FIGO position statement on induction of foetal asystole in abortions at advanced gestations

Induction of foetal asystole refers to the medical procedure that intentionally causes the cessation of the foetal heart (cardioplegia). In the context of abortions at advanced gestations, cardioplegia is sometimes performed to ensure that the foetus is not delivered with any signs of life.¹ This approach is generally taken to comply with maternal requests, religious beliefs, to avoid any potential legal and ethical implications of a live birth, and for technical reasons. 

Induced abortion at advanced gestation may be necessary for a number of reasons (see our position statement Improving access to abortion beyond 12 weeks of pregnancy). Therefore, evidence-based training and adequate equipment should be available to ensure its safety and availability in every setting in accordance with local laws.

Ethical considerations

Induction of foetal asystole, particularly in the context of abortions at advanced gestations, is a highly sensitive issue. The ethical considerations primarily revolve around the following.

Viability

Viability is defined as the point at which a foetus can potentially survive outside the womb, generally considered to be around 24–28 weeks of gestation. The gestational age at which extrauterine survival is possible depends on the context and technical resources available and has not been defined by an absolute number of gestational weeks or weight.†

Although viability is a medical concept relevant to neonatal and intensive care provision in the context of spontaneous or medically indicated preterm deliveries, it is frequently associated with local laws related to induced abortions.

The gestational age at which extrauterine survival is possible depends on the context and technical resources available, but in general, transient signs of life may be seen from the 20th week. The earliest gestational age at which survival has been achieved with the most advanced technology has been reported to be around 23 weeks. 

In the context of induced abortion at advanced gestations, irrespective of the reason, induction of foetal asystole should be considered at least, at the lowest gestational age at which survival without intervention is possible. This cut off depends on the technical resources available in each country or region. Clinical decisions should be responsive and appropriate to the legal and medical setting in which the services are being provided and according to the broadest interpretation of the law, understood as the one that better protects the pregnant person’s fundamental human rights.

Foetal pain

The question of foetal pain during cardioplegia and abortions at advanced gestations is a contentious issue. Research suggests that the structural pathways to sense pain develop around 29 weeks of pregnancy, and it is unlikely that the foetus can experience pain until birth.^2,3 This is because the ability to perceive painful sensations and emotions depends on several factors, ranging from the functions of neurological structures that develop throughout the foetal period (starting at 24–28 weeks) to the psychological and social experiences that only occur after birth.

Pre-procedure cardioplegia ensures that the delivered foetus does not experience suffering after birth and prevents the delivery of a live newborn during an abortion procedure.

Legal implications

In some jurisdictions, performing foetal asystole is legally required in abortions at advanced gestations to avoid the possibility of a live birth, which can have legal, ethical, medical and emotional implications for both patients and healthcare providers.

Although induction of foetal asystole should be regarded as a healthcare intervention with no need of regulation outside the context of health, countries and territories have varying laws regarding the gestation at which this procedure is required, or whether it is allowed.

Indications for induction of foetal asystole

Medico-legal indications

In some countries or territories, laws regarding abortion at peri or post viability require induction of foetal asystole before other abortion procedures are performed. Legal gestational age limits for abortion are very varied around the world. Where abortion in such circumstances is permitted at gestations when extrauterine survival is possible (peri or post viability), cardioplegia should be performed to avoid an unintended live birth resulting from the intervention (either at short or long term).

Ethical indications

In many hospital settings, ethical norms and hospital policies require neonatal resuscitation if there are signs of life at delivery at a peri viable gestational age. If the intention is to perform an abortion, cardioplegia can be performed to ensure that the foetus will not be delivered with signs of life, thus avoiding any policy implications surrounding neonatal resuscitation and iatrogenic prematurity.

Maternal request

In some circumstances, a patient may request for foetal asystole for social, cultural or religious beliefs. In these situations, the risks and benefits of cardioplegia should be discussed to enable shared decision-making regarding induction of foetal asystole for maternal request. Risks are related to inadvertent injection into maternal circulation, infection, and discomfort at puncture site. Maternal benefits may include decreased uterine blood flow and shorter interval times of induction after fetal demise.

Methods of inducing foetal asystole

Several methods are used to induce foetal asystole during peri and post viable abortions.⁴ The choice of method for inducing foetal asystole depends on local–regional medication availability and the training and preferences of the provider, after presenting the available options to the patient.

Potassium chloride injection^5,6

• Potassium chloride (KCI) is injected directly into the foetal heart or umbilical vein under ultrasound guidance.
• This method induces fetal asystole (cardiac arrest) almost immediately⁷ in over 99% of cases with adequate training and skills.
• Dose: 5–15 mL of KCl solution (2 mEq/mL) given in 5mL increments.

Lidocaine injection⁸

• Lidocaine, a more widely available medication, is injected directly into the foetal heart or intrathoracically, under ultrasound guidance, causing foetal asystole with the first dose in 99% of the cases when injected intracardiac, and 97% if intrathoracic.
• Dose: 20 mL of 1% lidocaine or 10 mL 2% lidocaine. A second dose may be required; a maximum dose up to 480 mg of lidocaine is safe.

Digoxin injection^9,10

• Digoxin is injected into the amniotic sac or directly into the fetus 24-48 hours before an abortion procedure.
• The injection can be performed transabdominally or transvaginally at the time of cervical preparation before dilation and evacuation.
• It is technically easier, and can even be done without ultrasound guidance, but takes longer to induce foetal demise, and the efficacy is variable depending on the location of the injection. If injected, intracardiac effectiveness can be over 99% in the next few minutes. Intrafoetal injection is over 98% effective typically within 6 hours. Intraamniotic injection is up to 92% effective at 24 hours.
• Dose: 1mg (intrafoetal) to 2 mg (intraamniotic) of digoxin.

Umbilical cord transection

• In some cases, cutting the umbilical cord to stop the blood supply from the placenta is possible. This method is typically used during provision of procedural abortions – dilation and evacuation.
• Cessation of foetal cardiac motion after cord transection may take several minutes.

Conclusion

Induction of foetal asystole in abortions at advanced gestations is a complex and sensitive issue that intersects with social, legal and ethical concerns. It is generally performed to ensure that there are no signs of life during an abortion procedure or to avoid survival in accordance with the definition of induced abortion.^‡ There are several methods of safe and effective cardioplegia. 

Healthcare providers involved in these procedures must be aware of the local laws, ethical guidelines, and the specific medical circumstances that allow or necessitate inducing foetal cardioplegia. Clear communication with patients about the rationale, process and implications of the procedure is also crucial in ensuring shared decision-making and compassionate care.

References

† Neither FIGO nor WHO have a position on the gestational age of viability, because viability varies greatly depending on resources, context and foetal conditions.

‡ According to World Health Organization (2019), International statistical classification of diseases and related health problems, artificial termination of an ongoing pregnancy (also referred to as induced abortion, legal abortion, foetal reduction) is defined by ICD-11 as the complete expulsion or extraction from a woman of an embryo or a foetus (irrespective of the duration of the pregnancy), following a deliberate interruption of an ongoing pregnancy by medical or surgical means, which is not intended to result in a live birth. 

1 Diedrich J, Goldfarb CN, Raidoo S, Drey E, Reeves MF; with the assistance of Jessica Atrio, Vinita Goyal, and Sarah Prager on behalf of the Clinical Affiars Committee and Lorie Harper on behalf of the Society for Maternal-Fetal Medicine. Society of Family Planning Clinical Recommendation: Induction of fetal asystole before abortion Jointly developed with the Society for Maternal-Fetal Medicine. Contraception. 2024 Nov;139:110551

2 Royal College of Obstetricians and Gynaecologists. RCOG Fetal Awareness Evidence Review, December 2022. London: RCOG, 2022.

3 Lee SJ, Ralston HJ, Drey EA, Partridge JC, Rosen MA. Fetal pain: a systematic multidisciplinary review of the evidence. JAMA. 2005 Aug 24;294(8):947-54. doi: 10.1001/jama.294.8.947.

4 Tufa TH, Prager S, Lavelanet AF, Kim C. Drugs used to induce fetal demise prior to abortion: a systematic review. Contracept X. 2020 Nov 9;2:100046

5 Singh S., Seligman N.S., Jackson B., Berghella V. Fetal Intracardiac potassium chloride injection to expedite second-trimester dilation and evacuation. Fetal Diagn Ther. 2012;31:63–68.

6 Govender L., Moodley J. Late termination of pregnancy by intracardiac potassium chloride injection: 5 years’ experience at a tertiary referral Centre. S Afr Med J. 2013;103:47–51.

7 Sfakianaki A.K., Davis K.J., Copel J.A., Stanwood N.L., Lipkind H.S. Potassium chloride–induced fetal demise. J Ultrasound Med. 2014;33:337–341

8 Reeves MF, Goldfarb CN, Rubin SL, Kuperstock JL, DiBianco L, Picciotto A. Transabdominal lidocaine to induce fetal demise: a cohort study. BMJ Sex Reprod Health. 2022 Oct;48(4):275-280. doi: 10.1136/bmjsrh-2021-201350.

9 Dean G., Colarossi L., Lunde B., Jacobs A.R., Porsch L.M., Paul M.E. Safety of digoxin for fetal demise before second-trimester abortion by dilation and evacuation. Contraception. 2012;85:144–149

10 Tocce K., Sheeder J.L., Edwards L.J., Teal S.B. Feasibility, effectiveness and safety of transvaginal digoxin administration prior to dilation and evacuation