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1.
Artigo em Inglês | MEDLINE | ID: mdl-32316548

RESUMO

Background: Ethically controversial medical procedures, such as the termination of pregnancy, are frequently associated with a discrepancy between personal attitude and values versus requirements related to a professional situation. The study aimed to assess emotional complications in midwives participating in pregnancy termination procedures. Methods: The study included 181 midwives working in state-governed healthcare facilities in central and eastern Poland. The Oldenburg Burnout Inventory (OLBI) and the present authors' own questionnaire were used in the study. The results indicating the level of occupational burnout were presented in two scales: the exhaustion scale and the disengagement scale. Results: The study revealed that 48% of midwives had never participated in pregnancy termination procedures due to fetal defects. The level of occupational burnout described with the exhaustion factor (t = 2.06; p < 0.041) and disengagement factor (t = 2.96; p < 0.003) was significantly higher in the group of midwives participating in pregnancy termination procedures due to fetal defects than in the group of midwives who did not participate in pregnancy terminations. The most common factors contributing to burnout reported by midwives who participated in pregnancy terminations were: moral dilemmas (68%), seeing the aborted fetus (65%), anticipating the child's death in case it was born with signs of life (59%) and the lack of professional psychological support for medical personnel (56%). Conclusions: Importantly, pregnancy termination should be performed by persons who find such procedures acceptable from the viewpoint of their value system. It is a protective factor in regards to work with women who undergo terminations. Moreover, developing a system of informational and psychological support for midwives participating in pregnancy termination procedures is also a significant aspect.

2.
Int J Mol Sci ; 21(8)2020 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-32344726

RESUMO

Uterine fibroids (UFs) are the most common benign tumors of the female genital tract. Their prevalence usually is estimated at 30-40%, but may reach up to 70-80% in predisposed groups of women. UFs may cause various clinical issues which might constitute the major reason of the overall deterioration of the quality of life. The mechanisms leading to UFs formation and growth still remain poorly understood. The transformation of smooth muscle cells of the uterus into abnormal, immortal cells, capable of clonal division, is thought to be a starting point of all pathways leading to UF formation. Micro-ribonucleic acids (miRNAs) are non-coding single-stranded RNAs about 22 nucleotides in length, that regulate gene expression. One of recent advances in this field is the comprehension of the role of miRNAs in tumorigenesis. Alterations in the levels of miRNAs are related to the formation and growth of several tumors which show a distinct miRNA signature. The aim of this review is to summarize the current data about the role of miRNAs in the pathophysiology of UFs. We also discuss future directions in the miRNA research area with an emphasis on novel diagnostic opportunities or patient-tailored therapies. In our opinion data concerning the regulation of miRNA and its gene targets in the UFs are still insufficient in comparison with gynecological malignancies. The potential translational use of miRNA and derived technologies in the clinical care is at the early phase and needs far more evidence. However, it is one of the main areas of interest for the future as the use of miRNAs in the diagnostics and treatment of UFs is a new and exciting opportunity.

4.
Arch Gynecol Obstet ; 301(4): 885-894, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32140807

RESUMO

PURPOSE: The aim of this review is to provide an overview of the literature about the perception and management of anxiety and pain in women undergoing an office hysteroscopic procedure. METHODS: We performed a systematic literature search in Embase, PubMed/MEDLINE, Cochrane Library and Web of Science for original studies written in English (registered in PROSPERO 2019-CRD42019132341), using the terms 'hysteroscopy' AND 'pain' AND 'anxiety' published up to January 2019. Only original articles (randomized, observational and retrospective studies) about management of anxiety and pain related to the hysteroscopic procedure were considered eligible. RESULTS: Our literature search produced 84 records. After exclusions, 11 studies including 2222 patients showed the following results: (a) pain experienced during hysteroscopy is negatively affected by preprocedural anxiety; (b) pharmacological interventions seem to be help in reducing pain during hysteroscopy; (c) waiting time before the procedure is a significant factor affecting patients' anxiety; (d) music during the procedure may be helpful in reducing anxiety. CONCLUSIONS: The utilization of office hysteroscopy is hampered by varying levels of anxiety and pain perceived by women who are candidates for the procedure. For these reasons, it is essential to identify effective pharmacological and non-pharmacological strategies to alleviate these factors. We recommend further studies especially focusing on non-pharmacological interventions to facilitate the dissemination of good clinical practices among hysteroscopists.

5.
Obstet Gynecol Surv ; 75(2): 127-135, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32105337

RESUMO

Importance: Uterine leiomyomas, also referred to as myomas or fibroids, are the most common benign tumors of the reproductive tract. Ulipristal acetate (UPA) is an active selective progesterone receptor modulator used as preoperative treatment for uterine myomas. Purpose: The aim of this review is to provide an overview of the literature about the effects of UPA administration before hysteroscopic myomectomy. The clinical question in "PICO" format was in patients affected by uterine myomas undergoing operative hysteroscopic management, "Does UPA impact the surgical outcomes?" Evidence Acquisition: We performed a systematic literature search in PubMed/MEDLINE and Embase for original studies written in English (registered in PROSPERO CRD42018092201), using the terms "hysteroscopy" AND "ulipristal acetate" published up to March 2019. Original articles about UPA treatment before hysteroscopic myomectomy (randomized, observational, retrospective studies) were considered eligible. Results: Our literature search produced 32 records. After exclusions, 4 studies were considered eligible for analysis. Results show that UPA does not worsen the overall technical difficulty of hysteroscopic myomectomy. Moreover, it may increase the chance of complete primary myomectomy in complex hysteroscopic procedures. Conclusions and Relevance: Despite the positive results presented in this systematic review, low-quality evidence exists yet on the impact of UPA treatment before hysteroscopic myomectomy. High-quality prospective randomized controlled trials are required to establish the impact of UPA on surgical outcomes of patients treated for uterine myomas by hysteroscopy. Moreover, long-term outcomes of myomectomies after UPA treatment (such as frequency of myoma recurrence, recovery time, and quality of life) should be determined.

6.
Curr Pharm Des ; 26(3): 300-309, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31985366

RESUMO

BACKGROUND: Vilaprisan (VPR) is a new orally available selective progesterone receptor modulator (SPRM), with anti-proliferative activity against uterine fibroids (UFs). It definitively causes suppression of ovulation and inhibition of proliferation of endometrial, myometrial and UF cells. PURPOSE: This review aims to summarize current knowledge on VPR from all studies, including clinical trials, conducted to date and to contextualize the potential role of VPR in future medical regimens for the treatment of UFs. METHODS: We performed a literature search in PubMed US National Library of Medicine and Google Scholar databases. Both databases were extensively searched for all original and review articles/book chapters as well as congress abstracts published in English until July 2019. The use of VPR for UF therapy was identified by using the keywords: "uterine fibroids" and "vilaprisan". RESULTS: In phase I and II clinical trials, VPR was shown to be effective in ameliorating UF-related clinical symptoms, especially abnormal or excessive uterine bleeding and in shrinking UFs. The tolerability of VPR is roughly similar to that of ulipristal acetate (UPA) and it tends to be more favorable than that of GnRH-agonists. CONCLUSION: Presently, all trials examining the utility of VPR for the treatment of UF are halted; likely, due to the recently reported cases of hepato-toxicity with UPA, in addition to non reassuring toxicology results from preclinical long-term testing on rodents, carried out in parallel with late stage testing on humans. An accurate summary of robust data related to the safety of VPR is urgently needed to draw definitive conclusions on the future clinical development of this drug for UF therapy.

7.
Curr Opin Obstet Gynecol ; 32(2): 159-165, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31895105

RESUMO

PURPOSE OF REVIEW: The aim of this systematic review is to summarize the current evidence regarding the effectiveness of hysterectomy and hysteroscopic endometrial resection in improving quality of life (QoL), sexual function and psychological wellbeing of women abnormal uterine bleeding. RECENT FINDINGS: We performed a systematic literature search in PubMed/MEDLINE and Embase for original studies written in English (registered in PROSPERO 2019 CRD42019133632), using the terms 'endometrial ablation', 'endometrial destruction', 'endometrial resection', 'hysterectomy', 'menorrhagia', 'dysfunctional uterine bleeding', 'quality of life', 'sexuality' published up to April 2019. Our literature search produced 159 records. After exclusions, nine studies were included showing the following results: both types of treatment significantly improve QoL and psychological wellbeing; hysterectomy is associated with higher rates of satisfaction; hysterectomy is not associated with a significant deterioration in sexual function. SUMMARY: Hysterectomy is currently more advantageous in terms of improving abnormal uterine bleeding and satisfaction rates than hysteroscopic endometrial destruction techniques. Furthermore, there is some evidence of a greater improvement in general health for women undergoing hysterectomy. However, high-quality prospective randomized controlled trials should be implemented to investigate the effectiveness of hysterectomy and endometrial ablation in the improvement of QoL outcomes in larger patient cohorts.

8.
Mol Biol Rep ; 47(2): 855-866, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30900134

RESUMO

Obesity is associated with inflammation, which can disturb genome stability. Tumor necrosis factor (TNF-α) polymorphism was found to affect TNF-α protein production and inflammation. Therefore, the present study illustrates the relationship between TNF-α polymorphism, the degree of inflammation assessed by serum high sensitivity C-reactive protein concentration (CRP-hs) and basal DNA damage in patients with obesity (BMI 30-34.9 kg/m2) and control subjects with proper body mass (BMI < 25 kg/m2). A total of 115 participants (75 obese premenopausal women; and 40 age-, and gender-matched controls) were included. Biochemical parameters (serum concentrations of total-cholesterol, HDL-cholesterol, LDL- cholesterol, triglycerides, glucose, apolipoprotein AI, CRP-hs) and endogenous DNA damage (determined by comet assay) were measured. TNF-α G-308A polymorphism (rs1800629) was analyzed by PCR-RFLP (PCR-restriction fragments length polymorphism). An effect of TNF-α genotype on serum CRP-hs concentration was noted (p = 0.031). In general, carriers of the rare A allele of the TNF-α G-308A polymorphism had significantly lower endogenous DNA damage and serum CRP-hs concentrations than GG homozygotes, however, the protective effect of the A allele was especially visible in non-obese women. Serum CRP-hs concentrations and levels of DNA damage (% DNA in tail) were significantly higher in obese than in controls (p = 0.001 and p < 0.0001, respectively). The adjusted multiple linear regression analyses revealed a significant, independent impact of obesity on DNA damage (p = 0.00000) and no effect of other covariates i.e. age, TNF-α genotype and serum CRP-hs concentration. Our study showed that obesity has a significant impact on the levels of endogenous DNA damage. Obesity abolished the protective effect of A allele of the TNF-α G-308A polymorphism on DNA damage and on inflammation development observed in non-obese A allele carriers.

9.
Artigo em Inglês | MEDLINE | ID: mdl-31835554

RESUMO

Due to the nature of their work, physicians are exposed to chronic stress. This may potentially lead to the widespread occurrence of occupational burnout syndrome (BS). The aim of this systematic review study was to summarize available published data concerning the prevalence of BS in Polish doctors. The literature search was performed using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar. The last search was performed on September 27th, 2019. Only articles in English or Polish on graduated doctors practicing in Poland were taken into account. All types of original research were considered eligible. However, review articles, book chapters, case reports, case series, conference papers, study protocols and articles in languages other than English and Polish were excluded. There were no restrictions on age, seniority or specialty of study participants. The literature search revealed a total of 21 studies that met the inclusion criteria. The results of individual studies were very diverse, which makes it difficult to draw specific conclusions. However, the problem of burnout among Polish doctors is valid and worth special attention from society, health policy leaders, and doctors themselves. High-quality research is essential to for a better understanding of this topic.

10.
Artigo em Inglês | MEDLINE | ID: mdl-31532753

RESUMO

Endometriosis is a benign gynecological disease which symptoms can provide a severe impact on patient's quality of life with subsequent impact on psychological well-being. Different therapeutic strategies are available to treat this disease, such as surgery, hormonal therapies, and nonsteroidal anti-inflammatory drugs. Nevertheless, the efficacy of conventional medical treatments is limited or intermittent in most of the patients due to the associated side effects. Therefore, a woman with endometriosis often search for additional and alternative options, and phytotherapy might be a promising alternative and complementary strategy. Different medicinal plants, multicomponent herbal preparations, and phytochemicals were investigated for pharmacological proprieties in endometriosis therapy. In most of the cases, the effect on endometriosis was related to phenolic compounds, such as flavonoids and phenolic acids reporting anti-inflammatory, proapoptotic, antioxidant, and immunomodulatory functions. Moreover, some phytochemicals have been related to a strong phytoestrogenic effect modulating the estrogen activity. Although promising, available evidence is based on in vitro and animal models of endometriosis with a limited number of well-performed clinical studies. There are almost none randomized control trials in this area. Therefore, properly constructed clinical trials are mandatory to achieve more conclusive results about the promising role of phytotherapy in the management of endometriosis.

11.
Prz Menopauzalny ; 18(2): 89-93, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31485205

RESUMO

Overactive bladder syndrome (OAB) is defined by the presence of urinary urgency, with or without urge incontinence, usually accompanied by an increase in urinary frequency and nocturia in the absence of urinary tract infections (UTI) or other diseases. The overall prevalence of OAB symptoms in the female population is reported to be 16.6% and increases with advancing age and menopause. The aetiology of OAB is not fully understood and is likely to affect a heterogeneous population of patients due to changes to their central and peripheral nervous systems. Although OAB is frequently associated with female sexual dysfunction (FSD), its real impact on sexual function in women has been evaluated only in a few studies. The first line of treatment for OAB includes behavioural modification and physical therapy, either as monotherapies or in combination. Many patients who have not had success in managing their symptoms with more conservative therapies may decide to resort to third-line treatments for refractory OAB. These treatments include neuromodulation therapies, particularly transvaginal electrical stimulation (TES) and sacral neuromodulation (SN). The aim of this short commentary is to provide an overview of the effectiveness of these treatments and of their impact on quality of life, body image, sexual function, and emotional well-being.

12.
Prz Menopauzalny ; 18(2): 116-122, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31488961

RESUMO

The climacteric is considered a natural phase in a woman's aging process and is defined as the period starting from the decline in ovarian activity until after the end of ovarian function. Genitourinary syndrome of menopause (GSM) is commonly observed in menopausal women and is characterised by a collection of symptoms resulting from changes to the internal and external genitalia as well as the lower urinary tract. Several studies have demonstrated the close association between sexual dysfunction and symptoms related to GSM. Many medications, at different doses, have been studied over the years for the treatment of the symptoms of GSM. More specifically, ultralow-dose intravaginal oestriol and intravaginal dehydroepiandrosterone (DHEA) are reported to improve symptoms, signs, and quality of life of women with GSM, and they are safe owing to their specific local effect. While the dosage and the administration of intravaginal DHEA are well defined, the literature on intravaginal oestriol is less uniform: different doses and times of administration are proposed with different possible combinations with other non-pharmacological therapies, although a more standardised treatment may be necessary. The aim of this review is to summarise the available data about the effects of ultralow-concentration oestriol and intravaginal DHEA on the menopause-related symptoms, quality of life, and sexual function of women affected by GSM.

13.
Int J Hyperthermia ; 36(1): 975-979, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31542975

RESUMO

This is a report of an unintended application of MR-HIFU therapy of uterine fibroids (UFs) in a woman in early pregnancy and should be treated as the first description of such an event. A 37-year-old nullipara with confirmed UFs, who suffered from excessive uterine bleeding and dysmenorrhea, was qualified for MR-HIFU therapy to reduce UF-related symptoms. The procedure took place 2 months later. No complications occurred and the patient was discharged home in good overall condition. About 5 weeks after the procedure the patient was diagnosed with viable intrauterine pregnancy. Basing on early pregnancy ultrasound it was calculated that at the time of MR-HIFU procedure the patient was about 10 (+/- 3 days) days after the conception. Later, the pregnancy was uncomplicated and she gave birth to a healthy neonate. Physical examinations did not reveal any abnormalities in her child. Symptoms associated with UFs significantly decreased after the therapy and pregnancy. Despite the fact that the pregnancy being subjected to MR-HIFU treatment had further uncomplicated course, the presented case indicates that counseling/management in women at reproductive age should be standardized to avoid unknown consequences of such unrecommended procedures for the fetus. According to current standards MR-HIFU procedures to treat UFs should never be performed without a negative pregnancy test.


Assuntos
Ablação por Ultrassom Focalizado de Alta Intensidade/métodos , Leiomioma/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Adulto , Feminino , Humanos , Gravidez
14.
Artigo em Inglês | MEDLINE | ID: mdl-31540023

RESUMO

BACKGROUND: The study aims to define the profile of women who decide to exercise their right to terminate a pregnancy and their future reproductive plans. METHODS: Patients found eligible for termination for medical reasons between 2014 and 2016 were asked to complete an anonymous survey consisting of sixty questions examining the determinants of the decision to terminate a pregnancy. In total, 150 completed surveys were returned (62.5%). RESULTS: Environmental factors, such as age, education, place of residence, marital status and financial status did not affect the decision-making process. The majority of the respondents were females under 35 years of age (71.3%). In most cases, the pregnancies had been planned and long-awaited (62.7%). The study also indicated that 22.6% of the patients who had been against abortion changed their mind when they encountered problems themselves. In addition, 20% of them changed their views on the acceptability of abortion. Termination had an impact on the participants future reproductive plans. Eighteen percent of the patients said they were definitely not planning more pregnancies. The majority (84.09%) of these women said that the reason was the traumatic experiences related to their pregnancy. CONCLUSIONS: The personal experience of a pregnancy termination procedure changed women's opinions about pregnancy termination and modified further reproductive plans.


Assuntos
Aborto Induzido/psicologia , Tomada de Decisões , Adolescente , Adulto , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Reprodução , Inquéritos e Questionários , Adulto Jovem
15.
J Psychosom Obstet Gynaecol ; : 1-7, 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31373525

RESUMO

Purpose: Relational and sexual problems are frequent in patients with a diagnosis of gynecological cancer, because this disease has a strong negative impact on female identity and sexuality. Psychological and sexual functioning is affected by inauspicious diagnosis. Furthermore, therapies may compromise reproductive function. The aim of this study is to propose a general overview on the impact of gynecological cancer on quality of life and psychological and sexual functioning, as well as on the importance of adequate counseling related to fertility preservation techniques. Materials and methods: We provide a narrative overview of the recent literature about quality of life and fertility preservation counselling in women with gynecological cancer. Results and conclusions: According to recent studies, 75% of women between 18 and 45 years with a diagnosis of cancer wish to have children. When cancer affects the reproductive system, the psychological distress is even stronger because there is a loss of menstrual function and fertility. Currently, fertility preservation techniques in women with gynecological cancer are beneficial and lead to an improvement in the quality of life.

16.
Curr Pharm Des ; 25(22): 2467-2473, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31333107

RESUMO

BACKGROUND: Gestational Diabetes Mellitus (GDM), defined as glucose intolerance with onset or first recognition during pregnancy, represents one of the most common maternal-fetal complications during pregnancy and it is associated with poor perinatal outcomes. To date, GDM is a rising condition over the last decades coinciding with the ongoing epidemic of obesity and Type 2 Diabetes Mellitus (T2DM). OBJECTIVE: The aim of this review is to discuss the role of diet and nutritional interventions in preventing GDM with the explanation of the special role of myo-inositol (MI) in this matter. METHODS: We performed an overview of the most recent literature data on the subject with particular attention to the effectiveness of diet and nutritional interventions in the prevention of GDM with the special role of MI. RESULTS: Nutritional intervention and physical activity before and during pregnancy are mandatory in women affected by GDM. Moreover, the availability of insulin-sensitizers such as different forms of inositol has dramatically changed the scenario, allowing the treatment of several metabolic diseases, such as those related to glucose dysbalance. Although the optimal dose, frequency, and form of MI administration need to be further investigated, diet supplementation with MI appears to be an attractive alternative for the GDM prevention as well as for the reduction of GDM-related complications. CONCLUSIONS: More studies should be conducted to prove the most effective nutritional intervention in GDM. Regarding the potential effectiveness of MI, further evidence in multicenter, randomized controlled trials is needed to draw firm conclusions.

17.
Int J Hyperthermia ; 36(1): 582-590, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31159642

RESUMO

Introduction: Uterine fibroids (UFs) are benign tumors of female genital tract. Clinically symptomatic UFs may be a cause of serious health problems for many women worldwide. The optimal choice of a treatment method should fit a patient's specific life situation or expectancies (especially fertility) as much as possible. In line with the general current trend in medicine and surgery, great importance is attached to the development of minimally invasive radiological procedures e.g., magnetic resonance guided focused ultrasound (MRgFUS). Materials and methods: Single-center retrospective cohort study conducted at the Department of Obstetrics and Gynecology of Pro-Familia Hospital in Rzeszów, Poland. The study group consisted of 276 patients suffering from UFs and treated with MR-HIFU over the period from April 2015 to May 2018. Results: In our group 20 out of 276 patients conceived after the MR-HIFU therapy (7.25%). A general improvement and alleviation of symptoms of the disease after MRgFUS/MR-HIFU procedure were observed in 80% (n = 16) of study participants that conceived. 15% (n = 3) did not report any changes in disease severity. Out of 11 patients who already gave birth - 63.64% (n = 7) underwent cesarean section. Conclusions: MRgFUS/MR-HIFU seems to be an interesting minimally invasive alternative for women with UFs who wish to conceive and deliver after the procedure. This method does not increase the rate of spontaneous abortions or pregnancy complications. In our opinion, it is important to take off an unjustified badge stating that MRgFUS/MR-HIFU method is contraindicated in women with UFs who wish to conceive.


Assuntos
Ablação por Ultrassom Focalizado de Alta Intensidade/métodos , Leiomioma/diagnóstico por imagem , Leiomioma/cirurgia , Imagem por Ressonância Magnética Intervencionista/métodos , Obstetrícia/métodos , Adulto , Estudos de Coortes , Feminino , Humanos , Leiomioma/patologia , Polônia , Estudos Retrospectivos , Adulto Jovem
18.
Mol Biol Rep ; 46(3): 3613, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31079317

RESUMO

The original publication has been updated. The names in the original publication were not in the correct order. The family name was followed by the first name. This is now corrected.

19.
Eur J Contracept Reprod Health Care ; 24(2): 124-129, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30931638

RESUMO

OBJECTIVES: Polish society is strongly influenced by the Catholic Church and Poland has one of the most restrictive abortion laws in Europe. We attempted to gather information by questionnaire from women considering termination of pregnancy (TOP). Women were asked about their perceptions of the attending medical staff and whether they felt they had been fully informed of their rights, as well as about conduct of the procedure itself in light of physicians' use of the 'conscience clause'. METHODS: Between June 2014 and May 2016 all women deemed eligible for TOP for medical reasons were asked to complete an anonymous questionnaire (n = 240). A total of 150 questionnaires (62.5%) were returned and analysed. RESULTS: Most respondents (95%) lived in a town or city, and a significant number (40%) lived outside the area where the study centre was located. The main reason for such a large group of out-of-region respondents (53%) was the lack of centres offering TOP in the area where the women lived. Only one attending obstetrician did not support a decision to abort the pregnancy. Although 65% of treating physicians supported the woman's decision, only 8% were willing to perform the procedure themselves. CONCLUSION: Most regional centres offer no access to TOP, despite the legal right of women to abort their pregnancy in the event of a severe fetal defect. Some physicians refuse to perform abortions, citing conscientious objection. Double standards among treating physicians have been detected, as many support the decision of their patient but refuse to perform the procedure themselves.


Assuntos
Aborto Induzido/psicologia , Corpo Clínico/psicologia , Gestantes/psicologia , Adulto , Consciência , Tomada de Decisões , Feminino , Humanos , Percepção , Polônia , Gravidez , Pesquisa Qualitativa , Recusa do Médico a Tratar , Inquéritos e Questionários
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