From the revised guidelines on women seeking induced abortion, by the Royal College of Obstetricians and Gynaecologists (United Kingdom), made public today:
(Tip: Le Salon Beige)6.7 Feticide
Feticide should be performed before medical abortion after 21 weeks and 6 days of gestation to ensure that there is no risk of a live birth.
Evidence supporting recommendation 6.21
Inducing fetal death before medical abortion may have beneficial emotional, ethical and legal consequences.The RCOG guidance on termination of pregnancy for fetal abnormality (published in 2010) clearly explains the legal situation around late-stage abortions (see Chapter 2). Where a decision to abort a pregnancy after 21 weeks and 6 days is taken, feticide should be routinely offered. In abortions where the fetal abnormality is not compatible with life, abortion without feticide may be preferred. However, in cases where the fetal abnormality is not lethal or the abortion is not for fetal abnormality and is being undertaken after 21 weeks and 6 days of gestation, failure to perform feticide could result in a live birth and survival, which contradicts the intention of the abortion. Regarding fetal pain and awareness, the RCOG has published guidance and concluded that ‘In reviewing the neuroanatomical and physiological evidence in the fetus, it was apparent that connections from the periphery to the cortex are not intact before 24 weeks of gestation and, as most neuroscientists believe that the cortex is necessary for pain perception, it can be concluded that the fetus cannot experience pain in any sense prior to this gestation.’
Very few abortions on grounds C or D are undertaken at late gestations. Only 9% of abortions occur after 13 weeks and only 1.5% occur after 20 weeks of gestation. In Great Britain, those few are, for the most part, undertaken within the specialist independent sector. When the method of abortion chosen by a specialist practitioner is surgical (D&E), the nature of the procedure ensures that there is no risk of a live birth, although in one study 91% of women indicated a preference that the fetus was dead. When medical abortion is chosen, special steps are required to ensure that the fetus is dead at the time of abortion. The RCOG recommends feticide for abortions over 21 weeks and 6 days of gestation, except in the case of lethal fetal abnormality, and that feticide should always be performed by an appropriately trained practitioner (under consultant supervision) using aseptic conditions and with continuous ultrasound.
The RCOG recommends intracardiac potassium chloride (KCl) 2–3 ml strong (15%) injection into a cardiac ventricle. A repeat injection may be required if asystole has not occurred after 30–60 seconds. Asystole should be observed for at least 2 minutes and fetal demise should be confirmed by ultrasound scan after 30–60 minutes.
Fetal demise may also be induced by intra-amniotic or intrathoracic injection of digoxin (up to 1 mg) and by umbilical venous or intracardiac injection of 1% lidocaine (up to 30 ml); however, neither procedure consistently induces fetal demise.
A dose of digoxin 1 mg given either intra-amniotically or intrafetally will cause fetal death in 87% of cases; the latter method is much more rapid. A dose of digoxin 1.5 mg given intra-amniotically caused death within 20 hours (in most cases there was still fetal cardiac activity at 4 hours). In a large retrospective review, Molaei et al. (2008) concluded that the overall failure rate with digoxin was 7%, although there were no failures with an intrafetal dose of 1 mg. Importantly, in this review there were no adverse effects at any of the doses used.
Intracardiac injection of either KCl or intrathoracic injection of digoxin requires considerably more skill than intra-amniotic injection of digoxin. While the latter may be slightly less effective in inducing fetal demise, its use may be an option for services that lack personnel with sufficient skill in administering intracardiac injections.