Emeka Oloto

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    Effectiveness of intracardiac potassium chloride for feticide prior to termination of pregnancy between 20 and 24 weeks

    Emeka Oloto (Great Britain)

     

    Background.There is a rising trend in the number of abortions carried out for England and Wales residents and the total was 193737 in 20061. Only 1.5% (2948) of these was carried out at 20 weeks and over of which 34% (1002) were reported as involving feticide. In United Kingdom, termination of pregnancy (TOP) can only be carried out in a National Health Service (NHS) hospital or in a place approved for the purpose by the Secretary of State for Health (non-NHS setting). In 2006, 75328 (39%) of all abortions were performed in the NHS hospitals of which 679 (<1%) were at gestations of 20 weeks and above. The distribution of the feticide procedures between the two settings was not obvious from the published data1.

    Objective. This study was conducted to assess the effectiveness and safety of intracardiac Potassium Chloride administration in inducing fetal demise prior to second trimester pregnancy termination in a non-NHS setting.

    Patients and Methods.Data regarding the age, parity, gestation, dose of KCl required to achieve asystole, presence or absence of cardiac activity at delivery or immediately before surgery, duration of procedure (from entering to leaving the theatre) and complications were prospectively collected in an excel spreadsheet from February 2007 till date. The feticide was carried out in theatre under general anaesthesia, aseptic conditions and continuous ultrasound guidance. A 16 cm 17-G Chiba needle (Cook Ob/Gyn, Spencer, Indiana, USA) was inserted into the fetal heart and a concentrated KCl (15% , 20mM/10ml ; B-Braun Melsungen AG, Germany) was injected 1 ml at a time until fetal asystole was achieved. A minimum of 5 mls of KCl was given in each case but the dose required to achieve asystole was recorded. Fetal cardiac activity was then observed for about 1-2 minutes to confirm that asystole persisted, but scan was not repeated thereafter. Anti-D immunoglobulin (500 iu) prophylaxis was given to all RhD-negative women. Following feticide, labour was induced for those undergoing medical TOP and surgery the following day for the rest.

    Results.Till date241 feticide procedures have been carried out for women between 20 and 24 weeks gestation (mean gestational age of 22 weeks) of which 2 (0.8%) failed to achieve fetal demise. Fifty women (21%) had medical TOP while the rest had surgery. The average age of the patients was 22 years (range 13 – 42 years) and the average parity was 1 (range 0 – 5). 48% of the women were teenagers. The average duration of procedure was 12 minutes (range 5 – 40 minutes) and the average dose of KCl required to achieve asystole was 3 mls (range 1 – 15 mls). No live birth occurred and no maternal complication. The two cases where feticide failed were for planned surgery which was carried out successfully.

    Discussion.The Royal College of Obstetrician and Gynaecologists (RCOG) recommended that the method chosen for all terminations at gestational age of more than 21 weeks and 6 days should ensure that the fetus is burn dead. Feticide prior to TOP at late gestation is necessary to avoid resuscitation dilemma for patients, nurses and doctors2; to avoid medico-legal and economic consequences of live birth that survives3; to shorten the mean ‘initiation-expulsion interval4; to reduce the prostaglandin requirement for mid-trimester medical abortion5; and to soften fetal cortical bones which aids surgery and minimises risk to the patients4. Of the available methods for feticide6, intracardiac injection of potassium Chloride (KCl) appears to be the most effective. The average dose of KCl required in this study (3mls) is similar to that reported recently7, but much less than the amount reported by Bhide et al.8

    Conclusion.This is, to my knowledge, the first report of the experience of using intracardiac KCl for feticide prior to mid-trimester abortion in non-NHS setting in United Kingdom. It is an effective and safe procedure in non-NHS settings with appropriately trained team and should not be limited to tertiary fetal medicine unit as suggested by Pasquini et al.7

    References.

    1.      Department of Health Abortion Statistics, England and Wales: 2006, Statistical Bulletin 2007/xx. London: Department of Health 2007.

    2.      Royal College of Obstetricians and Gynaecologists. Further Issues Relating to Late Abortion, Fetal Viability and Registration of Births and Deaths. RCOG Statement London; RCOG Press; 2001.

    3.      Clark et al. An Infant who survived Abortion and Neonatal Intensive Care. Blumenthal PD et al. Abortion by Labour Induction. A Clinician’s guide to Medical and Surgical Abortion.

    5.      Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstet Gynecol 1999;94:139-41.

    6.      National Abortion Federation – Clinical Practice Bulletin: Digoxin Administration. May 2, 2007.

    7.      Pasquini L, Pontello V, Kumar S. Intracardiac injection of potassium chloride as Method for feticide: experience from a single UK tertiary centre. BJOG 2008;115(4):528-531.

    8.     Bhide A, Sairam S, Hollis B et al. Comparison of feticide carried out by cordocentesis versus cardiac puncture. Ulrasound Obstet Gyncol 2002;20:230-2.