Intracardiac Potassium Chloride Research Articles

Medical termination of pregnancy with digoxin in a patient affected by severe congenital toxoplasmosis.

SynopsisIntrafetal digoxin is a safer and effective alternative to perform medical termination of pregnancy over intracardiac potassium chloride in cases of massive placental inflammation, such as congenital infections.

Cesarean Scar Pregnancy: A Tertiary Care Center Experience

Objectives: To describe the management and treatment outcomes of cesarean scar pregnancies diagnosed in a tertiary care center. Methods: This study retrospectively described all cases of cesarean scar pregnancy diagnosed and managed at a tertiary care center over a 3-year period. Maternal demographics, clinical presentation, treatment methods, and outcomes were all included in the analysis. Results: uring the study period, 5 cases of cesarean scar pregnancy were diagnosed and managed. The median gestational age at diagnosis was 8 weeks, and all fetuses had positive cardiac activity. All cases were initially treated with systemic intramuscular (IM) methotrexate (MTX), but only one case responded well due to fetal bradycardia present prior to treatment. One patient received further management with transvaginal intracardiac potassium chloride (KCL) injection, which resulted in maternal sepsis, hemorrhage, and ICU admission. The other 3 cases were managed by transabdominal intra-gestational sac MTX +/- KCL and showed good clinical response. Two of these cases required an interval dilation & curettage (D&C) due to persistent vaginal spotting with no complications. Conclusions: It is recommended to avoid using systemic IM MTX as the first-line treatment for scar pregnancy unless the pregnancy is failing or non-viable. Intra-gestational sac treatment may cause persistent retained products of conception, leading to bothersome vaginal spotting. An interval ultrasound guided D&C appears to be safe for managing this complication, but the exact interval needs to be determined through further studies. Sepsis is a rare complication of invasive medical treatment, and close surveillance is advised.

EVALUATION OF INTRACARDIAC ADMINISTRATION OF POTASSIUM CHLORIDE, IVERMECTIN, OR LIDOCAINE HYDROCHLORIDE FOR EUTHANASIA OF ANESTHETIZED BLUE CRABS (CALLINECTES SAPIDUS).

Methods to anesthetize and euthanize aquatic invertebrates have proven unreliable in decapods; thus studies to optimize euthanasia techniques for crustaceans are needed. Study objectives were to evaluate efficacy of intracardiac potassium chloride (KCl), ivermectin, or lidocaine hydrochloride (HCl) for euthanasia of anesthetized blue crabs (Callinectes sapidus). Twenty adult male crabs (n = 5/group) were immersed in 500 mg/L eugenol for 5 min beyond loss of the righting reflex and then randomly administered intracardiac 10 mEq/kg KCl (333 mg/mL), 5 mg/kg ivermectin (10 mg/ml), 100 mg/kg lidocaine hydrochloride (HCl) (20 mg/ml), or 5 ml/kg saline (0.9%). Serial heart rate assessments were made using a Doppler probe placed over the dorsum, and times to loss of righting reflex, Doppler sound cessation, and/or recovery were recorded. Median (range) time to loss of righting reflex was 32 (17-57) min. One crab in all groups, except lidocaine HCl, had no detectable Doppler sounds prior to injection. In the remaining crabs, Doppler sound cessation occurred in 4/4, 4/4, 4/5, and 0/4 crabs administered KCl, ivermectin, lidocaine HCl, and saline, respectively. Median (range) time to Doppler sound cessation was 30 (0-55), 18 (16-28), and 50 (0-90) s in KCl, ivermectin, and lidocaine HCl groups, respectively. Tonic limb movements were observed in 5/5 KCl-treated crabs. Median (range) time to recovery was 180 (115-345) and 300 m in four saline-treated crabs and one lidocaine HCl-treated crab, respectively. Intracardiac KCl at 10 mEq/kg and ivermectin at 5 mg/kg were effective, rapid methods for euthanasia of anesthetized blue crabs.

Intraamniotic digoxin administration versus intracardiac or funic potassium chloride administration to induce foetal demise before termination of pregnancy: a prospective study

Different foeticide techniques and pharmacological agents have been used to achieve foetal asystole. This study aimed to compare the success of intraamniotic digoxin, intracardiac potassium chloride (KCl), and funic KCl in achieving foetal asystole and discuss procedural difficulties for physicians and clinical outcomes. This prospective observational study included 124 patients who received foeticide at 22–31 weeks of gestation. All procedures were performed transabdominally, and 1 mg of intraamniotic digoxin, funic KCl, or intracardiac KCl was administered. Procedure times, procedural difficulty scores, patient pain scores, decrease in haematocrit levels, induction and hospitalisation times, and the presence of chorioamnionitis were recorded. The foeticide success rates were 93.0, 95.1, and 97.5% for intraamniotic digoxin, intracardiac KCl, and funic KCl, respectively. Intraamniotic digoxin was associated with shorter procedure times, lower procedural difficulty scores, and lower patient pain scores (p < 0.001). Decreases in haematocrit, induction times, and chorioamnionitis were similar in all three procedures. Success rates and clinical results were similar for all three procedures. Foeticide with intra-amniotic digoxin has a high success rate, the procedure is easier to perform, and patients experience less procedural pain. IMPACT STATEMENT What 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.

Robotic Assisted Resection of 16 Week Uterine Horn Pregnancy: A Minimally Invasive Approach to the Second Trimester Ectopic Pregnancy

<h3>Study Objective</h3> To demonstrate by video our surgical approach of the resection of a second trimester rudimentary horn ectopic pregnancy. <h3>Design</h3> Case Report <h3>Setting</h3> University hospital. Patient in dorsal lithotomy position. <h3>Patients or Participants</h3> A 22-year-old primigravida presented at 16 weeks gestation following two failed elective terminations, in the setting of a spontaneous pregnancy with a known uterine anomaly. The patient reported a prior diagnostic laparoscopy revealing a left unicornuate uterus. Outside ultrasounds reported an intrauterine pregnancy however MRI upon admission revealed a fetus located within a thin-walled structure separate from the main uterine cavity, consistent with a rudimentary horn pregnancy. <h3>Interventions</h3> A fetal intracardiac potassium chloride injection was completed by maternal fetal medicine to halt the growth of the pregnancy during pre-operative planning. Tranexamic acid was administered preoperatively to minimize blood loss. Ureteral stents were placed to safely identify the ureters with the knowledge that Mullerian anomalies are often associated with concomitant renal abnormalities. Robotic assisted laparoscopy was used to resect the rudimentary uterine horn containing the 16-week gestation with ipsilateral ureterolysis and uterine artery ligation. <h3>Measurements and Main Results</h3> Exam under anesthesia and diagnostic laparoscopy revealed a unicornuate uterus with a communicating rudimentary horn. The procedure was uncomplicated with an estimated blood loss of 100cc. The patient's hemoglobin remained stable from 11.7 preoperatively to 10.8 postoperatively. She was meeting all milestones and discharged home on postoperative day one. <h3>Conclusion</h3> Rudimentary uterine horn pregnancies are rare and best managed by a multidisciplinary team. Robotic-assisted surgery may decrease blood loss, length of stay and comorbidities from surgery in the setting of a rudimentary horn ectopic pregnancy. Rather than assuming infertility, long-acting reversible contraceptives should be offered to women to prevent recurrence.

Protrusion of placental tissue through the cervical os as an unusual presentation of placenta accreta: A case report

IntroductionAbnormal placentation commonly occurs in women with a history of uterine surgery or placenta previa. Placenta accreta spectrum can occur in the setting of lesser-known risk factors and anatomical locations.CaseA 41-year-old woman (G6P4014) at 18 weeks of gestation without major risk factors was diagnosed with a placenta accreta after presenting for desired termination of pregnancy. On examination, placental tissue was found to be protruding through the cervical os and this was confirmed by magnetic resonance imaging (MRI). Management included pregnancy termination with intracardiac potassium chloride injection, uterine artery embolization, and a total abdominal hysterectomy.ConclusionProtruding cervical tissue should raise suspicion for placenta accreta. Appropriate evaluation and surgical planning should be performed to ensure a safe delivery.

Different treatment modalities for cesarean scar pregnancies: a single-center experience and literature review.

Cesarean scar pregnancy (CSP) remains a sporadic form of ectopic pregnancy associated with a severe life-threatening condition. There is no consensus on the treatment modality or a generally accepted guideline in CSP. This study aims to evaluate the outcomes of the different treatment modalities used in CSP treatment at a single center, as well as a literature review. This is a retrospective case series study that was conducted; all women who diagnosed with CSP between January 2013 and November 2019 at Women's Specialized Hospital, King Fahad Medical City. The clinical characteristics, diagnosis, different treatment modalities, and clinical outcomes were analyzed. Twenty-seven cases of CSP identified during the study period. The median maternal age was 38years (range 23-47years). The gestational age at diagnosis ranged between 5weeks and 5days to 13weeks and 6days. All diagnoses were made by ultrasound. The absence of embryonic cardiac activity was seen in 10 cases (37.03%). The most commonly used method for first-line treatment was medical treatment. A total of 14 patients (51.85%) were treated with systemic methotrexate (MTX), three (11.1%) intra-sac and systemic MTX, and two (7.4%) intra-cardiac potassium chloride (KCl) along with systemic MTX, five (18.51%) cases had expectant management, one case initially treated with Laparotomy Wedge resection, and one case treated with uterine artery embolization (UAE) and systemic MTX. A total of 20 (74.07%) patients were treated successfully with first-line treatment. Seven (25.92%) patients needed additional second-line treatment. Among them, only one case had surgical intervention. None of the women in the medical treatment group experienced any side effects. Based on ANOVA results, there is no considerable relationship between the mean time of resolution of β-hCG and four treatment modalities for CSP (p = 0.2406). There was no statistical significance when the fetal viability at the time of diagnosis was compared to the need for second-line treatment of CSP (p = 0.58). The treatment of CSP should be individualized based on risk factors. Diagnosis and management of CSP need expertise and a multidisciplinary approach to prevent complications. Early diagnosis and management of cesarean scar ectopic pregnancy remains the mainstay for a successful outcome.

The Utility of Feticide Procedure to Shorten the Induction-to-Abortion Interval in Medical Abortion

Aim: To evaluate the effect of intracardiac potassium chloride feticide procedure (FP) on the induction-to-abortion (I-to-A) interval for various indications in the termination of pregnancy. Method: Medically indicated abortions between 17 and 28 weeks’ gestation were retrospectively evaluated and allocated into 2 groups: Cases with (group 1, n = 58) or without an FP (group 2, n = 60). I-to-A intervals were compared across the groups, considering different baseline parameters and fetal abnormality categories. Results: There were no differences among the groups except in gestational age (GA; mean, 21.2 vs. 19.6 weeks, p = 0.01) in group 1. Overall, the I-to-A interval was shorter (900 ± 233 vs. 1,198 ± 375 min, p = 0.001) and prolonged medical abortion (I-to-A interval > 48 h) was less common (2% vs. 6%, p = 0.03) in group 1. The facilitating effect of FP persisted when indications were categorized as central nervous system, chromosomal, other structural abnormalities, and unclassified conditions. Logistic regression analyses demonstrated the following features to be associated with expulsion of fetus after 24-h: (1) advanced GA (> 24 week; aOR 6.9, 95% CI 3.24–14.72), (2) central nervous system abnormalities (aOR 5.3, 95% CI 2.6–11.4), (3) lack of feticide (aOR 3.67, 95% CI 2.24–10.72). Conclusion: FPs seem to shorten the I-to-A interval and decrease prolonged I-to-A interval rates. This facilitating effect remains unchanged for various medical indications.

Post-Mortem Magnetic Resonance Imaging Appearances of Feticide in Perinatal Deaths

Objective: The aim of this study was to characterise the imaging features seen in fetuses having undergone feticide by intracardiac potassium chloride injection compared to those of non-terminated fetuses at post-mortem magnetic resonance imaging (PMMRI). Methods: A case-control study was performed comparing PMMRI findings between two groups of patients – those having undergone feticide were matched to a control group of miscarried/stillborn fetuses. The groups were matched according to gestational age, weight, and time since death. Two independent readers reviewed the PMMRI for thoracic, abdominal, and musculoskeletal imaging features. The Fishers exact test was conducted for differences between the patient groups. Results: Twenty-six cases of feticide (mean gestation 25 weeks [20–36]) and 75 non-terminated fetuses (mean gestation 26.7 weeks [19–36]) were compared. There was a higher proportion of feticide cases demonstrating pneumothorax (23.1 vs. 1.3%, p = 0.001), haemothorax (42.3 vs. 4%, p = 0.001), pneumopericardium (30.8 vs. 5.3%, p = 0.002), and haemopericardium (34.6 vs. 0%, p = 0.0001). Intracardiac gas and intra-abdominal findings were higher in the feticide group, but the differences were not statistically significant. Conclusion: Characteristic PMMRI features of feticide can help improve reporter confidence in differentiating iatrogenic from physiological/pathological processes.

Outcomes of dilation and evacuation with and without feticide by intra-cardiac potassium chloride injection: a service evaluation

ObjectiveTo compare procedure duration, complications, and acceptability of dilation and evacuation (D&E) with and without feticide by intra-cardiac potassium chloride (KCL) injection. Study designWe 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. ResultsWe 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). ConclusionsFeticide 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.

OP23.04: Selective reduction in complex triplet pregnancy by radio frequency ablation: single centre experience

The risk of miscarriage and preterm delivery are significantly higher in multiple pregnancies with a monochorionic pair. Intra fetal anastomosis in monochorionic (MC) pair preclude the use of intracardiac potassium chloride and fetal reduction must be performed using cord occlusion techniques such as bipolar cord coagulation, interstitial laser or by radiofrequency ablation. We present our series of selective reduction in complex triplet pregnancy with an MC pair using radiofrequency ablation (RFA). This was a retrospective study of the procedures in our unit for the period between 2010 and 2016. We had 25 cases of complex triplets (19 Dichorionic and 6 Monochorionic triplets). The indications for fetal reduction include 14 of multifetal pregnancy reduction, 9 cases of TTTs in the Monochorionic pair, 1 of fetal anomaly in co twin and 1 of discordant growth in the MC pair. Outcome data was available in 24 cases. Median GA at procedure was 15.4 weeks (range 12.1-21.7) and at delivery was 32.9 weeks (range 17.4-41). We had 3 miscarriages; 2 cases occurred within 2 weeks of procedure. IUD of the co-twin occurred in 3 cases (2 in DCTA and 1 in MCTA). The median GA at delivery following MFPR in complex triplets was 34.6 weeks and in the TTTS group was 32.3 weeks. Complications included complex thermal injury to the co twin in 1 case resulting in the subsequent termination of the co twin. There were no cases of neurological impairment in the survivors post procedure. This is the largest case series of fetal reduction in complex triplets by RFA. Selective reduction by RFA in complex triplet pregnancies resulted in a total pregnancy loss in 12.5% of the cases with an 87.5% favourable outcome, in other words two live babies at discharge from hospital. The gestational age was higher at delivery in the MFPR group compared to other indications for selective fetal reduction. This data is useful in appropriate counselling of complex triplex pregnancies.

Selective Fetal Reduction of Conjoined Twins in Twin Pregnancy

ABSTRACT Background The incidence of conjoined twins is rare. In early pregnancy, transvaginal ultrasound may facilitate diagnosis and prompt intervention can be done. Case Report A 35 years old patient with history of infertility for 17 years conceived after In vitro fertilization–embryo transfer with donor oocytes due to ovarian factor; three embryos were transferred. Transvaginal sonography was done on 21st day after transfer and it revealed three gestational sacs with fetal pole in all the sacs. Repeat TVS done on 65th day post embryo transfer revealed one gestational sac with single live embryo, second sac with two embryos joined at thorax and abdomen with a common heart, and two heads. Couple was then counseled for fetal reduction in view of expected poor outcome of conjoined twins. Selective fetal reduction was done at 12 weeks gestation with intra-cardiac potassium chloride administration. Pregnancy is now ongoing with an apparently normal live singleton fetus. Conclusion When conjoined twins are detected early, fetal reduction is a good modality of management. These pregnancies are associated with severe complications, maternal and fetal morbidity and mortality. Hence, the sooner the fetal reduction is, the better the management of conjoined twins. How to cite this article Choudhary S, Mishra V, Aggarwal R, Agarwal H. Selective Fetal Reduction of Conjoined Twins in Twin Pregnancy. J South Asian Feder Obst Gynae 2017;9(3):277-279.

Successful Conservative Management of a Case of Cervical Ectopic Pregnancy complicated with Preexisting Cardiomyopathy

ABSTRACT Background Cervical ectopic pregnancies account for less than 1% of all pregnancies. It may present with abnormal and occasionally heavy bleeding. Aim To understand the challenges associated with management of cervical ectopic pregnancies and learn to individualize the available treatment modalities for a successful outcome. Case report A 42-year-old woman, G6P2L2MTP3 with amenorrhea of 2 months, was diagnosed with cervical ectopic pregnancy of 9 weeks on ultrasonography. She was a known case of dilated cardiomyopathy with type II diastolic dysfunction and an ejection fraction of 25%. The patient was given systemic methotrexate followed by intra-amniotic methotrexate and fetal intracardiac potassium chloride. She was followed up with serial β-human chorionic gonadotropin (hCG) reports. However, she developed abdominal pain with bleeding per vaginum and ultrasonography suggestive of a hematoma. The patient was then taken up for a bilateral uterine artery embolization followed by an immediate suction evacuation. The products of conception sent for histopathology confirmed the microscopic diagnosis of cervical pregnancy. Conclusion It is a challenging clinical situation to diagnose and manage. It needs to be diagnosed early, and management needs to be individualized. Clinical significance Even with advanced diagnostic modalities and reduction in current mortality rates, cervical pregnancy remains a life-threatening condition. It is of utmost importance to be thorough with the emerging trends in its management, as it comes with the promise of being unpredictably catastrophic. How to cite this article Raza N, PaiDhungat NP. Successful Conservative Management of a Case of Cervical Ectopic Pregnancy complicated with Preexisting Cardiomyopathy. J South Asian Feder Obst Gynae 2017;9(4):356-359.

Management of extensive placenta percreta with induced fetal demise and delayed hysterectomy

Abstract Abnormal placentation is a significant source of maternal morbidity and mortality with increasing incidence due to rising rates of cesarean delivery. While traditionally managed with cesarean-hysterectomy, other management strategies are available. We report a case of a G4P2 woman with two prior cesarean deliveries, who presented at 21 weeks and was diagnosed with an extensive placenta percreta. She expressed a desire for pregnancy termination. Given extensive intra-abdominal placental invasion, intrauterine fetal demise was induced with fetal intracardiac potassium chloride, systemic methotrexate was administered, and the pregnancy was managed conservatively with the demised fetus in situ. Resolution of placental tissue occurred over 4 months. Chorioamnionitis developed at the equivalent of 41 weeks’ gestational age, and she underwent a successful gravid hysterectomy. Antepartum management with induced fetal demise and delayed hysterectomy can be considered in extreme cases of previable invasive placenta percreta.

Potassium Chloride–Induced Fetal Demise

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. 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. 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. Intracardiac KCl injection is an effective and safe method for induced fetal demise.

Late termination of pregnancy by intracardiac potassium chloride injection: 5 years' experience at a tertiary referral centre

To report our experience with intracardiac potassium chloride (KCl) injection as a method of feticide for severe congenital abnormalities beyond 24 weeks' gestation. A retrospective chart review. Patient demographics and types of fetal anomalies were analysed according to the groups that accepted or declined late termination of pregnancy (LTOP, ≥24 weeks) for severe congenital abnormalities. Of 3 896 women referred to the Fetal Medicine Unit at Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, 2 209 (56.7%) were at ≥24 weeks' gestation at their first visit. LTOP for severe congenital abnormalities was offered to 253 (11.5%), of whom 191 (75.5%) accepted. Differences in maternal age, parity, race and religion were not statistically significant. The type of fetal abnormalities and gestational age at diagnosis influenced the decision-making process in >80% of the women. The most frequent indications for LTOP were brain and spinal abnormalities (53.0%), and aneuploidy (20.6%). Feticide by ultrasound-guided intracardiac KCl injection was performed in 138/191 cases (72.2%); 53 women who accepted LTOP did not undergo feticide for a variety of reasons. The mean interval between diagnosis and performance of feticide was 10 days (range 0 - 42 days). Fetal asystole was achieved in all cases within 2 minutes by a single-needle injection of intracardiac KCl; the mean duration of the procedure was 12 minutes (range 6 - 25 minutes). There were no maternal complications, and stillbirths occurred in all cases. Feticide by ultrasound-guided intracardiac KCl injection was an acceptable, safe and effective method for LTOP. Further studies are needed to determine the minimum dosage of KCl required to achieve the desired effect.

Fetal Intracardiac Potassium Chloride Injection to Expedite Second-Trimester Dilation and Evacuation

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.

Induction of fetal demise before abortion

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.

Conservative Management of Cervical Ectopic Pregnancy Resistant to Methotrexate Therapy

A case of methotrexate resistant cervical ectopic pregnancy is presented. It was successfully treated by fetocide with intracardiac potassium-chloride followed by selective internal-iliac and descending-cervical-artery embolisation and subsequent curettage. Such a stepwise approach is advisable to preserve fertility.

Successful conservative treatment of a 14‐week gestational age cervical pregnancy by primary local injection of single‐dose intra‐amniotic methotrexate and intracardiac potassium chloride feticide

Successful conservative treatment of a 14‐week gestational age cervical pregnancy by primary local injection of single‐dose intra‐amniotic methotrexate and intracardiac potassium chloride feticide