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Schiff I, Shangaris P, Grinsted M, Sankaran S. Feticide Before Termination of Pregnancy in Singleton Pregnancy - Trends in England and Wales 2012-2020, a Cross-sectional Study. Reprod Sci 2024; 31:441-451. [PMID: 37749446 PMCID: PMC10827943 DOI: 10.1007/s43032-023-01352-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/07/2023] [Indexed: 09/27/2023]
Abstract
Feticide is the practice of inducing fetal demise before the termination of pregnancy. In England and Wales, it is recommended for terminations of pregnancy beyond 21+6 weeks of gestation. This project analyses the trends in feticide in singleton pregnancy in England and Wales between 2012 and 2020. This project was a retrospective study that analysed data extracted from the Health and Social Act 4 (HSA4) forms submitted to the Department of Health and Social Care (DHSC). The data extracted by the DHSC included the prevalence of feticide, methods of feticide and termination, statutory grounds, gestation, service provider, maternal age, ethnicity and obstetric history. In addition, data analysis was carried out to identify trends. Between 2012 and 2020, there were 9310 feticides in England and Wales, undertaken in 0.5% of all abortions. The prevalence of feticide fluctuated; however, there was an overall decrease from 1084 cases in 2012 to 1000 cases in 2020. Intracardiac injection of potassium chloride was the most frequent method of achieving feticide (67.2%). Just over half (55.8%) of feticides took place under Ground E of the Abortion Act 1967, with the main indication being congenital malformations of the nervous system. Two-fifths (40.2%) of feticides took place at 23 weeks, 22.8% at 22 weeks and 13.5% between 20 and 21 weeks. The remainder occurred at later gestations: 17.5% at 24-29 weeks and 5.9% beyond 29 weeks. During our study period, it was more common for feticides to be carried out as part of a medical termination than a surgical termination and 60.3% occurred in NHS hospitals. Women undergoing feticide were mostly aged 30-34 years (38.3%) and of White ethnicity (78.6%). Feticide is an essential component of comprehensive abortion care for women undergoing late second and third-trimester abortions. This study provides insight into how feticide is carried out in England and Wales and demonstrates the effect of the COVID-19 pandemic on reducing feticide prevalence. Future research should analyse in more detail the use of the different methods of feticide.
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Affiliation(s)
- Isabelle Schiff
- GKT School of Medical Education, King's College London, Guy's Campus, Great Maze Pond, London, UK
| | - Panicos Shangaris
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Guy's Campus, Great Maze Pond, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom.
- School of Life Course and Population Sciences, King's College London, 10th Floor North Wing St Thomas' Hospital, London, London, UK.
- Fetal Medicine Research Institute, King's College Hospital, London, UK.
- Department of Women and Children, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | | | - Srividhya Sankaran
- Department of Women and Children, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Health and Social Care, London, UK
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Zwerling B, Edelman A, Jackson A, Burke A, Prabhu M. Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine. Am J Obstet Gynecol 2023:S0002-9378(23)00726-3. [PMID: 37821258 DOI: 10.1016/j.ajog.2023.09.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 10/13/2023]
Abstract
The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.
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Affiliation(s)
- Blake Zwerling
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States.
| | - Alison Edelman
- Department of Obstetrics & Gynecology, Division of Complex Family Planning, Oregon Health & Science University, Portland, OR, United States
| | - Anwar Jackson
- Department of Obstetrics & Gynecology, Aurora Health Care, Milwaukee, WI, United States
| | - Anne Burke
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | - Malavika Prabhu
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Obstetrics and Gynecology, Yawkey Center for Outpatient Care, Boston, MA, United States
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Zwerling B, Edelman A, Jackson A, Burke A, Prabhu WTAOM. Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine. Contraception 2023:110143. [PMID: 37821241 DOI: 10.1016/j.contraception.2023.110143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 10/13/2023]
Abstract
The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.
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Affiliation(s)
- Blake Zwerling
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States.
| | - Alison Edelman
- Department of Obstetrics & Gynecology, Division of Complex Family Planning, Oregon Health & Science University, Portland, OR, United States
| | - Anwar Jackson
- Department of Obstetrics & Gynecology, Aurora Health Care, Milwaukee, WI, United States
| | - Anne Burke
- Department of Gynecology & Obstetrics, Division of Family Planning, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | - With The Assistance Of Malavika Prabhu
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Obstetrics and Gynecology, Yawkey Center for Outpatient Care, Boston, MA, United States
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A new and more effective feticide technique in late termination of pregnancy: potassium chloride injection into the interventricular septum of the fetal heart. Arch Gynecol Obstet 2023; 307:779-787. [PMID: 36271257 DOI: 10.1007/s00404-022-06795-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/12/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study sought to compare the efficacy and outcomes of fetal intracardiac intraventricular and interventricular septal potassium chloride (KCl) injections during the induced fetal demise process in a cohort of pregnant women with severe fetal abnormality who opted for late termination of pregnancy (TOP). MATERIALS AND METHODS This study consisted of 158 pregnant women who requested late TOP for severe fetal abnormality between 22 and 36 weeks of pregnancy. Participants were randomly assigned with the simple randomization procedure to one of two feticide procedure groups: the intraventricular KCl injection group and the interventricular septal KCl administration group. We studied the clinical outcomes of both the feticide procedures. RESULTS The median total dose of strong KCl was significantly lower in the interventricular septal KCl administration group (3 mL) than in the intraventricular KCl injection group (5 mL, p < 0.001). The median time to reach asystole and the median total duration of the procedure was significantly shorter in the interventricular septal KCl administration group (42 s and 85 s, respectively) than in the intraventricular KCl injection group (115 s and 150 s, respectively, p < 0.001). We detected a statistically significant correlation between the gestational week at feticide and the total dose of KCl (r = 0.705, p < 0.001), time to reach asystole (r = 0.653, p < 0.001), and total duration of the procedure (r = 0.683, p < 0.001). CONCLUSION KCl administered directly into the interventricular septum induces immediate and permanent fetal cardiac asystole with a 100% of success rate without comprising maternal safety. We did not observe any maternal complications related to the procedure in our cases. Since the consequences of failed feticide procedure are challenging for both parents and healthcare providers, and providers are also concerned about potential legal implications regarding an unintended live birth, it is crucial to guide a strict protocol to confirm permanent fetal cardiac asystole.
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Akalın M, Demirci O, Gokcer O, İsmailov H, Sahap Odacilar A, Dizdarogulları GE, Kahramanoğlu Ö, Ocal A, Bolat G, Eriç Özdemir M. Intraamniotic digoxin administration versus intracardiac or funic potassium chloride administration to induce foetal demise before termination of pregnancy: a prospective study. J OBSTET GYNAECOL 2022; 42:3477-3483. [PMID: 36369861 DOI: 10.1080/01443615.2022.2144173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Münip Akalın
- Department of Perinatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Oya Demirci
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
| | - Oya Gokcer
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
| | - Hayal İsmailov
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
| | - Ali Sahap Odacilar
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
| | - Gizem Elif Dizdarogulları
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
| | - Özge Kahramanoğlu
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
| | - Aydın Ocal
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
| | - Guher Bolat
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
| | - Mucize Eriç Özdemir
- Department of Perinatology, University of Health Sciences Zeynep Kamil Women’s and Children’s Disease Training and Research Hospital, Istanbul, Turkey
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Reeves MF, Goldfarb CN, Rubin SL, Kuperstock JL, DiBianco L, Picciotto A. Transabdominal lidocaine to induce fetal demise: a cohort study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:275-280. [PMID: 35383110 DOI: 10.1136/bmjsrh-2021-201350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/23/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION We sought to assess the efficacy of transabdominal intrafetal lidocaine to achieve fetal demise before pregnancy termination. METHODS This study was a retrospective cohort analysis of patients undergoing transabdominal intrafetal lidocaine injections prior to abortion procedures after 24 weeks from January 2018 to June 2020 at DuPont Clinic, an outpatient obstetrics and gynaecology clinic in Washington, DC, USA. We recorded data on maternal factors, gestational age, time of injection and fetal asystole, and injection dose and location. We defined successful intrafetal lidocaine injection as asystole achieved prior to the patient leaving the clinic. RESULTS We performed injections in 338 fetuses in 335 patients, with a median gestational age of 27 weeks and 6 days (range 24-32 weeks). Lidocaine dose was 200-240 mg in 310 cases (91.7%) and 400-480 mg in 27 cases (8.0%) without difference in success (p>0.05). Lidocaine successfully induced fetal demise with one injection in 331 cases (97.9%). A second injection was required to induce demise for five fetuses (1.5%). Intracardiac injection was successful in 280 of 285 cases (98.3%), with asystole confirmed within 1 min in 75% of cases. Intrathoracic injection caused asystole in 45 of 47 cases (95.7%), with asystole confirmed within 2 min in 75% of cases. Success was not significantly associated with gestational age, body mass index or parity (p>0.05). One patient reported lidocaine-related side effects (0.3%). CONCLUSIONS Intrafetal lidocaine is a safe and effective method of inducing fetal demise. Intracardiac injection achieves fetal asystole almost immediately. Intrathoracic injection is also highly effective.
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Affiliation(s)
- Matthew F Reeves
- DuPont Clinic, Washington, District of Columbia, USA
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Balitmore, Maryland, USA
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Caroline N Goldfarb
- DuPont Clinic, Washington, District of Columbia, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jessica L Kuperstock
- DuPont Clinic, Washington, District of Columbia, USA
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Leah DiBianco
- DuPont Clinic, Washington, District of Columbia, USA
| | - Andrea Picciotto
- DuPont Clinic, Washington, District of Columbia, USA
- Kansas City University College of Osteopathic Medicine, Kansas City, Missouri, USA
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Loughran D, Jacob J, Calello D, Nelson L. Direct maternal injection of digoxin in error during a fetal pre-termination procedure. Clin Toxicol (Phila) 2022; 60:776-778. [PMID: 35107053 DOI: 10.1080/15563650.2022.2032129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- David Loughran
- Department of Medical Toxicology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jeena Jacob
- Department of Medical Toxicology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Diane Calello
- Department of Medical Toxicology, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Lewis Nelson
- Department of Medical Toxicology, Rutgers New Jersey Medical School, Newark, NJ, USA
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Effectiveness of intra-cardiac lidocaine and intra-amniotic digoxin at inducing fetal demise before second trimester abortion past 20 weeks at a tertiary Hospital in Ethiopia: A retrospective review. Contracept X 2022; 4:100082. [PMID: 36017486 PMCID: PMC9396292 DOI: 10.1016/j.conx.2022.100082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022] Open
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Costescu D, Mui C. When there is only one patient: Induction of labour for termination of pregnancy. Best Pract Res Clin Obstet Gynaecol 2021; 79:81-94. [PMID: 35000810 DOI: 10.1016/j.bpobgyn.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 12/21/2022]
Abstract
Induction of labour when no live birth is anticipated presents a number of unique considerations for members of the healthcare team. The main indication for Induction of Labour for Termination of Pregnancy (iTOP) is intrauterine fetal death (IUFD) beyond a gestational age where surgical management is available, but may also be indicated in the setting of induction abortion (with or without feticide), and termination of pregnancy (with or without infant palliation) for pregnancies where a lethal fetal anomaly is diagnosed. In tertiary care centres, iTOP may represent a significant proportion of labouring patients. Despite this, there are few guidelines dedicated specifically to iTOP in either obstetrical or family planning specialties. In this article, we will consider four main themes from an evidence-informed perspective: method selection; pre-induction preparation; clinical considerations during and after iTOP; and complications management.
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Affiliation(s)
- Dustin Costescu
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, L8N 3Z5, Canada.
| | - Carween Mui
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, L8N 3Z5, Canada
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Nippita S, Carranza ASO, Paul ME. Funic potassium chloride injection during intact dilation and evacuation. Contraception 2021; 104:275-277. [PMID: 33831443 DOI: 10.1016/j.contraception.2021.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe effectiveness of funic potassium chloride (KCl) injection for fetal demise during intact dilation and evacuation (D&E). STUDY DESIGN We abstracted medical records of patients who underwent standard or intact D&E to identify those who had intact D&E from 20 weeks 0 days through 23 weeks 6 days from February 2016 to August 2017 at one academic center. We extracted data on time to asystole following KCl injection, as well as incidents including hemorrhage, infection, uterine perforation, and unplanned admissions for up to 6 months following each procedure. RESULTS Of 57 procedures, 32 (56%) were intact. Median time from KCl injection to fetal asystole was 48 seconds (interquartile range [IQR] 34-100). Median time to asystole at weeks 20 and 21 (46 seconds [IQR 34-60 seconds]) did not differ significantly from weeks 22 and 23 (85 seconds [IQR 34-200 seconds]), p = 0.15. Asystole occurred in less than four minutes in all cases but one. No adverse events occurred with either the funic KCl injections or the intact D&E procedures. CONCLUSION Funic KCl injection for intact D&E usually causes fetal asystole in less than 4 minutes. IMPLICATIONS Funic KCl injection under direct visualization is a feasible method to induce fetal asystole at the time of intact dilation and evacuation.
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Affiliation(s)
- Siripanth Nippita
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
| | | | - Maureen E Paul
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
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11
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Disseminated herpes simplex virus 2 as a complication of pregnancy. IDCases 2021; 24:e01107. [PMID: 33889496 PMCID: PMC8047449 DOI: 10.1016/j.idcr.2021.e01107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022] Open
Abstract
Disseminated herpes simplex virus 2 (HSV-2) infection, is a rare but devastating infection in pregnancy women. We present the case of a 30-year-old gravida 3, para 2-0-0-2, at 26 weeks 2 days gestation who presented with eleven days of vague and indolent symptoms before a diagnosis of disseminated HSV-2 infection with associated hepatitis was made. While the patient clinically improved with empiric acyclovir treatment, possibility of significant harm to the fetus remained, and the patient request elective termination. The authors review the epidemiology, diagnosis, treatment, and prognosis of disseminated HSV-2 infection in pregnancy.
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Tolu LB, Tufa TH, Abas F, Kahn C, MacAfee L, Prager S, Bell JD. Intra-cardiac lidocaine administration to induce fetal demise before late second-trimester abortion: Retrospective review. Int J Gynaecol Obstet 2020; 153:125-129. [PMID: 33043458 DOI: 10.1002/ijgo.13419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/15/2020] [Accepted: 10/09/2020] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Lemi Belay Tolu
- Department of Obstetrics & Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Tesfaye H Tufa
- Department of Obstetrics & Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Ferid Abas
- Department of Obstetrics & Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Chavi Kahn
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Lauren MacAfee
- Department of Obstetrics, Gynecology and Reproductive Science, University of Vermont, Burlington, VT, USA
| | - Sarah Prager
- Department of Obstetrics & Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.,Department of Obstetrics & Gynecology, University of Washington, Seattle, WA, USA
| | - Jason D Bell
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI, USA
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Tufa TH, Prager S, Lavelanet AF, Kim C. Drugs used to induce fetal demise prior to abortion: a systematic review. Contracept X 2020; 2:100046. [PMID: 33294839 PMCID: PMC7689273 DOI: 10.1016/j.conx.2020.100046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/17/2020] [Accepted: 10/19/2020] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Tesfaye H Tufa
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.,UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Sarah Prager
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.,Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, USA
| | - Antonella F Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Caron Kim
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Tufa TH, Lavelanet AF, Belay L, Seboka B, Bell J. Feasibility of intra-amniotic digoxin administration by obstetrics and gynecology trainees to induce fetal demise prior to medical abortion beyond 20 weeks. BMJ SEXUAL & REPRODUCTIVE HEALTH 2020; 46:308-312. [PMID: 32241827 PMCID: PMC7569366 DOI: 10.1136/bmjsrh-2019-200396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 02/27/2020] [Accepted: 03/11/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Tesfaye Hurissa Tufa
- Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Lemi Belay
- Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Berhanu Seboka
- Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Jason Bell
- Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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15
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Goergen SK, Alibrahim E, Govender N, Stanislavsky A, Abel C, Prystupa S, Collett J, Shelmerdine SC, Arthurs OJ. Diagnostic assessment of foetal brain malformations with intra-uterine MRI versus perinatal post-mortem MRI. Neuroradiology 2019; 61:921-934. [PMID: 31076826 PMCID: PMC6620257 DOI: 10.1007/s00234-019-02218-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/16/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate differences in diagnostic yield of intra-uterine foetal (iuMR) and post-mortem MRI (PMMR) for complex brain malformations, using autopsy as the reference standard. METHODS In this retrospective, multicentre study spanning 2 years, we reviewed 13 terminated singleton pregnancies with a prenatal ultrasound finding of complex foetal cerebral abnormalities, referred for both iuMR and PMMR. The iuMR and PMMR studies of the brain were reported independently by two groups of radiologists, blinded to each other's reports. Descriptive statistics were used to compare differences in intracranial abnormalities with autopsy (and genetic testing, where present) as reference standard. RESULTS The median gestational age at termination was 24.6 weeks (IQR 22-29) with median time between delivery and PMMR of 133 h (IQR 101-165). There was full concordance between iuMR and PMMR findings and autopsy in 2/13 (15.3%) cases. Partial concordance between both imaging modalities was present in 6/13 (46.2%) and total discordance in the remainder (5/13, 38.5%). When compared to autopsy, PMMR missed important key findings specifically for neuronal migration and cerebellar anomalies, whereas iuMR appeared to overcall CSF space abnormalities which were less crucial to reaching the final overall diagnosis. CONCLUSIONS iuMR should be performed to improve foetal phenotyping where there is a prenatal ultrasound for complex foetal brain abnormalities. Reliance on PMMR alone is likely to result in misdiagnosis in a majority of cases.
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Affiliation(s)
- Stacy K Goergen
- Monash Imaging, Clayton, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Ekaterina Alibrahim
- Department of Medical Imaging, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Nishentha Govender
- Department of Medical Imaging, Royal Women's Hospital, Parkville, Victoria, Australia
| | | | - Christian Abel
- Department of Medical Imaging, John Hunter Hospital, Newcastle, New South Wales, Australia
- Department of Anatomical Pathology, Monash Health, Clayton, Victoria, Australia
| | - Stacey Prystupa
- Department of Medical Imaging, John Hunter Hospital, Newcastle, New South Wales, Australia
- Department of Anatomical Pathology, Monash Health, Clayton, Victoria, Australia
| | - Jacquelene Collett
- Department of Anatomical Pathology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Susan C Shelmerdine
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
- UCL Great Ormond Street Institute of Child Health, London, UK.
| | - Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
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16
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Lerma K, Blumenthal PD. Current and potential methods for second trimester abortion. Best Pract Res Clin Obstet Gynaecol 2019; 63:24-36. [PMID: 31281014 DOI: 10.1016/j.bpobgyn.2019.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/26/2022]
Abstract
Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.
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Affiliation(s)
- Klaira Lerma
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA.
| | - Paul D Blumenthal
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA
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17
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Sharvit M, Klein Z, Silber M, Pomeranz M, Agizim R, Schonman R, Fishman A. Intra-amniotic digoxin for feticide between 21 and 30 weeks of gestation: a prospective study. BJOG 2019; 126:885-889. [PMID: 30703286 DOI: 10.1111/1471-0528.15640] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2018] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- M Sharvit
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Z Klein
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - M Silber
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - M Pomeranz
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - R Agizim
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - R Schonman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - A Fishman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
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18
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Lohr PA, Parsons JH, Taylor J, Morroni C. Outcomes of dilation and evacuation with and without feticide by intra-cardiac potassium chloride injection: a service evaluation. Contraception 2018; 98:S0010-7824(18)30146-X. [PMID: 29680767 DOI: 10.1016/j.contraception.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 04/12/2018] [Accepted: 04/15/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Chelsea Morroni
- Liverpool School of Tropical Medicine, Liverpool, UK; University of Witwatersand Reproductive Health and HIV Institute, Johannesburg; Botswana UPenn Partnership, Gaborone, Botswana
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McNamara B, Russo J, Chaiken S, Jacobson J, Kerns J. A qualitative study of digoxin injection before dilation and evacuation. Contraception 2018; 97:515-519. [PMID: 29477630 DOI: 10.1016/j.contraception.2018.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Blair McNamara
- Yale University School of Medicine, New Haven, CT 06520, USA.
| | - Jennefer Russo
- Planned Parenthood of Orange and San Bernardino Counties, Orange, CA 92866, USA
| | | | - Janet Jacobson
- Planned Parenthood of Orange and San Bernardino Counties, Orange, CA 92866, USA
| | - Jennifer Kerns
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA 94110, USA
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20
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Abstract
OBJECTIVE To evaluate the rate of live birth and the duration of survival after termination of pregnancy without feticide. METHODS We conducted a retrospective analysis of 241 terminations of pregnancy without feticide for fetal anomalies or genetic abnormalities between 20 0/7 and 24 0/7 weeks of gestation at a single tertiary care referral center in Europe between February 2003 and May 2017. A multivariate binary regression model was used to evaluate factors associated with live birth. RESULTS Pregnancies were terminated at a mean gestational age of 22.1±1.1 completed weeks of gestation. Median birth weight was 440 g (range 141-1,890 g). Live birth occurred in 122 cases (50.6%, 95% CI 44.4-56.8); median survival time was 32 minutes (range 1-267 minutes). Factors associated with live birth were gestational age at labor induction (odds ratio 1.41, 95% CI 1.01-2.01; P=.049) and fetal anomalies (P=.046). CONCLUSION After termination of pregnancy without feticide between 20 0/7 and 24 0/7 weeks of gestation, the live birth rate was 50.6% (95% CI 44.4-56.8). A lower gestational age at labor induction and the presence of skeletal, cerebral, renal, or multiple fetal anomalies increased the chance of stillbirth.
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21
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Denny CC, Baron MB, Lederle L, Drey EA, Kerns JL. Induction of fetal demise before pregnancy termination: practices of family planning providers. Contraception 2015; 92:241-5. [PMID: 25998938 DOI: 10.1016/j.contraception.2015.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 05/07/2015] [Accepted: 05/09/2015] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Colleen C Denny
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences.
| | | | - Lauren Lederle
- University of California, San Francisco School of Medicine
| | - Eleanor A Drey
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences
| | - Jennifer L Kerns
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences
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22
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Calder AD, Offiah AC. Foetal radiography for suspected skeletal dysplasia: technique, normal appearances, diagnostic approach. Pediatr Radiol 2015; 45:536-48. [PMID: 25173408 DOI: 10.1007/s00247-014-3130-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 06/20/2014] [Accepted: 07/15/2014] [Indexed: 11/26/2022]
Abstract
Despite advances in antenatal imaging and genetic techniques, post-delivery post-mortem foetal radiography remains the key investigation in accurate diagnosis of skeletal dysplasia manifesting in the foetus. Foetal radiography is best performed using pathology-specimen radiography equipment and is often carried out in the pathology department without involvement of the radiology unit. However, paediatric radiologists may be asked to interpret post-mortem foetal radiographs when an abnormality is suspected. Many foetal radiographs are carried out before 20 weeks' gestation, and the interpreting radiologist needs to be familiar with the range of normal post-mortem foetal appearances at different gestational ages, as well as the appearances of some of the more commonly presenting skeletal dysplasias, and will benefit from a systematic approach when assessing more challenging cases. In this pictorial essay, we illustrate various normal post-mortem foetal radiographic appearances, give examples of commonly occurring skeletal dysplasias, and describe an approach to establishing more difficult diagnoses.
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Affiliation(s)
- Alistair D Calder
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK,
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23
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Nonsurgical Management of Live Tubal Ectopic Pregnancy by Ultrasound-Guided Local Injection and Systemic Methotrexate. J Minim Invasive Gynecol 2014; 21:642-9. [DOI: 10.1016/j.jmig.2014.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 01/10/2014] [Accepted: 01/12/2014] [Indexed: 11/18/2022]
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Sfakianaki AK, Davis KJ, Copel JA, Stanwood NL, Lipkind HS. Potassium chloride-induced fetal demise: a retrospective cohort study of efficacy and safety. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:337-341. [PMID: 24449738 DOI: 10.7863/ultra.33.2.337] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Induction of fetal demise before second-trimester termination is performed for a number of reasons. One method for inducing fetal demise is via sonographically guided intracardiac potassium chloride (KCl) injection. We performed a retrospective cohort study to determine the efficacy and safety of intracardiac KCl injection as a method of second-trimester induced fetal demise. METHODS We reviewed records from patients who were referred for induced fetal demise from October 2002 to October 2011. We excluded patients undergoing selective fetal reduction in multiple gestations. Procedural complications, the dose of KCl, and the number of failed procedures were determined. RESULTS Of the 192 completed procedures, 191 were successful (99.5%). The median gestational age at termination was 22 weeks (range, 15.4-24.9 weeks), and most terminations were surgical (68.0%). Major indications for termination were fetal anomalies (41.6%), unwanted pregnancy (20.8%), and aneuploidy (15.7%). The median dose of KCl was 10 mL (range, 3-40 mL). We found a significant correlation between the dose of KCl and estimated fetal weight. There was no significant correlation between the dose of KCl and body mass index or gestational age. We had 1 maternal complication of a seizure after needle placement but before KCl injection. CONCLUSIONS Intracardiac KCl injection is an effective and safe method for induced fetal demise.
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Affiliation(s)
- Anna K Sfakianaki
- Sections of Maternal-Fetal Medicine and Family Planning, Department Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, 333 Cedar St, PO Box 208063, New Haven, CT 06520 USA.
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25
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Umbilical cord transection to induce fetal demise prior to second-trimester D&E abortion. Contraception 2013; 88:712-6. [DOI: 10.1016/j.contraception.2013.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 11/22/2022]
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26
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Tocce K, Sheeder JL, Edwards LJ, Teal SB. Feasibility, effectiveness and safety of transvaginal digoxin administration prior to dilation and evacuation. Contraception 2013; 88:706-11. [PMID: 24034581 DOI: 10.1016/j.contraception.2013.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Kristina Tocce
- University of Colorado Denver School of Medicine, Department of Obstetrics and Gynecology, Mail Stop 198-2 AO1, 12631 E. 17th Avenue, Room 4006, Aurora, CO 80045, USA.
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Garg M, Markovchick N. Hyperkalemic Paralysis: An Elective Abortion Gone Wrong. J Emerg Med 2013; 45:190-3. [DOI: 10.1016/j.jemermed.2013.01.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 08/30/2012] [Accepted: 01/29/2013] [Indexed: 10/26/2022]
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Interruption of nonviable pregnancies of 24-28 weeks' gestation using medical methods: release date June 2013 SFP guideline #20133. Contraception 2013; 88:341-9. [PMID: 23756114 DOI: 10.1016/j.contraception.2013.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The need to interrupt a pregnancy between 24 and 28 weeks of gestation is uncommon and is typically due to fetal demise or lethal anomalies. Nonetheless, treatment options become more limited at these gestations, when access to surgical methods may not be available in many circumstances. The efficacy of misoprostol with or without mifepristone has been well studied in the first and earlier second trimesters of pregnancy, but its use beyond 24 weeks' gestation is less well described. This document attempts to synthesize the existing evidence for the use of misoprostol with or without mifepristone to induce labor for nonviable pregnancies at gestations of 24-28 weeks. The composite evidence suggests that a regimen combining mifepristone and misoprostol may shorten the time to expulsion, though the overall success rates are similar to those seen with misoprostol-only regimens.
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Transvaginal administration of intraamniotic digoxin prior to dilation and evacuation. Contraception 2012; 87:76-80. [PMID: 22959902 DOI: 10.1016/j.contraception.2012.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 07/13/2012] [Accepted: 07/27/2012] [Indexed: 11/21/2022]
Abstract
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.
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Grimes DA, Stuart GS, Raymond EG. Feticidal digoxin injection before dilation and evacuation abortion. Contraception 2012; 85:140-3. [DOI: 10.1016/j.contraception.2011.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
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Singh S, Seligman NS, Jackson B, Berghella V. Fetal intracardiac potassium chloride injection to expedite second-trimester dilation and evacuation. Fetal Diagn Ther 2011; 31:63-8. [PMID: 22189183 DOI: 10.1159/000333815] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Accepted: 09/22/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine whether potassium chloride (KCl)-induced feticide prior to termination by dilation and evacuation (D&E) improves surgical outcome. METHODS We conducted a retrospective study of women who underwent second-trimester (13 0/7 to 23 6/7 weeks) D&E at an urban university-based hospital between January 2000 and July 2010. Women were divided into 3 cohorts: (1) D&E for termination of pregnancy after feticide, (2) D&E without feticide, and (3) D&E for spontaneous pregnancy loss. We compared maternal characteristics, various perioperative variables, and surgical outcomes for all 3 groups. Anesthesia time was used as a surrogate for operative time in the primary outcome. RESULTS We analyzed 128 pregnancies (group 1: n = 23, group 2: n = 53, group 3: n = 52). Baseline maternal characteristics did not differ among the 3 groups. Anesthesia time was longest in the termination with KCl group (group 1: 116.9 min vs. group 2: 94.5 min and group 3: 90.3 min, p = 0.004), however, the effect was mitigated after controlling for fetal size (p = 0.176). There was no difference in blood loss (p = 0.968). Complications were uncommon, however, cervical lacerations were more common in the termination with KCl group (2 vs. 0 and 0, p = 0.010). CONCLUSION Presurgical feticide with KCl was not associated with shorter anesthesia time. The decision to perform feticide should be based on other considerations, such as patient preference.
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Affiliation(s)
- Sareena Singh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Dean G, Colarossi L, Lunde B, Jacobs AR, Porsch LM, Paul ME. Safety of digoxin for fetal demise before second-trimester abortion by dilation and evacuation. Contraception 2011; 85:144-9. [PMID: 22067788 DOI: 10.1016/j.contraception.2011.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 05/19/2011] [Accepted: 05/21/2011] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Gillian Dean
- Planned Parenthood of New York City, New York, NY 10012, USA.
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