What complications have arisen after early medical abortion -’both pills by post’’ policy in the uk during Covid? Do these increase the risk of subsequent premature birth?

ABSTRACT

BackgroundDuring 2019 NICE and the RCOG introduced UK guidelines normalising the early medical abortion (EMA) protocol for pregnancies prior to 10 weeks gestation. Mifepristone is taken at the abortion clinic, and the second pill, Misoprostol may be taken unsupervised at home 36–48 hours later. In March 2020, UK EMA policy changed, and telemedicine with ‘both pills by post’(BPBP) was authorised by DHSC, during Covid-19.MethodsA worldwide systematic review and meta-analyses were conducted to compare risk of PTB after one or more abortions compared to none, and PB after medical versus surgical abortion. Systematic evidence on outcomes after medical abortion are recorded through the Finnish Abortion registry. Mannisto (2013) published a paper showing that when surgical abortion, or evacuation of retained products of conception (ERPC) is required after a medical abortion, it increases the risk of subsequent PB by 241%. Very little data has been collected on this subject in England. We examine data from FOI requests to CQC in Dec 2020 and to NHS Acute hospital trust A&E departments in England and Wales (E&W) to investigate the incidence of complications (haemorrhage and sepsis) and ERPC after EMA and BPBP since April 2020.ResultsOur meta-analysis showed adj OR of 1.52, 95% CI (1.43–1.62), for increased risk of PTB after Abortion, compared to none. Surgical abortion carried more risk (RR 1.23) than Medical Abortion. FOI (response rate 67%) showed a 5.9% EMA failure rate in E&W from data from NHS A&E depts between April 2020 and 2021. This is similar to EMA failure rate (5.48%) published in Marie Stopes Australia 2020 report. It means that more than 7,400 women per annum across England have had complications from EMA since the Covid approval for telemedicine and BPBP. 2.4% needed a subsequent ERPC, which increases further the risk of a PTB in a later pregnancy. Incidence of complications or ERPC after EMA is 0.75%, 5x higher than reported by DHSC (0.15%).ConclusionThese results suggest that this policy of BPBP during Covid-19, should revert to in-person consultation for EMA for the safety of women. The BPBP was a departure from Evidence Based Medicine. Abortion should be appropriately governanced, and outcomes fully evaluated with evidence collected using longitudinal data via the NHS number on HSA4 forms. This would inform a safer policy for the wellbeing of women and help to reduce the increasing rates of PTB for the future.