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Abortion has been legal in England, Scotland and Wales since 1967 when the Abortion Act was passed. The Act did not extend to Northern Ireland and abortion there has been highly restricted. Around 200,000 abortions are performed in Britain each year. In law, only doctors may authorize or perform abortions, but aspects of care can be delegated to other members of a healthcare team. Nearly three-quarters of abortions in the country are undertaken medically, a service mainly delivered by nurses and midwives. There are learning outcomes for abortion care in undergraduate medical education curricula and for post-graduate training in obstetrics and gynecology and community sexual and reproductive health care. However, a waning sense of responsibility by gynecologists to provide abortion care and, in England, a shift of abortion services away from National Health Service hospitals where training occurs to independent clinics, has resulted in fewer opportunities for practical exposure, role-modeling and mentorship. Formal education in abortion care for nurses and midwives is limited; most undertake professional development while working in an abortion service. Medical, nursing and midwifery colleges throughout the United Kingdom are actively working on improving the status of education in abortion care.
Recurrent miscarriage (RM) affects between 1-2% of fertile couples and is a clinical condition of heterogeneous etiology. Parental structural chromosome rearrangements are reported in 3-8% of couples suffering recurrent miscarriage and testing of both partners is therefore recommended. Conventional cytogenetic analysis of miscarriage tissue from women with a history of RM has detected a 26-57% abnormality rate. In the RM population, the prevalence of reported uterine malformations range widely from between 1.8% to 37.6%. Diagnostic tools for detecting uterine anomalies include two- and three-dimensional ultrasound, hysteroscopy, laparoscopy and magnetic resonance imaging (MRI). The antiphospholipid syndrome (APS) remains entrenched as one of the most studied factors associated with RM. Natural killer (NK) cells are found in peripheral blood and within the endometrium and have been associated with RM. Presently, many of the RM investigations are controversial because of limited studies, inconsistent terminology and small and poorly designed treatment studies.
This chapter develops the hypothesis that some women with a history of recurrent miscarriage (RM) are in a prothrombotic state outside of pregnancy. The causes of RM have been grouped into six main categories: genetic, anatomical, infective, endocrinological, immunological and unexplained. The thrombophilic disorders play a part in the aetiology of recurrent pregnancy loss at various gestations. Haemostasis in vivo is a balancing act between the coagulation and fibrinolytic pathways, and plays a vital role in the establishment and maintenance of pregnancy. Prospective studies have shown an increased prevalence of acquired thrombophilic disorders in women with a history of RM. Women with a history of RM are at greater risk of later pregnancy complications such as pre-eclampsia, fetal growth restriction and intrauterine death. Revised criteria for the diagnosis of Primary antiphospholipid syndrome (PAPS) recognise the obstetric manifestations of antiphospholipid antibodies (aPL), such as a history of pre-eclampsia and preterm labour.
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