Recommendation:
- Induced fetal demise prior to medical abortion or dilatation and evacuation (D&E) at or after 13 weeks gestation does not increase the safety of abortion. However, there may be legal, facility or social reasons for inducing preprocedure fetal demise.
Strength of recommendation: Strong
Quality of evidence: Low
Background
Some providers may induce fetal demise before medical abortion or D&E at or after 13 weeks gestation for a variety of reasons. Clients, providers or staff may prefer that fetal demise occurs before an abortion procedure (Jackson et al., 2001) or it may be dictated by the facility’s practices. Additionally, induced fetal demise is one way to prevent transient fetal survival following a medical abortion. A large Canadian retrospective cohort study that included 13,777 abortions between 15 and 29 gestational weeks found that transient fetal survival occurred in 11% of cases and that risk increased with more advanced gestational age (Auger et al., 2024).
Safety and efficacy of inducing fetal demise
A retrospective cohort study comparing people who received an intrauterine digoxin injection prior to D&E with historical controls who did not receive digoxin showed an increase in complications, including more hospital admissions, extramural deliveries and infections in the group who received digoxin (Dean et al., 2012). One case series including nearly 5,000 D&E abortions after digoxin injection found rates of extramural deliveries (0.3%) and infection (0.04%) that authors concluded were acceptably low (Steward et al., 2012). A retrospective cohort study comparing women who underwent fetal intracardiac potassium chloride injection before D&E to women who did not undergo the additional procedure found that while procedure duration was decreased by 3.5 minutes when fetal demise was induced, there was an increase in women’s pain and in the incidence of uterine atony (Lohr et al., 2018).
A retrospective cohort from Ethiopia compared intra-amniotic digoxin, intracardiac lidocaine, and no induced demise in 208 patients undergoing medical abortion between 20 and 28 weeks, finding no differences in induction-to-abortion interval or successful abortion between the three groups (Sium, Shimles, & Gudu, 2023). Two retrospective comparative cohort studies measured the effect of intracardiac potassium chloride on induction-to-abortion interval when administered before medical abortion. In one study with a gestational age range of 17-28 weeks, the induction-to-abortion interval was significantly shorter in women who received the injection (15 hours) compared to those who did not (19.9 hours) (Akkurt et al., 2018). A similar study among women with a mean gestational age of 21 weeks found no difference in time-to-abortion between those with pre-procedure potassium chloride for feticide (35 hours) versus those without (32 hours) (Sik et al., 2019). Use of potassium chloride before medical abortion is associated with increased tissue degeneration at fetal autopsy (Chiu et al., 2025).
Technique
Fetal demise can be achieved prior to abortion at or after 13 weeks by injecting potassium chloride or xylocaine directly into the fetal heart, or digoxin into the fetus or amniotic fluid (Nandi, Schultz, & Roncari, 2022).
Potassium chloride/xylocaine:
Potassium chloride or xylocaine injection requires skill in ultrasound guidance techniques and has more potential risk due to the possibility of maternal intravascular injection which can cause cardiac arrest (Borgatta & Kapp, 2011; Coke et al., 2004; Maurice et al., 2019). One study randomized 158 people with pregnancies between 22 and 36 weeks gestation to either fetal intracardiac intraventricular potassium chloride injection or intraseptal injection, and found that both methods were 100% successful with no complications. Intraseptal injection achieved asystole more quickly with lower doses of potassium chloride than intraventricular (Süzen Çaypınar et al., 2023). In one retrospective cohort study including 80 people with pregnancies between 21 and 27 weeks gestation, the administration of intracardiac xylocaine resulted in fetal demise in 95% of pregnancies with no serious adverse events, although two participants developed side effects attributed to the injection (Tolu et al., 2020).
Digoxin
Digoxin is injected either transabdominally or transvaginally (Tocce et al., 2013) 1-2 days before the planned abortion procedure.
In a pharmacokinetic study of eight women between 19-23 weeks who had intra-amniotic injection of digoxin 1mg prior to D&E, maternal serum digoxin levels were in the low therapeutic range and were not associated with cardiac changes (Drey et al., 2000). A pilot randomized trial of intra-amniotic or intra-fetal digoxin at doses of 1mg or 1.5mg showed an overall rate of fetal demise of 87% with no difference in effectiveness based on the dose or route of administration (Nucatola, Roth, & Gatter, 2010). In a prospective cohort study of 59 women undergoing termination of pregnancy between 21-30 weeks, digoxin 2mg administered intra-amniotically resulted in fetal demise for more than 90% of cases, with no adverse maternal effects (Sharvit, et al., 2018). In one retrospective cohort study including 49 people undergoing medical abortion between 20-27 weeks, digoxin 1mg administered intra-amniotically resulted in fetal demise in 90% of cases. Two participants expelled the pregnancy outside of the hospital (Tufa, et al., 2020). One prospective cohort study compared effectiveness of intra-amniotic lidocaine (n=50) to digoxin (n=101) prior to medical abortion between 20 and 28 weeks gestation, finding no differences in induction-to-abortion interval or effectiveness between the two groups, although interval from drug administration to fetal asystole was longer in the digoxin group (Sium et al., 2025). In this same cohort of patients, intra-amniotic digoxin was more acceptable to patients than lidocaine (Sium, Prager, & Reeves, 2024).
References
Akkurt, M. O., Akkurt, I., Yavuz, A., Yalcin, S. E., Coskun, B., & Sezik, M. (2018). The Utility of Feticide Procedure to Shorten the Induction-to-Abortion Interval in Medical Abortion. Gynecology and Obstetric Investigation, 1-7. DOI: 10.1159/000491085.
Auger, N., Brousseau, É., Ayoub, A., & Fraser, W. D. (2024). Second-trimester abortion and risk of live birth. American Journal of Obstetrics & Gynecology, 230(6), 679.e1-679.e9.
Borgatta, L., & Kapp, N. (2011). Clinical guidelines. Labor induction abortion in the second trimester. Contraception, 84(1), 4-18.
Chui, K., Terry, J., Hutcheon, J. A., Mayer, C., & Liauw, J. (2025). Potassium chloride intracardiac fetal injection and tissue degeneration at fetal autopsy following induction abortion. Contraception, 150.
Coke, G. A., Baschat, A. A., Mighty, H. E., & Malinow, A. M. (2004). Maternal cardiac arrest associated with attempted fetal injection of potassium chloride. International Journal of Obstetric Anesthesia, 13(4), 287-290.
Dean, G., Colarossi, L., Lunde, B., Jacobs, A. R., Porsch, L. M., & Paul, M. E. (2012). Safety of digoxin for fetal demise before second-trimester abortion by dilation and evacuation. Contraception, 85(2), 144-149.
Denny, C. C., Baron, M. B., Lederle, L., Drey, E. A., & Kerns, J. L. (2015). Induction of fetal demise before pregnancy termination: Practices of family planning providers. Contraception, 92(3), 241-245.
Drey, E. A., Thomas, L. J., Benowitz, N. L., Goldschlager, N., & Darney, P. D. (2000). Safety of intra-amniotic digoxin administration before late second-trimester abortion by dilation and evacuation. American Journal of Obstetrics & Gynecology, 182(5), 1063-1066.
Lohr, P. A., Parsons, J. H., Taylor, J., & Morroni, C. (2018). Outcomes of dilation and evacuation with and without feticide by intra-cardiac potassium chloride injection: a service evaluation. Contraception, 98, 100-5.
Maurice, P., Letourneau, A., Benachi, A., & Jouannic, J.M. (2019). Feticide in second- and third-trimester termination of pregnancy for fetal anomalies: Results of a national survey. Â Prenatal Diagnosis, 39(13), 1269-1272.
Nandi, P., Schultz, A., & Roncari, D. (2022). The Use of Feticidal Agents Before Dilation and Evacuation or Induction of Labor for Later Abortion. Clinical Obstetrics and Gynecology, 65(4), 708.
Nucatola, D., Roth, N., & Gatter, M. (2010). A randomized pilot study on the effectiveness and side-effect profiles of two doses of digoxin as fetocide when administered intraamniotically or intrafetally prior to second-trimester surgical abortion. Contraception, 81(1), 67-74.
Sharvit, M., Klein, Z., Silber, M., Pomeranz, M., Agizim, R., Schonman, R., & Fishman, A. (2019). Intra-amniotic digoxin for feticide between 21 and 30 weeks of gestation: A prospective study. BJOG: An International Journal of Obstetrics & Gynaecology, 126(7), 885-889.
Sik, A., Bilecan, S., Kumbasar, S., Akpak, Y.K., & Aba, Y.A. (2019). Does feticide shorten termination duration in second trimester pregnancy termination? African Health Science, 19(1), 1544-1553.
Sium, A. F., Lemma, K., Beyene, Z., Tolu, L. B., Hailu, D., Reeves, M. F., & Prager, S. (2025). Inducing fetal demise in a low-middle income country: A prospective cohort of intracardiac lidocaine versus intra-amniotic digoxin for inducing fetal demise before second-trimester medication abortion. International Journal of Gynecology & Obstetrics, 170(3), 1262–1266.
Steward, R., Melamed, A., Kim, R., Nucatola, D., & Gatter, M. (2012). Infection and extramural delivery with use of digoxin as a feticidal agent. Contraception, 85(2), 150-154.
Süzen Çaypınar, S., Oğlak, S. C., Polat, İ., Kurt Bilirer, K., Sezer, S., Gedik Özköse, Z., & Karakaş, S. (2023). A new and more effective feticide technique in late termination of pregnancy: potassium chloride injection into the interventricular septum of the fetal heart. Archives of Gynecology and Obstetrics, 307(3), 779–787.
Tocce, K., Sheeder, J.L., Edwards, L.J., & Teal, S. (2013). Feasibility, effectiveness and safety of transvaginal digoxin administration prior to dilation and evacuation. Contraception, 88(6), 706-711.
Tolu, L.B., Tufa, T.H., Abas, F., Kahn, C., MacAfee, L., Prager, S. & Bell, J.D. (2021). Intra-cardiac lidocaine administration to induce fetal demise before late second-trimester abortion: Retrospective review. International Journal of Gynaecology and Obstetrics, 153(1), 125-129.
Tufa, T.H., Lavelanet, A.F., Belay, L., Seboka, B., & Bell, J. (2020). Feasibility of intra-amniotic digoxin administration by obstetrics and gynecology trainees to induce fetal demise prior to medical abortion beyond 20 weeks. BMJ Sexual and Reproductive Health, 46(4), 308-312.