

    Ultrasound Obstet Gynecol

    (1996)
  • GrabD. et al.

    Twin, acardiac, outcome

    Fetus

    (1992)
  • DenbowM.L.

    Selective termination by intrahepatic vein alcohol injection of a monochorionic twin pregnancy discordant for fetal abnormality

    Br J Obstet Gynaecol

    (1997)
  • HolzgreveW.

    A simpler technique for umbilical-cord blockade of an acardiac twin

    N Engl J Med

    (1994)
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