title: Paracetamol poisoning

text: Intentional overdosing (self-poisoning, with suicidal intent) is frequently implicated in paracetamol toxicity. In a 2006 review, paracetamol was the most frequently ingested compound in intentional overdosing.


title: Paracetamol poisoning

text: In rare individuals, paracetamol toxicity can result from normal use. This may be due to individual ("idiosyncratic") differences in the expression and activity of certain enzymes in one of the metabolic pathways that handle paracetamol (see paracetamol's metabolism).


title: Paracetamol poisoning

text: A number of factors can potentially increase the risk of developing paracetamol toxicity. Chronic excessive alcohol consumption can induce CYP2E1, thus increasing the potential toxicity of paracetamol. In one study of patients with liver injury, 64% reported alcohol intakes of greater than 80 grams a day, while 35% took 60 grams a day or less. Whether chronic alcoholism should be considered a risk factor has been debated by some clinical toxicologists. For chronic alcohol users, acute alcohol ingestion at the time of a paracetamol overdose may have a protective effect. For non-chronic alcohol users, acute alcohol consumption had no protective effect.


title: Paracetamol poisoning

text: Fasting is a risk factor, possibly because of depletion of liver glutathione reserves. The concomitant use of the CYP2E1 inducer isoniazid increases the risk of hepatotoxicity, though whether 2E1 induction is related to the hepatotoxicity in this case is unclear. Concomitant use of other drugs that induce CYP enzymes, such as antiepileptics including carbamazepine, phenytoin, and barbiturates, have also been reported as risk factors.


title: Paracetamol poisoning

text: When taken in normal therapeutic doses, paracetamol has been shown to be safe. Following a therapeutic dose, it is mostly converted to nontoxic metabolites via Phase II metabolism by conjugation with sulfate and glucuronide, with a small portion being oxidized via the cytochrome P450 enzyme system. Cytochromes and 3A4 convert approximately 5% of paracetamol to a highly reactive intermediary metabolite, "N"-acetyl-"p"-benzoquinone imine (NAPQI). Under normal conditions, NAPQI is detoxified by conjugation with glutathione to form cysteine and mercapturic acid conjugates.


title: Paracetamol poisoning

text: In cases of paracetamol overdose, the sulfate and glucuronide pathways become saturated, and more paracetamol is shunted to the cytochrome P450 system to produce NAPQI. As a result, hepatocellular supplies of glutathione become depleted, as the demand for glutathione is higher than its regeneration. NAPQI therefore remains in its toxic form in the liver and reacts with cellular membrane molecules, resulting in widespread hepatocyte damage and death, leading to acute liver necrosis. In animal studies, the liver's stores of glutathione must be depleted to less than 70% of normal levels before liver toxicity occurs.


title: Paracetamol poisoning

text: A person's history of taking paracetamol is somewhat accurate for the diagnosis. The most effective way to diagnose poisoning is by obtaining a blood paracetamol level. A drug nomogram developed in 1975, called the Rumack-Matthew nomogram, estimates the risk of toxicity based on the serum concentration of paracetamol at a given number of hours after ingestion. To determine the risk of potential hepatotoxicity, the paracetamol level is traced along the nomogram. Use of a timed serum paracetamol level plotted on the nomogram appears to be the best marker indicating the potential for liver injury. A paracetamol level drawn in the first four hours after ingestion may underestimate the amount in the system because paracetamol may still be in the process of being absorbed from the gastrointestinal tract. Therefore, a serum level taken before 4 hours is not recommended.


title: Paracetamol poisoning

text: Clinical or biochemical evidence of liver toxicity may develop in one to four days, although, in severe cases, it may be evident in 12 hours. Right-upper-quadrant tenderness may be present and can aid in diagnosis. Laboratory studies may show evidence of liver necrosis with elevated AST, ALT, bilirubin, and prolonged coagulation times, particularly an elevated prothrombin time. After paracetamol overdose, when AST and ALT exceed 1000 IU/L, paracetamol-induced hepatotoxicity can be diagnosed. In some cases, the AST and ALT levels can exceed 10,000 IU/L.


title: Paracetamol poisoning

text: Paracetamol may be quantified in blood, plasma, or urine as a diagnostic tool in clinical poisoning situations or to aid in the medicolegal investigation of suspicious deaths. The concentration in serum after a typical dose of paracetamol usually peaks below 30 mg/L, which equals 200 μmol/L. Levels of 30–300 mg/L (200–2000 μmol/L) are often observed in overdose patients. Postmortem blood levels have ranged from 50 to 400 mg/L in persons dying due to acute overdosage. Automated colorimetric techniques, gas chromatography and liquid chromatography are currently in use for the laboratory analysis of the drug in physiological specimens.


title: Paracetamol poisoning

text: Limiting the availability of paracetamol tablets has been attempted in some countries. In the UK, sales of over-the-counter paracetamol are restricted to packs of 32 x 500 mg tablets in pharmacies, and 16 x 500 mg tablets in non-pharmacy outlets. Pharmacists may provide up to 100 tablets for those with chronic conditions at the pharmacist's discretion. In Ireland, the limits are 24 and 12 tablets, respectively. Subsequent study suggests that the reduced availability in large numbers had a significant effect in reducing poisoning deaths from paracetamol overdose.


title: Paracetamol poisoning

text: One suggested method of prevention is to make paracetamol a prescription-only medicine, or to remove it entirely from the market. However, overdose is a relatively minor problem; for example, 0.08% of the UK population (over 50 thousand people) present with paracetamol overdose each year. In contrast, paracetamol is a safe and effective medication that is taken without complications by millions of people. In addition, alternative pain relief medications such as aspirin are more toxic in overdose, whereas non-steroidal anti-inflammatory drugs are associated with more adverse effects following normal use.


title: Paracetamol poisoning

text: One strategy for reducing harm done by acetaminophen overdoses is selling paracetamol pre-combined in tablets either with an emetic or an antidote. Paradote was a tablet sold in the UK which combined 500 mg paracetamol with 100 mg methionine, an amino acid formerly used in the treatment of paracetamol overdose.


title: Paracetamol poisoning

text: There have been no studies so far on the effectiveness of paracetamol when given in combination with its most commonly used antidote, acetylcysteine.


title: Paracetamol poisoning

text: Calcitriol, the active metabolite of vitamin D, appears to be a catalyst for glutathione production. Calcitriol was found to increase glutathione levels in rat astrocyte primary cultures on average by 42%, increasing glutathione protein concentrations from 29 nmol/mg to 41 nmol/mg, 24 and 48 hours after administration; it continued to have an influence on glutathione levels 96 hours after administration. It has been proposed that co-administration of calcitriol, via injection, may improve treatment outcomes.


title: Paracetamol poisoning

text: Paracetamol ester prodrug with L-pyroglutamic acid (PCA), a biosynthetic precursor of glutathione, has been synthesized to reduce paracetamol hepatotoxicity and improve bioavailability. The toxicological studies of different paracetamol esters show that L-5-oxo-pyrrolidine-2-paracetamol carboxylate reduces toxicity after administration of an overdose of paracetamol to mice. The liver glutathione values in mice induced by intraperitoneal injection of the ester are superimposable with the GSH levels recorded in untreated mice control group. The mice group treated with an equivalent dose of paracetamol showed a significative decrease of glutathione of 35% (p<0.01 vs untreated control group). The oral LD50 was found to be greater than 2000 mg kg-1, whereas the intraperitoneal LD50 was 1900 mg kg-1. These results taken together with the good hydrolysis and bioavailability data show that this ester is a potential candidate as a prodrug of paracetamol.


title: Paracetamol poisoning

text: In adults, the initial treatment for paracetamol overdose is gastrointestinal decontamination. Paracetamol absorption from the gastrointestinal tract is complete within two hours under normal circumstances, so decontamination is most helpful if performed within this timeframe. Gastric lavage, better known as stomach pumping, may be considered if the amount ingested is potentially life-threatening and the procedure can be performed within 60 minutes of ingestion. Activated charcoal is the most common gastrointestinal decontamination procedure as it adsorbs paracetamol, reducing its gastrointestinal absorption. Administering activated charcoal also poses less risk of aspiration than gastric lavage.


title: Paracetamol poisoning

text: It appears that the most benefit from activated charcoal is gained if it is given within 30 minutes to two hours of ingestion. Administering activated charcoal later than 2 hours can be considered in patients that may have delayed gastric emptying due to co-ingested drugs or following ingestion of sustained- or delayed-release paracetamol preparations. Activated charcoal should also be administered if co-ingested drugs warrant decontamination. There was reluctance to give activated charcoal in paracetamol overdose, because of the concern that it may also absorb the oral antidote acetylcysteine. Studies have shown that 39% less acetylcysteine is absorbed into the body when they are administered together. There are conflicting recommendations regarding whether to change the dosing of oral acetylcysteine after the administration of activated charcoal, and even whether the dosing of acetylcysteine needs to be altered at all. Intravenous acetylcysteine has no interaction with activated charcoal.


title: Paracetamol poisoning

text: Inducing vomiting with syrup of ipecac has no role in paracetamol overdose because the vomiting it induces delays the effective administration of activated charcoal and oral acetylcysteine. Liver injury is extremely rare after acute accidental ingestion in children under 6 years of age. Children with accidental exposures do not require gastrointestinal decontamination with either gastric lavage, activated charcoal, or syrup of ipecac.


title: Paracetamol poisoning

text: Acetylcysteine, also called "N"-acetylcysteine or NAC, works to reduce paracetamol toxicity by replenishing body stores of the antioxidant glutathione. Glutathione reacts with the toxic NAPQI metabolite so that it does not damage cells and can be safely excreted. NAC was usually given following a treatment nomogram (one for patients with risk factors, and one for those without) but the use of the nomogram is no longer recommended as the evidence base to support the use of risk factors was poor and inconsistent and many of the risk factors are imprecise and difficult to determine with sufficient certainty in clinical practice. Cysteamine and methionine have also been used to prevent hepatotoxicity, although studies show that both are associated with more adverse effects than acetylcysteine. Additionally, acetylcysteine has been shown to be a more effective antidote, particularly in patients presenting greater than 8 hours post-ingestion and for those who present with liver failure symptoms.


title: Paracetamol poisoning

text: If the person presents less than eight hours after paracetamol overdose, then acetylcysteine significantly reduces the risk of serious hepatotoxicity and guarantees survival. If acetylcysteine is started more than 8 hours after ingestion, there is a sharp decline in its effectiveness because the cascade of toxic events in the liver has already begun, and the risk of acute liver necrosis and death increases dramatically. Although acetylcysteine is most effective if given early, it still has beneficial effects if given as late as 48 hours after ingestion. If the person presents more than eight hours after the paracetamol overdose, then activated charcoal is not useful, and acetylcysteine is started immediately. In earlier presentations, charcoal can be given when the patient arrives and acetylcysteine is initiated while waiting for the paracetamol level results to return from the laboratory.


title: Paracetamol poisoning

text: In United States practice, intravenous (IV) and oral administration are considered to be equally effective and safe if given within 8 hours of ingestion. However, IV is the only recommended route in Australasian and British practice. Oral acetylcysteine is given as a 140 mg/kg loading dose followed by 70 mg/kg every four hours for 17 more doses, and if the patient vomits within 1 hour of dose, the dose must be repeated. Oral acetylcysteine may be poorly tolerated due to its unpleasant taste, odor, and its tendency to cause nausea and vomiting. If repeated doses of charcoal are indicated because of another ingested drug, then subsequent doses of charcoal and acetylcysteine should be staggered.


title: Paracetamol poisoning

text: Intravenous acetylcysteine is given as a continuous infusion over 20 hours for a total dose 300 mg/kg. Recommended administration involves infusion of a 150 mg/kg loading dose over 15 to 60 minutes, followed by a 50 mg/kg infusion over four hours; the last 100 mg/kg are infused over the remaining 16 hours of the protocol. Intravenous acetylcysteine has the advantage of shortening hospital stay, increasing both doctor and patient convenience, and allowing administration of activated charcoal to reduce absorption of both the paracetamol and any co-ingested drugs without concerns about interference with oral acetylcysteine. Intravenous dosing varies with weight, specifically in children. For patients less than 20 kg, the loading dose is 150 mg/kg in 3 mL/kg diluent, administered over 60 minutes; the second dose is 50 mg/kg in 7 mL/kg diluent over 4 hours; and the third and final dose is 100 mg/kg in 14 mL/kg diluent over 16 hours.


title: Paracetamol poisoning

text: The most common adverse effect to acetylcysteine treatment is an anaphylactoid reaction, usually manifested by rash, wheeze, or mild hypotension. Adverse reactions are more common in people treated with IV acetylcysteine, occurring in up to 20% of patients. Anaphylactoid reactions are more likely to occur with the first infusion (the loading dose). Rarely, severe life-threatening reactions may occur in predisposed individuals, such as patients with asthma or atopic dermatitis, and may be characterized by respiratory distress, facial swelling, and even death.


title: Paracetamol poisoning

text: If an anaphylactoid reaction occurs the acetylcysteine is temporarily halted or slowed and antihistamines and other supportive care is administered. For example, a nebulised beta-agonist like salbutamol may be indicated in the event of significant bronchospasm (or prophylactically in patients with a history of bronchospasm secondary to acetylcysteine). It is also important to closely monitor fluids and electrolytes.


title: Paracetamol poisoning

text: In people who develop acute liver failure or who are otherwise expected to die from liver failure, the mainstay of management is liver transplantation. Liver transplants are performed in specialist centers. The most commonly used criteria for liver transplant were developed by physicians at King's College Hospital in London. Patients are recommended for transplant if they have an arterial blood pH less than 7.3 after fluid resuscitation or if a patient has Grade III or IV encephalopathy, a prothrombin time greater than 100 seconds, and a serum creatinine greater than 300 mmol/L In a 24-hour period. Other forms of liver support have been used including partial liver transplants. These techniques have the advantage of supporting the patient while their own liver regenerates. Once liver function returns immunosuppressive drugs are commenced and they have to take immunosuppressive medication for the rest of their lives.


title: Paracetamol poisoning

text: The mortality rate from paracetamol overdose increases two days after the ingestion, reaches a maximum on day four, and then gradually decreases. Acidosis is the most important single indicator of probable mortality and the need for transplantation. A mortality rate of 95% without transplant was reported in patients who had a documented pH less than 7.30. Other indicators of poor prognosis include chronic kidney disease (stage 3 or worse), hepatic encephalopathy, a markedly elevated prothrombin time, or an elevated blood lactic acid level (lactic acidosis). One study has shown that a factor V level less than 10% of normal indicated a poor prognosis (91% mortality), whereas a ratio of factor VIII to factor V of less than 30 indicated a good prognosis (100% survival). Patients with a poor prognosis are usually identified for likely liver transplantation. Patients that do not die are expected to fully recover and have a normal life expectancy and quality of life.


title: Paracetamol poisoning

text: Many over-the-counter and prescription-only medications contain paracetamol. Because of its wide availability paired with comparably high toxicity, (compared to ibuprofen and aspirin) there is a much higher potential for overdose. Paracetamol toxicity is one of the most common causes of poisoning worldwide. In the United States, the United Kingdom, Australia, and New Zealand, paracetamol is the most common cause of drug overdoses. Additionally, in both the United States and the United Kingdom it is the most common cause of acute liver failure.


title: Paracetamol poisoning

text: In England and Wales an estimated 41,200 cases of paracetamol poisoning occurred in 1989 to 1990, with a mortality of 0.40%. It is estimated that 150 to 200 deaths and 15 to 20 liver transplants occur as a result of poisoning each year in England and Wales. Paracetamol overdose results in more calls to poison control centers in the US than overdose of any other pharmacological substance, accounting for more than 100,000 calls, as well as 56,000 emergency room visits, 2,600 hospitalizations, and 458 deaths due to acute liver failure per year. A study of cases of acute liver failure between November 2000 and October 2004 by the Centers for Disease Control and Prevention in the USA found that paracetamol was the cause of 41% of all cases in adults, and 25% of cases in children.


title: Miscarriage

text: Miscarriage, also known in medical terms as a spontaneous abortion and pregnancy loss, is the death of an embryo or fetus before it is able to survive independently. Miscarriage before 6 weeks of gestation is defined by ESHRE as biochemical loss. Once ultrasound or histological evidence shows that a pregnancy has existed, the used term is clinical miscarriage, which can be "early" before 12 weeks and "late" between 12-21 weeks. Fetal death after 20 weeks of gestation is also known as a stillbirth. The most common symptom of a miscarriage is vaginal bleeding with or without pain. Sadness, anxiety, and guilt may occur afterwards. Tissue and clot-like material may leave the uterus and pass through and out of the vagina. Recurrent miscarriage (also referred to medically as Recurrent Spontaneous Abortion or RSA) may also be considered a form of infertility.


title: Miscarriage

text: Risk factors for miscarriage include being an older parent, previous miscarriage, exposure to tobacco smoke, obesity, diabetes, thyroid problems, and drug or alcohol use. About 80% of miscarriages occur in the first 12 weeks of pregnancy (the first trimester). The underlying cause in about half of cases involves chromosomal abnormalities. Diagnosis of a miscarriage may involve checking to see if the cervix is open or sealed, testing blood levels of human chorionic gonadotropin (hCG), and an ultrasound. Other conditions that can produce similar symptoms include an ectopic pregnancy and implantation bleeding.


title: Miscarriage

text: Prevention is occasionally possible with good prenatal care. Avoiding drugs, alcohol, infectious diseases, and radiation may decrease the risk of miscarriage. No specific treatment is usually needed during the first 7 to 14 days. Most miscarriages will complete without additional interventions. Occasionally the medication misoprostol or a procedure such as vacuum aspiration is used to remove the remaining tissue. Women who have a blood type of rhesus negative (Rh negative) may require Rho(D) immune globulin. Pain medication may be beneficial. Emotional support may help with processing the loss.


title: Miscarriage

text: Miscarriage is the most common complication of early pregnancy. Among women who know they are pregnant, the miscarriage rate is roughly 10% to 20%, while rates among all fertilisation is around 30% to 50%. In those under the age of 35 the risk is about 10% while it is about 45% in those over the age of 40. Risk begins to increase around the age of 30. About 5% of women have two miscarriages in a row. Some recommend not using the term "abortion" in discussions with those experiencing a miscarriage in an effort to decrease distress. In Britain, the term "miscarriage" has replaced any use of the term "spontaneous abortion" in relation to pregnancy loss and in response to complaints of insensitivity towards women who had suffered such loss. An additional benefit of this change is reducing confusion among medical laymen, who may not realize that the term "spontaneous abortion" refers to a naturally-occurring medical phenomenon, and not the intentional termination of pregnancy.


title: Miscarriage

text: Signs of a miscarriage include vaginal spotting, abdominal pain, cramping, and fluid, blood clots, and tissue passing from the vagina. Bleeding can be a symptom of miscarriage, but many women also have bleeding in early pregnancy and do not miscarry. Bleeding during the first half of pregnancy may be referred to as a threatened miscarriage. Of those who seek treatment for bleeding during pregnancy, about half will miscarry. Miscarriage may be detected during an ultrasound exam, or through serial human chorionic gonadotropin (HCG) testing.


title: Miscarriage

text: Miscarriage may occur for many reasons, not all of which can be identified. Risk factors are those things that increase the likelihood of having a miscarriage but do not necessarily cause a miscarriage. Up to 70 conditions, infections, medical procedures, lifestyle factors, occupational exposures, chemical exposure, and shift work are associated with increased risk for miscarriage. Some of these risks include endocrine, genetic, uterine, or hormonal abnormalities, reproductive tract infections, and tissue rejection caused by an autoimmune disorder.


title: Miscarriage

text: Most clinically apparent miscarriages (two-thirds to three-quarters in various studies) occur during the first trimester. About 30% to 40% of all fertilized eggs miscarry, often before the pregnancy is known. The embryo typically dies before the pregnancy is expelled; bleeding into the decidua basalis and tissue necrosis causes uterine contractions to expel the pregnancy. Early miscarriages can be due to a developmental abnormality of the placenta or other embryonic tissues. In some instances an embryo does not form but other tissues do. This has been called a "blighted ovum".


title: Miscarriage

text: Successful implantation of the zygote into the uterus is most likely eight to ten days after fertilization. If the zygote has not implanted by day ten, implantation becomes increasingly unlikely in subsequent days.


title: Miscarriage

text: A chemical pregnancy is a pregnancy that was detected by testing but ends in miscarriage before or around the time of the next expected period.


title: Miscarriage

text: Chromosomal abnormalities are found in more than half of embryos miscarried in the first 13 weeks. Half of embryonic miscarriages (25% of all miscarriages) have an aneuploidy (abnormal number of chromosomes). Common chromosome abnormalities found in miscarriages include an autosomal trisomy (22–32%), monosomy X (5–20%), triploidy (6–8%), tetraploidy (2–4%), or other structural chromosomal abnormalities (2%). Genetic problems are more likely to occur with older parents; this may account for the higher rates observed in older women.


title: Miscarriage

text: Second trimester losses may be due to maternal factors such as uterine malformation, growths in the uterus (fibroids), or cervical problems. These conditions also may contribute to premature birth. Unlike first-trimester miscarriages, second-trimester miscarriages are less likely to be caused by a genetic abnormality; chromosomal aberrations are found in a third of cases. Infection during the third trimester can cause a miscarriage.


title: Miscarriage

text: The age of the pregnant woman is a significant risk factor. Miscarriage rates increase steadily with age, with more substantial increases after age 35. In those under the age of 35 the risk is about 10% while it is about 45% in those over the age of 40. Risk begins to increase around the age of 30. Paternal age is associated with increased risk.


title: Miscarriage

text: Not only is obesity associated with miscarriage; it can result in sub-fertility and other adverse pregnancy outcomes. Recurrent miscarriage is also related to obesity. Women with bulimia nervosa and anorexia nervosa may have a greater risk for miscarriage. Nutrient deficiencies have not been found to impact miscarriage rates but hyperemesis gravidarum sometimes precedes a miscarriage.


title: Miscarriage

text: Caffeine consumption also has been correlated to miscarriage rates, at least at higher levels of intake. However, such higher rates are statistically significant only in certain circumstances.


title: Miscarriage

text: Vitamin supplementation has generally not shown to be effective in preventing miscarriage. Chinese traditional medicine has not been found to prevent miscarriage.


title: Miscarriage

text: Disorders of the thyroid may affect pregnancy outcomes. Related to this, iodine deficiency is strongly associated with an increased risk of miscarriage. The risk of miscarriage is increased in those with poorly controlled insulin-dependent diabetes mellitus. Women with well-controlled diabetes have the same risk of miscarriage as those without diabetes.


title: Miscarriage

text: Ingesting food that has been contaminated with listeriosis, toxoplasmosis, and salmonella is associated with an increased risk of miscarriage.


title: Miscarriage

text: Amniocentesis and chorionic villus sampling (CVS) are procedures conducted to assess the fetus. A sample of amniotic fluid is obtained by the insertion of a needle through the abdomen and into the uterus. Chorionic villus sampling is a similar procedure with a sample of tissue removed rather than fluid. These procedures are not associated with pregnancy loss during the second trimester but they are associated with miscarriages and birth defects in the first trimester. Miscarriage caused by invasive prenatal diagnosis (chorionic villus sampling (CVS) and amniocentesis) is rare (about 1%).


title: Miscarriage

text: The effects of surgery on pregnancy are not well-known including the effects of bariatric surgery. Abdominal and pelvic surgery are not risk factors for miscarriage. Ovarian tumours and cysts that are removed have not been found to increase the risk of miscarriage. The exception to this is the removal of the corpus luteum from the ovary. This can cause fluctuations in the hormones necessary to maintain the pregnancy.


title: Miscarriage

text: There is no significant association between antidepressant medication exposure and spontaneous abortion. The risk of miscarriage is not likely decreased by discontinuing SSRIs prior to pregnancy. Some available data suggest that there is a small increased risk of miscarriage for women taking any antidepressant, though this risk becomes less statistically significant when excluding studies of poor quality.


title: Miscarriage

text: Immunizations have not been found to cause miscarriage. Live vaccinations, like the MMR vaccine, can theoretically cause damage to the fetus as the live virus can cross the placenta and potentially increase the risk for miscarriage. Therefore, the Center for Disease Control (CDC) recommends against pregnant women receiving live vaccinations. However, there is no clear evidence that has shown live vaccinations to increase the risk for miscarriage or fetal abnormalities.


title: Miscarriage

text: Some live vaccinations include: MMR, varicella, certain types of the influenza vaccine, and rotavirus.


title: Miscarriage

text: Ionizing radiation levels given to a woman during cancer treatment cause miscarriage. Exposure can also impact fertility. The use of chemotherapeutic drugs used to treat childhood cancer increases the risk of future miscarriage.


title: Miscarriage

text: Several pre-existing diseases in pregnancy can potentially increase the risk of miscarriage, including diabetes, polycystic ovary syndrome (PCOS), hypothyroidism, certain infectious diseases, and autoimmune diseases. PCOS may increase the risk of miscarriage. Two studies suggested treatment with the drug metformin significantly lowers the rate of miscarriage in women with PCOS, but the quality of these studies has been questioned. Metformin treatment in pregnancy has not been shown to be safe. In 2007 the Royal College of Obstetricians and Gynaecologists also recommended against use of the drug to prevent miscarriage. Thrombophilias or defects in coagulation and bleeding were once thought to be a risk in miscarriage but have been subsequently questioned. Severe cases of hypothyroidism increase the risk of miscarriage. The effect of milder cases of hypothyroidism on miscarriage rates has not been established. A condition called luteal phase defect (LPD) is a failure of the uterine lining to be fully prepared for pregnancy. This can keep a fertilized egg from implanting or result in miscarriage.


title: Miscarriage

text: "Mycoplasma genitalium" infection is associated with increased risk of preterm birth and miscarriage.


title: Miscarriage

text: Infections can increase the risk of a miscarriage: rubella (German measles), cytomegalovirus, bacterial vaginosis, HIV, chlamydia, gonorrhoea, syphilis, and malaria.


title: Miscarriage

text: Autoimmunity is a possible cause of recurrent or late-term miscarriages. In the case of an autoimmune-induced miscarriage, the woman's body attacks the growing fetus or prevents normal pregnancy progression. Autoimmune disease may cause abnormalities in embryos, which in turn may lead to miscarriage. As an example, Celiac disease increases the risk of miscarriage by an odds ratio of approximately 1.4. A disruption in normal immune function can lead to the formation of antiphospholipid antibody syndrome. This will affect the ability to continue the pregnancy, and if a woman has repeated miscarriages, she can be tested for it. Approximately 15% of recurrent miscarriages are related to immunologic factors. The presence of anti-thyroid autoantibodies is associated with an increased risk with an odds ratio of 3.73 and 95% confidence interval 1.8–7.6. Having lupus also increases the risk for miscarriage. Immunohistochemical studies on decidual basalis and chorionic villi found that the imbalance of the immunological environment could be associated with recurrent pregnancy loss.


title: Miscarriage

text: Fifteen per cent of women who have experienced three or more recurring miscarriages have some anatomical defect that prevents the pregnancy from being carried for the entire term. The structure of the uterus affects the ability to carry a child to term. Anatomical differences are common and can be congenital.


title: Miscarriage

text: In some women, cervical incompetence or cervical insufficiency occurs with the inability of the cervix to stay closed during the entire pregnancy. It does not cause first trimester miscarriages. In the second trimester, it is associated with an increased risk of miscarriage. It is identified after a premature birth has occurred at about 16–18 weeks into the pregnancy. During the second trimester, major trauma can result in a miscarriage.


title: Miscarriage

text: Tobacco (cigarette) smokers have an increased risk of miscarriage. There is an increased risk regardless of which parent smokes, though the risk is higher when the gestational mother smokes.


title: Miscarriage

text: Nausea and vomiting of pregnancy (NVP, or morning sickness) is associated with a decreased risk. Several possible causes have been suggested for morning sickness but there is still no agreement. NVP may represent a defense mechanism which discourages the mother's ingestion of foods that are harmful to the fetus; according to this model, a lower frequency of miscarriage would be an expected consequence of the different food choices made by women experiencing NVP.


title: Miscarriage

text: Chemical and occupational exposures may have some effect in pregnancy outcomes. A cause and effect relationship almost can never be established. Those chemicals that are implicated in increasing the risk for miscarriage are DDT, lead, formaldehyde, arsenic, benzene and ethylene oxide. Video display terminals and ultrasound have not been found to have an effect on the rates of miscarriage. In dental offices where nitrous oxide is used with the absence of anesthetic gas scavenging equipment, there is a greater risk of miscarriage. For women who work with cytotoxic antineoplastic chemotherapeutic agents there is a small increased risk of miscarriage. No increased risk for cosmetologists has been found.


title: Miscarriage

text: Alcohol increases the risk of miscarriage. Cocaine use increases the rate of miscarriage. Some infections have been associated with miscarriage. These include "Ureaplasma urealyticum", "Mycoplasma hominis", group B streptococci, HIV-1, and syphilis. Infections of "Chlamydia trachomatis," "Camphylobacter fetus", and "Toxoplasma gondii" have not been found to be linked to miscarriage. Subclinical infections of the lining of the womb, commonly known as chronic endometritis are also associated with poor pregnancy outcomes, compared to women with treated chronic endometritis or no chronic endometritis.


title: Miscarriage

text: In the case of blood loss, pain, or both, transvaginal ultrasound is performed. If a viable intrauterine pregnancy is not found with ultrasound, blood tests (serial βHCG tests) can be performed to rule out ectopic pregnancy, which is a life-threatening situation.


title: Miscarriage

text: If hypotension, tachycardia, and anemia are discovered, exclusion of an ectopic pregnancy is important.


title: Miscarriage

text: A miscarriage may be confirmed by an obstetric ultrasound and by the examination of the passed tissue. When looking for microscopic pathologic symptoms, one looks for the products of conception. Microscopically, these include villi, trophoblast, fetal parts, and background gestational changes in the endometrium. When chromosomal abnormalities are found in more than one miscarriage, genetic testing of both parents may be done.


title: Miscarriage

text: A review article in "The New England Journal of Medicine" based on a consensus meeting of the Society of Radiologists in Ultrasound in America (SRU) has suggested that miscarriage should be diagnosed only if any of the following criteria are met upon ultrasonography visualization:


title: Miscarriage

text: A threatened miscarriage is any bleeding during the first half of pregnancy. At investigation it may be found that the fetus remains viable and the pregnancy continues without further problems.


title: Miscarriage

text: An anembryonic pregnancy (also called an "empty sac" or "blighted ovum") is a condition where the gestational sac develops normally, while the embryonic part of the pregnancy is either absent or stops growing very early. This accounts for approximately half of miscarriages. All other miscarriages are classified as embryonic miscarriages, meaning that there is an embryo present in the gestational sac. Half of embryonic miscarriages have aneuploidy (an abnormal number of chromosomes).


title: Miscarriage

text: An inevitable miscarriage occurs when the cervix has already dilated, but the fetus has yet to be expelled. This usually will progress to a complete miscarriage. The fetus may or may not have cardiac activity.


title: Miscarriage

text: An incomplete miscarriage occurs when some products of conception have been passed, but some remains inside the uterus. However, an increased distance between the uterine walls on transvaginal ultrasonography may also simply be an increased endometrial thickness and/or a polyp. The use of a Doppler ultrasound may be better in confirming the presence of significant retained products of conception in the uterine cavity. In cases of uncertainty, ectopic pregnancy must be excluded using techniques like serial beta-hCG measurements.


title: Miscarriage

text: A missed miscarriage is when the embryo or fetus has died, but a miscarriage has not yet occurred. It is also referred to as delayed miscarriage, silent miscarriage, or missed abortion.


title: Miscarriage

text: A septic miscarriage occurs when the tissue from a missed or incomplete miscarriage becomes infected, which carries the risk of spreading infection (septicaemia) and can be fatal.


title: Miscarriage

text: Recurrent miscarriage ("recurrent pregnancy loss" (RPL), "recurrent spontaneous abortion (RSA), or "habitual abortion") is the occurrence of multiple consecutive miscarriages; the exact number used to diagnose recurrent miscarriage varies; however two is the minimum threshold to meet the criteria. If the proportion of pregnancies ending in miscarriage is 15% and assuming that miscarriages are independent events, then the probability of two consecutive miscarriages is 2.25% and the probability of three consecutive miscarriages is 0.34%. The occurrence of recurrent pregnancy loss is 1%. A large majority (85%) of those who have had two miscarriages will conceive and carry normally afterward.


title: Miscarriage

text: The physical symptoms of a miscarriage vary according to the length of pregnancy, though most miscarriages cause pain or cramping. The size of blood clots and pregnancy tissue that are passed become larger with longer gestations. After 13 weeks' gestation, there is a higher risk of placenta retention.


title: Miscarriage

text: Prevention of a miscarriage can sometimes be accomplished by decreasing risk factors. This may include good prenatal care, avoiding drugs and alcohol, preventing infectious diseases, and avoiding x-rays. Identifying the cause of the miscarriage may help prevent future pregnancy loss, especially in cases of recurrent miscarriage. Often there is little a person can do to prevent a miscarriage. Vitamin supplementation before or during pregnancy has not been found to affect the risk of miscarriage. Progesterone has been shown to prevent miscarriage in women with 1) vaginal bleeding early in their current pregnancy and 2) a previous history of miscarriage.


title: Miscarriage

text: Maintaining a healthy weight and good prenatal care can reduce the risk of miscarriage. Some risk factors can be minimized by avoiding the following:


title: Miscarriage

text: Women who miscarry early in their pregnancy usually do not require any subsequent medical treatment but they can benefit from support and counseling. Most early miscarriages will complete on their own; in other cases, medication treatment or aspiration of the products of conception can be used to remove remaining tissue. While bed rest has been advocated to prevent miscarriage, this has not been found to be of benefit. Those who are experiencing or who have experienced a miscarriage benefit from the use of careful medical language. Significant distress can often be managed by the ability of the clinician to clearly explain terms without suggesting that the woman or couple are somehow to blame.


title: Miscarriage

text: Evidence to support Rho(D) immune globulin after a spontaneous miscarriage is unclear. In the UK, Rho(D) immune globulin is recommended in Rh-negative women after 12 weeks gestational age and before 12 weeks gestational age in those who need surgery or medication to complete the miscarriage.


title: Miscarriage

text: No treatment is necessary for a diagnosis of complete miscarriage (so long as ectopic pregnancy is ruled out). In cases of an incomplete miscarriage, empty sac, or missed abortion there are three treatment options: watchful waiting, medical management, and surgical treatment. With no treatment (watchful waiting), most miscarriages (65–80%) will pass naturally within two to six weeks. This treatment avoids the possible side effects and complications of medications and surgery, but increases the risk of mild bleeding, need for unplanned surgical treatment, and incomplete miscarriage. Medical treatment usually consists of using misoprostol (a prostaglandin) alone or in combination with mifepristone pre-treatment. These medications help the uterus to contract and expel the remaining tissue out of the body. This works within a few days in 95% of cases. Vacuum aspiration or sharp curettage can be used, with vacuum aspiration being lower-risk and more common.


title: Miscarriage

text: In delayed or incomplete miscarriage, treatment depends on the amount of tissue remaining in the uterus. Treatment can include surgical removal of the tissue with vacuum aspiration or misoprostol. Studies looking at the methods of anaesthesia for surgical management of incomplete miscarriage have not shown that any adaptation from normal practice is beneficial.


title: Miscarriage

text: An induced abortion may be performed by a qualified healthcare provider for women who cannot continue the pregnancy. Self-induced abortion performed by a woman or non-medical personnel can be dangerous and is still a cause of maternal mortality in some countries. In some locales it is illegal or carries heavy social stigma. However, in the United States, many choose to self-induce or self-manage their abortion and have done so safely.


title: Miscarriage

text: Some organizations recommend delaying sex after a miscarriage until the bleeding has stopped to decrease the risk of infection. However, there is not sufficient evidence for the routine use of antibiotic to try to avoid infection in incomplete abortion. Others recommend delaying attempts at pregnancy until one period has occurred to make it easier to determine the dates of a subsequent pregnancy. There is no evidence that getting pregnant in that first cycle affects outcomes and an early subsequent pregnancy may actually improve outcomes.


title: Miscarriage

text: Organizations exist that provide information and counselling to help those who have had a miscarriage. Family and friends often conduct a memorial or burial service. Hospitals also can provide support and help memorialize the event. Depending on locale others desire to have a private ceremony. Providing appropriate support with frequent discussions and sympathetic counselling are part of evaluation and treatment. Those who experience unexplained miscarriage can be treated with emotional support.


title: Miscarriage

text: Miscarriage leave is leave of absence in relation to miscarriage. The following countries offer paid or unpaid leave to women who have had a miscarriage.


title: Miscarriage

text: Every woman's personal experience of miscarriage is different, and women who have more than one miscarriage may react differently to each event.


title: Miscarriage

text: In Western cultures since the 1980s, medical providers assume that experiencing a miscarriage "is a major loss for all pregnant women". A miscarriage can result in anxiety, depression or stress for those involved. It can have an effect on the whole family. Many of those experiencing a miscarriage go through a grieving process. "Prenatal attachment" often exists that can be seen as parental sensitivity, love and preoccupation directed toward the unborn child. Serious emotional impact is usually experienced immediately after the miscarriage. Some may go through the same loss when an ectopic pregnancy is terminated. In some, the realization of the loss can take weeks. Providing family support to those experiencing the loss can be challenging because some find comfort in talking about the miscarriage while others may find the event painful to discuss. The father can have the same sense of loss. Expressing feelings of grief and loss can sometimes be harder for men. Some women are able to begin planning their next pregnancy after a few weeks of having the miscarriage. For others, planning another pregnancy can be difficult. Some facilities acknowledge the loss. Parents can name and hold their infant. They may be given mementos such as photos and footprints. Some conduct a funeral or memorial service. They may express the loss by planting a tree.


title: Miscarriage

text: Some health organizations recommend that sexual activity be delayed after the miscarriage. The menstrual cycle should resume after about three to four months. Women report that they were dissatisfied with the care they received from physicians and nurses.


title: Miscarriage

text: Some parents want to try to have a baby very soon after the miscarriage. The decision of trying to become pregnant again can be difficult. Reasons exist that may prompt parents to consider another pregnancy. For older mothers, there may be some sense of urgency. Other parents are optimistic that future pregnancies are likely to be successful. Many are hesitant and want to know about the risk of having another or more miscarriages. Some clinicians recommend that the women have one menstrual cycle before attempting another pregnancy. This is because the date of conception may be hard to determine. Also, the first menstrual cycle after a miscarriage can be much longer or shorter than expected. Parents may be advised to wait even longer if they have experienced late miscarriage or molar pregnancy, or are undergoing tests. Some parents wait for six months based upon recommendations from their health care provider.


title: Miscarriage

text: The risks of having another miscarriage vary according to the cause. The risk of having another miscarriage after a molar pregnancy is very low. The risk of another miscarriage is highest after the third miscarriage. Pre-conception care is available in some locales.


title: Miscarriage

text: There is a significant association between miscarriage and later development of coronary artery disease, but not of cerebrovascular disease.


title: Miscarriage

text: Among women who know they are pregnant, the miscarriage rate is roughly 10% to 20%, while rates among all fertilized zygotes are around 30% to 50%. A 2012 review found the risk of miscarriage between 5 and 20 weeks from 11% to 22%. Up to the 13th week of pregnancy, the risk of miscarriage each week was around 2%, dropping to 1% in week 14 and reducing slowly between 14 and 20 weeks.


title: Miscarriage

text: The precise rate is not known because a large number of miscarriages occur before pregnancies become established and before the woman is aware she is pregnant. Additionally, those with bleeding in early pregnancy may seek medical care more often than those not experiencing bleeding. Although some studies attempt to account for this by recruiting women who are planning pregnancies and testing for very early pregnancy, they still are not representative of the wider population.


title: Miscarriage

text: The prevalence of miscarriage increases with the age of both parents. In a Danish register-based study where the prevalence of miscarriage was 11%, the prevalence rose from 9% at 22 years of age to 84% by 48 years of age. Another, later study in 2013 found that when either parent was over the age of 40, the rate of known miscarriages doubled.


title: Miscarriage

text: Most affected women and family members refer to miscarriage as the loss of a baby, rather than an embryo or fetus, and healthcare providers are expected to respect and use the language that the person chooses. Clinical terms can suggest blame, increase distress, and even cause anger. Terms that are known to cause distress in those experiencing miscarriage include:


title: Miscarriage

text: Pregnancy loss is a broad term that is used for miscarriage, ectopic and molar pregnancies. The term "fetal death" applies variably in different countries and contexts, sometimes incorporating weight, and gestational age from 16 weeks in Norway, 20 weeks in the US and Australia, 24 weeks in the UK to 26 weeks in Italy and Spain. A fetus that died before birth after this gestational age may be referred to as a stillbirth. Under UK law, all stillbirths should be registered, although this does not apply to miscarriages.


title: Miscarriage

text: The medical terminology applied to experiences during early pregnancy has changed over time. Before the 1980s, health professionals used the phrase "spontaneous abortion" for a miscarriage and "induced abortion" for a termination of the pregnancy. In the late 1980s and 1990s, doctors became more conscious of their language in relation to early pregnancy loss. Some medical authors advocated change to use of "miscarriage" instead of "spontaneous abortion" because they argued this would be more respectful and help ease a distressing experience. The change was being recommended by some in the profession in Britain in the late 1990s. In 2005 the European Society for Human Reproduction and Embryology (ESHRE) published a paper aiming to facilitate a revision of nomenclature used to describe early pregnancy events.


title: Miscarriage

text: Society's reactions to miscarriage have changed over time. In the early 20th century, the focus was on the mother's physical health and the difficulties and disabilities that miscarriage could produce. Other reactions, such as the expense of medical treatments and relief at ending an unwanted pregnancy, were also heard. In the 1940s and 1950s, people were more likely to express relief, not because the miscarriage ended an unwanted or mistimed pregnancy, but because people believed that miscarriages were primarily caused by birth defects, and miscarrying meant that the family would not raise a child with disabilities. The dominant attitude in the mid-century was that a miscarriage, although temporarily distressing, was a blessing in disguise for the family, and that another pregnancy and a healthier baby would soon follow, especially if women trusted physicians and reduced their anxieties. Media articles were illustrated with pictures of babies, and magazine articles about miscarriage ended by introducing the healthy baby—usually a boy—that had shortly followed it.


title: Miscarriage

text: Beginning in the 1980s, miscarriage in the US was primarily framed in terms of the individual woman's personal emotional reaction, and especially her grief over a tragic outcome. The subject was portrayed in the media with images of an empty crib or an isolated, grieving woman, and stories about miscarriage were published in general-interest media outlets, not just women's magazines or health magazines. Family members were encouraged to grieve, to memorialize their losses through funerals and other rituals, and to think of themselves as being parents. This shift to recognizing these emotional responses was partly due to medical and political successes, which created an expectation that pregnancies are typically planned and safe, and to women's demands that their emotional reactions no longer be dismissed by the medical establishments. It also reinforces the anti-abortion movement’s belief that human life begins at conception or early in pregnancy, and that motherhood is a desirable life goal. The modern one-size-fits-all model of grief does not fit every woman's experience, and an expectation to perform grief creates unnecessary burdens for some women. The reframing of miscarriage as a private emotional experience brought less awareness of miscarriage and a sense of silence around the subject, especially compared to the public discussion of miscarriage during campaigns for access to birth control during the early 20th century, or the public campaigns to prevent miscarriages, stillbirths, and infant deaths by reducing industrial pollution during the 1970s.


title: Miscarriage

text: In places where induced abortion is illegal or carries social stigma, suspicion may surround miscarriage, complicating an already sensitive issue.


title: Miscarriage

text: In the 1960s, the use of the word "miscarriage" in Britain (instead of "spontaneous abortion") occurred after changes in legislation.


title: Miscarriage

text: Developments in ultrasound technology (in the early 1980s) allowed them to identify earlier miscarriages.


title: Miscarriage

text: According to French statutes, an infant born before the age of viability, determined to be 28 weeks, is not registered as a 'child'. If birth occurs after this, the infant is granted a certificate that allows women who have given birth to a stillborn child, to have a symbolic record of that child. This certificate can include a registered and given name to allow a funeral and acknowledgement of the event.


title: Miscarriage

text: Miscarriage occurs in all animals that experience pregnancy, though in such contexts it is more commonly referred to as a "spontaneous abortion" (the two terms are synonymous). There are a variety of known risk factors in non-human animals. For example, in sheep, miscarriage may be caused by crowding through doors, or being chased by dogs. In cows, spontaneous abortion may be caused by contagious disease, such as brucellosis or "Campylobacter", but often can be controlled by vaccination. In many species of sharks and rays, stress induced miscarriage occurs frequently on capture.


title: Miscarriage

text: Other diseases are also known to make animals susceptible to miscarriage. Spontaneous abortion occurs in pregnant prairie voles when their mate is removed and they are exposed to a new male, an example of the Bruce effect, although this effect is seen less in wild populations than in the laboratory. Female mice who had spontaneous abortions showed a sharp rise in the amount of time spent with unfamiliar males preceding the abortion than those who did not.


title: History of cricket

text: The sport of cricket has a known history beginning in the late 16th century. Having originated in south-east England, it became an established sport in the country in the 18th century and developed globally in the 19th and 20th centuries. International matches have been played since the 19th-century and formal Test cricket matches are considered to date from 1877. Cricket is the world's second most popular spectator sport after association football (soccer).


title: History of cricket

text: Internationally, cricket is governed by the International Cricket Council (ICC), which has over one hundred countries and territories in membership although only twelve currently play Test cricket.


title: History of cricket

text: The game's rules are defined in the "Laws of cricket". The game has various formats, ranging from one-day cricket played over a few hours to Test matches which can last up to five days.


title: History of cricket

text: Cricket was created during Saxon or Norman times by children living in the Weald, an area of dense woodlands and clearings in south-east England that lies across Kent and Sussex. The first definite written reference is from the end of the 16th century.


title: History of cricket

text: There have been several speculations about the game's origins, including some that it was created in France or Flanders. The earliest of these speculative references is from 1300 and concerns the future King Edward II playing at "creag and other games" in both Westminster and Newenden. It has been suggested that "creag" was an Old English word for cricket, but expert opinion is that it was an early spelling of "craic", meaning "fun and games in general".


title: History of cricket

text: It is generally believed that cricket survived as a children's game for many generations before it was increasingly taken up by adults around the beginning of the 17th century. Possibly cricket was derived from bowls, assuming bowls is the older sport, by the intervention of a batsman trying to stop the ball from reaching its target by hitting it away. Playing on sheep-grazed land or in clearings, the original implements may have been a matted lump of sheep's wool (or even a stone or a small lump of wood) as the ball; a stick or a crook or another farm tool as the bat; and a stool or a tree stump or a gate (e.g., a wicket gate) as the wicket.


title: History of cricket

text: In 1597 (Old Style – 1598 New Style) a court case in England concerning an ownership dispute over a plot of common land in Guildford, Surrey, mentions the game of . A 59-year-old coroner, John Derrick, testified that he and his school friends had played on the site fifty years earlier when they attended the Free School. Derrick's account proves beyond reasonable doubt that the game was being played in Surrey "circa" 1550, and is the earliest universally accepted reference to the game.


title: History of cricket

text: The first reference to cricket being played as an adult sport was in 1611, when two men in Sussex were prosecuted for playing cricket on Sunday instead of going to church. In the same year, a dictionary defined cricket as a boys' game, and this suggests that adult participation was a recent development.


title: History of cricket

text: A number of words are thought to be possible sources for the term "cricket". In the earliest definite reference, it was spelled . The name may have been derived from the Middle Dutch "krick"("-e"), meaning a stick; or the Old English or meaning a crutch or staff, or the French word meaning a wooden post. The Middle Dutch word means a long low stool used for kneeling in church; this resembled the long low wicket with two stumps used in early cricket. According to Heiner Gillmeister, a European language expert of the University of Bonn, "cricket" derives from the Middle Dutch phrase for hockey, (i.e., "with the stick chase").


title: History of cricket

text: It is more likely that the terminology of cricket was based on words in use in south-east England at the time and, given trade connections with the County of Flanders, especially in the 15th century when it belonged to the Duchy of Burgundy, many Middle Dutch words found their way into southern English dialects.


title: History of cricket

text: After the Civil War ended in 1648, the new Puritan government clamped down on "unlawful assemblies", in particular the more raucous sports such as football. Their laws also demanded a stricter observance of the Sabbath than there had been previously. As the Sabbath was the only free time available to the lower classes, cricket's popularity may have waned during the Commonwealth. However, it did flourish in public fee-paying schools such as Winchester and St Paul's. There is no actual evidence that Oliver Cromwell's regime banned cricket specifically and there are references to it during the interregnum that suggest it was acceptable to the authorities provided that it did not cause any "breach of the Sabbath". It is believed that the nobility in general adopted cricket at this time through involvement in village games.


title: History of cricket

text: Cricket thrived after the Restoration in 1660 and is believed to have first attracted gamblers making large bets at this time. It is possible, as believed by some historians, that top-class matches began. In 1664, the "Cavalier" Parliament passed the Gaming Act 1664 which limited stakes to £100, although that was still a fortune at the time, equivalent to about £ in present-day terms . Cricket had become a significant gambling sport by the end of the 17th century, as evidenced in 1697 by a newspaper report of a "great match" played in Sussex which was 11-a-side and played for high stakes of 50 guineas a side.


title: History of cricket

text: With freedom of the press having been granted in 1696, cricket for the first time could be reported in the newspapers. But it was a long time before the newspaper industry adapted sufficiently to provide frequent, let alone comprehensive, coverage of the game. During the first half of the 18th century, press reports tended to focus on the betting rather than on the play.


title: History of cricket

text: Gambling introduced the first patrons because some of the gamblers decided to strengthen their bets by forming their own teams and it is believed the first "county teams" were formed in the aftermath of the Restoration in 1660, especially as members of the nobility were employing "local experts" from village cricket as the earliest professionals. The first known game in which the teams use county names is in 1709 but there can be little doubt that these sort of fixtures were being arranged long before that. The match in 1697 was probably Sussex versus another county.


title: History of cricket

text: The most notable of the early patrons were a group of aristocrats and businessmen who were active from about 1725, which is the time that press coverage became more regular, perhaps as a result of the patrons' influence. These men included the 2nd Duke of Richmond, Sir William Gage, Alan Brodrick and Edwin Stead. For the first time, the press mentions individual players like Thomas Waymark.


title: History of cricket

text: Cricket was introduced to North America via the English colonies in the 17th century, probably before it had even reached the north of England. In the 18th century it arrived in other parts of the globe. It was introduced to the West Indies by colonists and to India by East India Company mariners in the first half of the century. It arrived in Australia almost as soon as colonisation began in 1788. New Zealand and South Africa followed in the early years of the 19th century.


title: History of cricket

text: Cricket never caught on in Canada, despite efforts by the upper class to promote the game as a way of identifying with the "mother country". Canada, unlike Australia and the West Indies, witnessed a continual decline in the popularity of the game during 1860 to 1960. Linked in the public consciousness to an upper-class sport, the game never became popular with the general public. In the summer season it had to compete with baseball. During the First World War, Canadian units stationed in France played baseball instead of cricket.


title: History of cricket

text: It's not clear when the basic rules of cricket such as bat and ball, the wicket, pitch dimensions, overs, how out, etc. were originally formulated. In 1728, the Duke of Richmond and Alan Brodick drew up Articles of Agreement to determine the code of practice in a particular game and this became a common feature, especially around payment of stake money and distributing the winnings given the importance of gambling.


title: History of cricket

text: In 1744, the "Laws of Cricket" were codified for the first time and then amended in 1774, when innovations such as lbw, middle stump and maximum bat width were added. These laws stated that "the principals shall choose from amongst the gentlemen present two umpires who shall absolutely decide all disputes". The codes were drawn up by the so-called "Star and Garter Club" whose members ultimately founded the Marylebone Cricket Club at Lord's in 1787. The MCC immediately became the custodian of the Laws and has made periodic revisions and recodifications subsequently.


title: History of cricket

text: The game continued to spread throughout England, and, in 1751, Yorkshire is first mentioned as a venue. The original form of bowling (i.e., rolling the ball along the ground as in bowls) was superseded sometime after 1760 when bowlers began to pitch the ball and study variations in line, length and pace. Scorecards began to be kept on a regular basis from 1772; since then, an increasingly clear picture has emerged of the sport's development.


title: History of cricket

text: The first famous clubs were London and Dartford in the early 18th century. London played its matches on the Artillery Ground, which still exists. Others followed, particularly Slindon in Sussex, which was backed by the Duke of Richmond and featured the star player Richard Newland. There were other prominent clubs at Maidenhead, Hornchurch, Maidstone, Sevenoaks, Bromley, Addington, Hadlow and Chertsey.


title: History of cricket

text: But far and away the most famous of the early clubs was Hambledon in Hampshire. It started as a parish organisation that first achieved prominence in 1756. The club itself was founded in the 1760s and was well patronised to the extent that it was the focal point of the game for about thirty years until the formation of MCC and the opening of Lord's Cricket Ground in 1787. Hambledon produced several outstanding players including the master batsman John Small and the first great fast bowler Thomas Brett. Their most notable opponent was the Chertsey and Surrey bowler Edward "Lumpy" Stevens, who is believed to have been the main proponent of the flighted delivery.


title: History of cricket

text: It was in answer to the flighted, or pitched, delivery that the straight bat was introduced. The old "hockey stick"–style of bat was only really effective against the ball being trundled or skimmed along the ground.


title: History of cricket

text: First-class cricket began in 1772. Three surviving scorecards exist of 1772 matches organised by the Hambledon Club which commence a continuous statistical record. Those three matches were all between a Hampshire XI and an England XI, the first played at Broadhalfpenny Down on 24 and 25 June. The two leading online archives begin their first-class coverage with this match which is numbered "first-class no. 1" by ESPNcricinfo and "f1" by CricketArchive. Broadhalfpenny Down continued in regular use by Hambledon/Hampshire teams until 1781.


title: History of cricket

text: The game also underwent a fundamental change of organisation with the formation for the first time of county clubs. All the modern county clubs, starting with Sussex in 1839, were founded during the 19th century. No sooner had the first county clubs established themselves than they faced what amounted to "player action" as William Clarke created the travelling All-England Eleven in 1846. Though a commercial venture, this team did much to popularise the game in districts which had never previously been visited by high-class cricketers. Other similar teams were created and this vogue lasted for about thirty years. But the counties and MCC prevailed.


title: History of cricket

text: The growth of cricket in the mid and late 19th century was assisted by the development of the railway network. For the first time, teams from a long distance apart could play one other without a prohibitively time-consuming journey. Spectators could travel longer distances to matches, increasing the size of crowds. Army units around the Empire had time on their hands, and encouraged the locals so they could have some entertaining competition. Most of the Empire embraced cricket, with the exception of Canada.


title: History of cricket

text: In 1864, another bowling revolution resulted in the legalisation of overarm and in the same year Wisden Cricketers' Almanack was first published. W. G. Grace began his long and influential career at this time, his feats doing much to increase cricket's popularity. He introduced technical innovations which revolutionised the game, particularly in batting.


title: History of cricket

text: The first ever international cricket game was between the US and Canada in 1844. The match was played at the grounds of the St George's Cricket Club in New York.


title: History of cricket

text: In 1859, a team of leading English professionals set off to North America on the first-ever overseas tour and, in 1862, the first English team toured Australia. Between May and October 1868, a team of Aboriginal Australians toured England in what was the first Australian cricket team to travel overseas.


title: History of cricket

text: In 1877, an England touring team in Australia played two matches against full Australian XIs that are now regarded as the inaugural Test matches. The following year, the Australians toured England for the first time and the success of this tour ensured a popular demand for similar ventures in future. No Tests were played in 1878 but more soon followed and, at The Oval in 1882, the Australian victory in a tense finish gave rise to The Ashes.


title: History of cricket

text: A significant development in domestic cricket occurred in 1890 when the official County Championship was constituted in England. Soon afterwards, in May 1894, the sport's first-class standard was officially defined. This organisational initiative has been repeated in other countries. Australia established the Sheffield Shield in 1892–93. Other national competitions to be established were the Currie Cup in South Africa, the Plunket Shield in New Zealand and the Ranji Trophy in India. The ICC re-defined first-class status in 1947 as a global concept.


title: History of cricket

text: The period from 1890 to the outbreak of the First World War has become one of nostalgia, ostensibly because the teams played cricket according to "the spirit of the game", but more realistically because it was a peacetime period that was shattered by the First World War. The era has been called The Golden Age of cricket and it featured numerous great names such as Grace, Wilfred Rhodes, C. B. Fry, Ranjitsinhji and Victor Trumper.


title: History of cricket

text: During most of the 19th-century standard overs were made up of four deliveries. In 1889 five-ball overs were introduced in first-class cricket, with a move to generally use six-ball overs in 1900.


title: History of cricket

text: In the 20th century, eight-ball overs were used at times in a number of countries, primarily Australia, where eight-balls were the standard over length between 1918/19 and 1978/79, South Africa and New Zealand. Since the 1979/80 Australian and New Zealand seasons, six balls per over have been used worldwide, and the most recent version of the Laws only permits six-ball overs.


title: History of cricket

text: The game of cricket was exported to other colonies around the world. The Imperial Cricket Conference was founded in 1909 with England, Australia and South Africa as the founder members. It had been set up with the Marylebone Cricket club, the Australian Board of Control for International Cricket, and the South African Cricket Association as the original associations of the ICC. This aimed to regulate international cricket between the three sides, considered the only three of equal status at the time. In 1926, both New Zealand and the West Indies were admitted as members, allowing them to play Test cricket against the other sides. However, at this time in the West Indies, cricket was primarily dominated by the white population. Originally, the ICC was not interested in broadening the international popularity of cricket. The organization was reluctant to invite non-commonwealth nations to play. New Zealand was restricted to play three-day test matches. New Zealand and India both became Test playing nations before World War II and Pakistan joined soon afterwards in 1952.


title: History of cricket

text: At the initial suggestion of Pakistan, the ICC was expanded to include non-Test playing countries from 1965, with Associate members being admitted. At the same time the organisation changed its name to the International Cricket Conference. The first limited-overs World Cups were played during the 1970s and Sri Lanka became the first Associate member to be raised to Test playing status in 1982. Because the ICC was predominantly a Western organization, the founding countries decided who was allowed to join the conference or engage in test cricket. There was no desire or attempt to create a set of Associate nations that would play in Test status, which is why countries such as Sri Lanka were not permitted to partake until the 1980s.


title: History of cricket

text: The international game continued to grow with the introduction of Affiliate Member status in 1984, a level of membership designed for sides with less history of playing cricket. In 1989 the ICC renamed itself the International Cricket Council. Zimbabwe became Full Members in 1992 and Bangladesh in 2000 before Afghanistan and Ireland were both admitted as Test sides in 2018, bringing the number of full members of the ICC to 12.


title: History of cricket

text: The greatest crisis to hit international cricket was brought about by apartheid, the South African policy of racial segregation. The situation began to crystallise after 1961 when South Africa left the Commonwealth of Nations and so, under the rules of the day, its cricket board had to leave the International Cricket Conference (ICC). Cricket's opposition to apartheid intensified in 1968 with the cancellation of England's tour to South Africa by the South African authorities, due to the inclusion in the England team of Basil D'Oliveira, a Cape Coloured player. In 1970, the ICC members voted to suspend South Africa indefinitely from international cricket competition.


title: History of cricket

text: Starved of top-level competition for its best players, the South African Cricket Board began funding so-called "rebel tours", offering large sums of money for international players to form teams and tour South Africa. The ICC's response was to blacklist any rebel players who agreed to tour South Africa, banning them from officially sanctioned international cricket. As players were poorly remunerated during the 1970s, several accepted the offer to tour South Africa, particularly players getting towards the end of their careers for which a blacklisting would have little effect.


title: History of cricket

text: The rebel tours continued into the 1980s but then progress was made in South African politics and it became clear that apartheid was ending. South Africa, now a "Rainbow Nation" under Nelson Mandela, was welcomed back into international sport in 1991.


title: History of cricket

text: The money problems of top cricketers were also the root cause of another cricketing crisis that arose in 1977 when the Australian media magnate Kerry Packer fell out with the Australian Cricket Board over TV rights. Taking advantage of the low remuneration paid to players, Packer retaliated by signing several of the best players in the world to a privately run cricket league outside the structure of international cricket. World Series Cricket hired some of the banned South African players and allowed them to show off their skills in an international arena against other world-class players. The schism lasted only until 1979 and the "rebel" players were allowed back into established international cricket, though many found that their national teams had moved on without them. Long-term results of World Series Cricket have included the introduction of significantly higher player salaries and innovations such as coloured kit and night games.


title: History of cricket

text: In the 1960s, English county teams began playing a version of cricket with games of only one innings each and a maximum number of overs per innings. Starting in 1963 as a knockout competition only, limited-overs cricket grew in popularity and, in 1969, a national league was created which consequently caused a reduction in the number of matches in the County Championship. The status of limited overs matches is governed by the official List A categorisation. Although many "traditional" cricket fans objected to the shorter form of the game, limited-overs cricket did have the advantage of delivering a result to spectators within a single day; it did improve cricket's appeal to younger or busier people; and it did prove commercially successful.


title: History of cricket

text: The first limited-overs international match took place at Melbourne Cricket Ground in 1971 as a time-filler after a Test match had been abandoned because of heavy rain on the opening days. It was tried simply as an experiment and to give the players some exercise, but turned out to be immensely popular. limited-overs internationals (LOIs or ODIs—one-day internationals) have since grown to become a massively popular form of the game, especially for busy people who want to be able to see a whole match. The International Cricket Council reacted to this development by organising the first Cricket World Cup in England in 1975, with all the Test-playing nations taking part.


title: History of cricket

text: Limited-overs cricket increased television ratings for cricket coverage. Innovative techniques introduced in coverage of limited-over matches were soon adopted for Test coverage. The innovations included presentation of in-depth statistics and graphical analysis, placing miniature cameras in the stumps, multiple usage of cameras to provide shots from several locations around the ground, high-speed photography and computer graphics technology enabling television viewers to study the course of a delivery and help them understand an umpire's decision.


title: History of cricket

text: In 1992, the use of a third umpire to adjudicate run-out appeals with television replays was introduced in the Test series between South Africa and India. The third umpire's duties have subsequently expanded to include decisions on other aspects of play such as stumpings, catches and boundaries. From 2011, the third umpire was being called upon to moderate review of umpires' decisions, including lbw, with the aid of virtual-reality tracking technologies (e.g., Hawk-Eye and Hot Spot), though such measures still could not free some disputed decisions from heated controversy.


title: History of cricket

text: In June 2001, the ICC introduced a "Test Championship Table" and, in October 2002, a "One-day International Championship Table". As indicated by ICC rankings, the various cricket formats have continued to be a major competitive sport in most former British Empire countries, notably the Indian subcontinent, and new participants including the Netherlands. In 2017, the number of countries with full ICC membership was increased to twelve by the addition of Afghanistan and Ireland.


title: History of cricket

text: The ICC expanded its development programme, aiming to produce more national teams capable of competing at the various formats. Development efforts are focused on African and Asian nations, and on the United States. In 2004, the ICC Intercontinental Cup brought first-class cricket to 12 nations, mostly for the first time. Cricket's newest innovation is Twenty20, essentially an evening entertainment. It has so far enjoyed enormous popularity and has attracted large attendances at matches as well as good TV audience ratings. The inaugural ICC Twenty20 World Cup tournament was held in 2007. The formation of Twenty20 leagues in India – the unofficial Indian Cricket League, which started in 2007, and the official Indian Premier League, starting in 2008 – raised much speculation in the cricketing press about their effect on the future of cricket.


title: History of cricket

text: Formats shorter than Twenty20 have also arisen at the domestic level, such as the T10 format, which is played in leagues organised by various Associate and Full Members, as well as the 100-ball format, which is played in The Hundred, a major limited-overs competition in England.


title: Middle name

text: In various cultures, a middle name is a portion of a personal name that is written between the person's first given name and their surname.


title: Middle name

text: A person may be given a middle name regardless of whether it is necessary to distinguish them from other people with the same given name and surname. In cultures where a given name is expected to precede the surname, additional names are likely to be placed after the given name and before the surname, and thus called middle names.


title: Middle name

text: The use of multiple middle names has been somewhat impeded recently by the increased use of computer databases that occasionally allow for only a single middle name or more commonly a middle initial in storing personal records, effectively preventing people with multiple middle names from being listed in such databases under their full name. This is worsened by longer compound names, like María del Pilar Pereyra or María de las Nieves García Fernández. A workaround would be to add the middle name alongside the first given name or surname, however this is not always possible.


title: Middle name

text: Among royalty and aristocracy, middle names have been used since the late 17th century (and possibly earlier), as exemplified in the name of the Stuart pretender James Francis Edward Stuart (1688–1766). Despite their relatively long existence in North America, the term "middle name" was not recorded until 1835, in the periodical "Harvardiana".


title: Middle name

text: Not every name that stands as the middle word in a three-name string is a middle name. Major classes of this theme are as follows:


title: Middle name

text: In the U.S., the middle name is often abbreviated to the middle initial (e.g. Mary Lee Bianchi becomes Mary L. Bianchi). This is usually standard for signatures or omitted entirely in everyday use (e.g. just Mary Bianchi). An individual may have more than one middle name, or none. In the United Kingdom, for comparison, she would usually be referred to as either Mary Bianchi, M. L. Bianchi or Mary Lee Bianchi, or she may choose Lee Bianchi, and informally there may be familiar shortenings.


title: Middle name

text: In countries that primarily speak English—such as Australia, Canada, Ireland, New Zealand, the United States, and the United Kingdom—the forename of a relative is sometimes used as one's middle name to honor familial heritage. Typical examples are a father named John William Smith whose son is named Thomas John Smith or a grandmother named Mary Grace Tilley whose granddaughter is named Ashley Mary Smith. In many cases in the United States, however, a person's middle name does not derive from relatives, but is used instead to honor close family friends or notable public figures. A rare case of an individual being given only an initial as a middle name, with the initial not explicitly standing for anything, was Harry S. Truman. (He once told reporters—apparently at odds with his own practice—that the S should thus not be followed by period.) Other people with single-letter middle names include Robert B. Hollander Jr. and Mark M Davis.


title: Middle name

text: More than two given names are fairly common. In England, they are traditionally more common among the upper and middle classes.


title: Middle name

text: There is a minor tradition in English-speaking countries whereby maiden names from the family tree that are especially celebrated by the family are carried into succeeding generations as middle names or as given names, whereas the tradition of married names would otherwise obliterate them. For example, this is how the first name of Johns Hopkins came to have the terminal "-s" that differentiates it from "John"; "Johns" was the surname of some of his ancestors. It is also how Robert Strange McNamara got his middle name (it was his mother's maiden name). There is some overlap between open-compound surnames and maiden-names-as-middle-names; in various cases the same motivation (preserving maiden names from oblivion) has produced both such kinds of names, and there are instances from the nineteenth century that are ambiguous today as to how the bearers of a name thus inspired parsed it themselves (either as part of a compound surname or as a middle name).


title: Middle name

text: The abbreviation "N.M.N." (no middle name) or "N.M.I." (no middle initial), with or without periods, is sometimes used in formal documents in the United States, where a middle initial or name is expected but the person does not have one. Rarely a person may assign themselves a middle initial to overcome the problems imposed by systems whose design failed to properly handle the absence of one or the ambiguity of human names' being non-unique. For example, David X. Cohen assigned himself a new middle initial to overcome a flaw in a system that failed to handle the ambiguity of human names properly (he was David S. Cohen but the system could not enter him because another David S. Cohen was already entered therein; using "X." circumvented the problem).


title: Middle name

text: A middle name that is rather unusual among English speakers is that of Jennifer 8. Lee, an American author. Lee was not given a middle name at birth so she chose "8" when she was a teenager, in a nod to her Chinese ancestry; in Chinese culture, the number eight symbolizes prosperity and good luck.


title: Middle name

text: In England and the United States, some who choose to be known primarily by their middle name abbreviate their first name as an initial, e.g. J. Edgar Hoover (John Edgar Hoover), J. Paul Getty (John Paul Getty), and F. Scott Fitzgerald (Francis Scott Key Fitzgerald).


title: Middle name

text: Many others simply omit the first name in regular usage, treating their middle name like a first name, e.g. Woodrow Wilson (Thomas Woodrow Wilson). It is increasingly common within political fields, with many U.S. politicians using their middle name as a first name - for example, Mitch McConnell (Addison Mitchell McConnell), Mitt Romney (Willard Mitt Romney), Jon Ossoff (Thomas Jonathan Ossoff), Jon Tester (Raymond Jon Tester), Ted Cruz (Rafael Edward Cruz) and Mike Rounds (Marion Michael Rounds) are all sitting U.S. Senators who use their middle names as first names.


title: Middle name

text: In Britain, many politicians, including several Prime Ministers, have been known primarily by their middle name, or one of their middle names. Examples include Neville Chamberlain (Arthur Neville Chamberlain), Jim Callaghan (Leonard James Callaghan), Ramsay MacDonald (James Ramsay MacDonald), Keir Hardie (James Keir Hardie), Enoch Powell (John Enoch Powell), Vince Cable (John Vincent Cable), Gordon Brown (James Gordon Brown), Boris Johnson (Alexander Boris de Pfeffel Johnson), and Liz Truss (Mary Elizabeth Truss).


title: Middle name

text: In Germany, during the Nazi period, several Nazis were known by their middle names. Examples include Joseph Goebbels (Paul Joseph Goebbels), Adolf Eichmann (Otto Adolf Eichmann), Erwin Rommel (Johannes Erwin Eugen Rommel), Hermann Fegelein (Hans Otto Georg Hermann Fegelein), Magda Goebbels (Johanna Maria Magdalena Goebbels) and Joachim von Ribbentrop (Ulrich Friedrich Wilhelm Joachim Ribbentrop).


title: Middle name

text: Traditionally, Chinese names consisted of three characters—the surname, followed by a two-character given name ("ming"), which is not separated into a first and middle name in usage. Two-character given names follow a naming tradition in which the first character of the given name (and thus the second character in the three-character full name) indicates the person's generation in his/her family. For example, the Yongzheng Emperor of the Qing dynasty has the given name "Yinzhen" (胤禛) while his brothers' names all begin with the character "Yin" (胤). His sons' and nephews' given names all begin with the character "Hong" (弘). Traditionally, the list of generational names may be decided many generations in advance by the ancestors. In such naming systems, the de facto given name is the last character of a person's full name. Even if that was the case most of the time, sometimes the person's given name is the middle character and not the last. A three-character name is both patriarchal and hierarchical, as it would inform of a person's belonging and rank within a family. During the One-child Policy, there was no need for a generation name as there was only one child in each generation. Many names in Mainland China were shortened to two-characters during this time, and there are many adults with shorter names remnant from this era. This would not be found in Taiwan or Hong Kong.


title: Middle name

text: A fading Chinese tradition is to use a courtesy name, called "zì" (字) in place of a male's given name in adulthood. Traditionally "zì" is given by one's father upon reaching the age of maturity at 20 years old. This name is intended for use in formal situations and formal writing and confers a status of adulthood and respect. Like the "ming", the "zì" is composed of two characters which usually reflect the meaning of the "ming". Prior to the 20th century, sinicized Koreans, Vietnamese, and Japanese were also referred to by their "zì". An alternative courtesy name is the "hào" (; Japanese gō; Korean: ho; Vietnamese: hiệu), which usually referred to as the pseudonym. A "hào" was usually self-chosen and it was possible to have more than one. It had no connection with the bearer's "míng" or "zì"; rather it was often a personal choice and may have reflected a personal belief or philosophy. Chinese adults may more frequently use the "hào" to refer to themselves. The "zì" or "hào" can be used independently of the given name and of each other, but the given name is almost always used with the family name in official situations.


title: Middle name

text: Some Chinese Americans move their Chinese given name (transliterated into the Latin alphabet) to the middle name position and use an English first name, e.g. James Chu-yu Soong, Jerry Chih-Yuan Yang, and Michelle Wingshan Kwan. The Chinese given name usually has two characters which are usually combined into a single middle name for better organizational purposes, especially with Cantonese names, such as Bruce Lee's middle name, Junfan. There are also some new immigrants whose Chinese given names are their first names followed by English middle names.


title: Middle name

text: The practice of taking English and Chinese given names is also common in Malaysia, Singapore, Hong Kong, and Taiwan. However, rather than placing the Chinese given name between the English given name and the family name, it is commonly placed after the family name in these places. Under such a system, Bruce Junfan Lee would have been Bruce Lee Junfan. This practice is consistent with both the Western convention of putting the given name before the family name and the Chinese convention of putting the given name after the family name.


title: Middle name

text: Traditional names in India vary regionally due to its ethnic and religious diversity. Modern Hindu names across India adopt a first name, which is usually a word in Sanskrit or an indigenous Indian language, a middle name, which is the name of a child's father or spouse in case of a married lady followed by the surname which is usually the caste that the person's family belongs to, usually taken from the father or husband. However, diversity exists even here, for instance middle and last names from the traditionally matrilineal Nair community in Kerala are based on the mother's family. For example, in the case of the well-known statesman, VK Krishna Menon, his first name would be Krishna, the V stands for Vengyalil, which is a well known aristocratic Nair family from Kerala that Krishna's mother belonged to, the K stands for Krishnan, his father's name and the surname is Menon, one of the Nair subcastes. In modern times, this name would perhaps be styled as Krishna Vengyalil Krishnan Menon, in that order, Vengyalil Krishnan being the middle name. Traditionally the Dalit population of India were excluded from India's caste system and do not have a middle name and a caste surname. The same is true for people who have given up their caste identity, whose name just includes the person's first name followed by their father's name. Sometimes, the place of birth of an individual is included as their middle name.


title: Middle name

text: Among the Sikhs of India, many have adopted the middle name Singh or Kaur which mean lion and princess respectively. This is followed by their Punjabi caste surname. Nowadays, many Sikhs have done away with their caste surname and have just kept Singh or Kaur as their surname. <br>


title: Middle name

text: Among Indian Muslims, similar naming conventions to Hindus and Sikhs are followed, but the names are usually in Arabic, Persian or Urdu.


title: Middle name

text: The naming convention of the Scandinavian countries do not use given names as middle names. While extra first names often are referred to as middle names in everyday language, the laws in these countries do not reflect this, and considers all of them first names. A person can have multiple first names, but usually only one of these is used when addressing the person, possibly creating confusion in some circumstances. An issued passport will contain all names, but all except the surname will be listed as first/given names. Names combined with a hyphen are counted as one name. A person named "Ulrika Britt-Inger Marie Fredriksson" have three first names and one last name, and either of the three first names could be chosen to be her . It usually is the first name in the order that a person uses day-to-day, and is often the only first name used even in formal settings. Unlike the middle names in some English speaking countries that are used as initials, the additional first names are either spelled out in full or fully omitted. Together with a person's personal identification number in Sweden, Denmark, Norway, or Iceland, only signing with the "tilltalsnamn" and the last name is usually sufficient for almost all legal documents. A person can change their "tilltalsnamn" to one of the other already given names without applying for a name change. It is possible to apply to have the order swapped if desired, as the first of the first names will be assumed to be the "tilltalsnamn".


title: Middle name

text: In Denmark, Sweden, and Norway, the legal term middle name refers most often to names that are originally surnames, but not part of the last name of the name bearer. A middle name could be e.g. one's mother's maiden name or the last name of another recent ancestor (for instance a grandparent). The historical purpose of middle names is to honour a relative or another person, particularly a godparent, or even a completely unrelated person, such as a locally or nationally prominent figure. Until the 19th century, it was not unusual to have the last name of a godparent as one's middle name, even when the godparent was not a blood relative. This practice, and the use of middle names in general, however, was mostly limited to the bourgeois class and the nobility, and was seldom seen among common people. In the 20th century, the use of middle names, especially one's mother's maiden name, was more widely adopted, although it is by no means mandatory. There are few set rules for how names are constructed today; people are required to have one or more given names and one family name, but the legal middle name is restrictive.


title: Middle name

text: In the example Carl Viggo Manthey Lange, the names Carl and Viggo are given names, while Manthey is a middle name and Lange is the family name. Manthey is his mother's maiden name. Unless his full name is used, he is correctly referred to as Mr. Lange, not as Mr. Manthey Lange. Carl Viggo Manthey Lange has a name typical of the Norwegian bourgeois class, with both his family name and his middle name being of foreign origin and being recognised surnames. Most Norwegians and Danes of the working class and peasant class used patronymics until the 19th century, when permanent family names became mandatory, first in Denmark in the early 19th century and then in Norway around 1900. A middle name is usually a recognised surname and not a patronymic. One reason middle names have become popular in the 20th century, particularly in Denmark, is that most Danish surnames originated as patronymics and are shared by a large number of people. The use of middle names in modern times serves to differentiate them from other people. For example, Danish politician Lars Løkke Rasmussen has some of the most common given and last names in Denmark (Lars and Rasmussen); his mother's maiden name is the slightly more unusual name Løkke, derived from a small agricultural property, so he uses it as a middle name, which differentiates him from other people named Lars Rasmussen.


title: Middle name

text: In Sweden, the position is much the same as in Denmark. Middle names were inaugurated in the previous Name Act of 1963, then called "tilläggsnamn" (additional name), and are called "mellannamn" (middle name) as of the present Name Act of 1983. However, it had previously been more common to join e.g. the last names of both of a child's parents, or for a married woman to join her maiden name and the husband's last name, as a double name with a hyphen; and large portions of the Swedish population have not adapted to the official system to this day, i.e. for almost 50 years. People often use a hyphen between their middle name and last name themselves, and/or are spelled that way by other people and by mass media.


title: Middle name

text: Occasionally, Scandinavians choose to use their middle name as their surname in everyday life. So Per Gottfrid Svartholm Warg has Per and Gottfrid as his given names, where Gottfrid, not Per, is his name of address, Svartholm as his middle name and Warg as his last name, but in practice he uses Svartholm as a surname. This usage, however, is unofficial. Historically, a middle name could become part of a double-barreled surname (family name) and hence cease to be a middle name, especially if used for several generations. There are many family names of this kind, which contributes to the confusion about middle names that shall not be hyphenated. Some of these double-barreled surnames are combined with a hyphen, while others are not, so a double surname without a hyphen can sometimes be indistinguishable from a middle name followed by a family name.