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Objective There are numerous studies reporting a disproportionally high prevalence of thrombophilia in women with a history of recurrent miscarriage (RM), which has led to overdiagnosis and treatment without an improvement in clinical outcomes. The objective of our study was to assess the prevalence of inherited and acquired thrombophilia in a large cohort of women with a history of early RM using internationally agreed diagnostic criteria and inclusion parameters and compare it to the meta-analysis results of existing literature.Methods Design Retrospective cohort study and systematic review of literature.Setting This is a retrospective cohort study set-up in two dedicated tertiary centres for women with RM in Southwest London and Surrey. We reviewed all the available literature related to causes of RMs. We ascertained the prevalence of thrombophilia in the study population and compared it with historical and published prevalence in the general population.Participants 1155 women between 2012 and 2017. All patients had three or more first trimester miscarriages and a full thrombophilia screen.Results The overall prevalence of thrombophilia in our study population is 9.2% (106/1155) with 8.1% (94/1155) of cases positive for inherited thrombophilia, which is similar to the general population; Factor V Leiden (4.9%; 57/1155) and prothrombin gene mutation (2.9%; 34/1155) were the most common inherited thrombophilias, while only 1% (12/1155) tested positive for acquired thrombophilia. Persistent positive lupus anticoagulant (LA) was found in 0.5% (6/1155) and persistent positive anticardiolipin (ACL) antibodies with a value ≥40 U/mL was found in 0.5% (6/1155) of patients. Tests for LA/ACL were performed a minimum of 12 weeks apart thus meeting the revised Sapporo criteria for a diagnosis of antiphospholipid syndrome.Conclusion The findings of our study demonstrate that the prevalence of inherited thrombophilia is similar in women with RM to that in the general population. Similarly, the prevalence of acquired thrombophilia, using the revised Sapporo criteria, in the cohort of RMs is similar to that in the general population. Therefore, we do not recommend investigation or treatment of inherited or acquired thrombophilia in women with RM.PROSPERO registration number CRD42020223554.

Previous work by Pettit et al (2017) drew on Socio-technical Transitions Theory (STT) to contextualise recent developments in the technological and operational eco-efficiency of ships which may ameliorate sustainability issues in shipping. Within STT the Multi-Level Perspective (MLP) is a framework used to explain the permeation of innovations into society (Geels, 2014). The framework has three levels: Landscape; Regime and Niche. In order to develop a better understanding of changes that may take place in the future, this paper uses the MLP to assess the broad range of challenges facing the shipping industry with respect to future CO2 emissions at each of the three levels. The framework is applied to four scenarios for global shipping in order to understand the potential range of outcomes for CO2 emissions. The four scenarios are: ‘Business as Usual’; ‘Managed Transition’; ‘Chaotic Transition’; and ‘Managed Degrowth’. It is contended that changes in the shipping industry alone are unlikely to lead to large-scale changes in its CO2 emissions. Under ‘Business as Usual’ conditions, CO2 emissions will continue to rise as the changes required at all three levels, but primarily at the regime level, will have limited impact. Under the other three scenarios, it is suggested that there is room for optimism that CO2 emissions will decline over time.