Women commonly complain of cognitive impairment during pregnancy; although some research has confirmed impairments using objective tests, the aetiology of this is uncertain. The relationship between disturbed sleep during pregnancy and cognitive functioning has not been specifically investigated. Using a correlational design, the present study aimed to examine the relationship between disturbed sleep and cognitive functioning during pregnancy. Method: Sixty-four women in the third trimester of pregnancy completed the Pittsburgh Sleep Quality Index and the Insomnia Severity Index. A sub-sample also undertook actigraphic monitoring to obtain objective estimates of sleep quality. Cognitive functioning was measured subjectively using the Cognitive Failures Questionnaire and objectively using the IntegNeuro computer package. Results: Women reported significant sleep disturbance, which was confirmed by actigraphic monitoring in a sub-sample. Poorer subjective and objective sleep quality was related to more self-reported cognitive failures. Subjective sleep quality was also significantly correlated with objective measures of delayed verbal recall, but not to other domains of cognitive functioning. Poorer objectively measured sleep was related to decreased vigilance. Women reporting significant sleep disturbance reported significantly more cognitive failures than good sleepers, although this difference was not reflected by performance on objective cognitive tests. Conclusion: Sleep disturbance during pregnancy is related to subjective cognitive impairment and to some domains of cognitive performance using objective cognitive tests.

This thesis examines obstetric practice associated with cephalopelvic disproportion in Glasgow between 1840 and 1900. Disproportion is a complication of labour, which occurs when there is a physical disparity between the size of the fetus and the size of the birth canal. The majority of these cases involved women who had suffered from rickets as a child, and had a deformed pelvis as a result. During this period the number of children affected by rickets appeared to increase, and as a consequence more cases of disproportion were encountered towards the end of the century. Descriptions of these cases found in a wide-range of published and unpublished materials have been used to analyse changes to obstetric practice in Glasgow. The complex nature of medical decision-making in cases of disproportion is shown. Methods available for the treatment of disproportion included caesarean section, craniotomy, forceps, induction of premature labour, symphysiotomy, and turning. Medical practitioners’ decisions were subject to social, medical and scientific factors. Practitioners’ choices were influenced by their experience, reports of successful cases both abroad and at home, the severity of the pelvic deformity, innovations in medical technique, perceptions of the value of the mother compared to her unborn child, location, and the decisions of the women and their friends and family. After the 1870s there was an increase in the number of women who were delivered by one of these forms of intervention at the Glasgow Maternity Hospital. This change can be attributed to an increase in the prevalence of this condition, but it also reflected a shift from women being admitted on social grounds to medical reasons. This change was in response to an acknowledgement that selecting cases earlier improved the chances of a successful outcome, as evidenced by Murdoch Cameron’s work with caesarean section. In addition, as obstetrics emerged as a specialism, obstetric practitioners claimed these difficult cases for themselves. It was stressed that general practitioners and midwives should send women to obstetric physicians as soon as they were aware of complications, and that obstetric specialists were to replace general surgeons as the operator in severe cases of disproportion when caesarean section was required.

This study reports on the analysis of 59 in-depth interviews conducted with people diagnosed with, or from families affected by, Spinal Muscular Atrophy (SMA). It focuses on attitudes towards, and actual uses of, prenatal testing and selective termination for SMA in reproductive decision making for this group of people, in order to focus on the role of experiential knowledge of SMA and its relationship to expert medical knowledge, within these highly complex decisions. Experiential knowledge has been described in the literature as knowledge derived from experience, whether ‘embodied’ (i.e. sensory) or ‘empathetic’ (i.e. based on the experiences of others). Experiential knowledge has frequently been positioned as being in opposition to, or even conflicting with, medical knowledge, particularly by feminists and disability rights supporters, for whom the tensions between experiential knowledge and medical knowledge have political significance. However, this research found the relationship between expert and experiential knowledge to be both fluid and dynamic, which had important implications for the way in which SMA was conceptualised, understood and responded to by families living with it. Whilst participants’ accounts of SMA were thoroughly grounded in their day-to-day realities with the condition, this knowledge always existed in and through a relationship with expert medical knowledge of SMA. The inherent uncertainties within and between experiential and expert knowledge, and the ways of conceptualising SMA that emerged from them, however, rather than alleviating, instead contributed to, and heightened, some of the social, ethical and moral dilemmas these families experienced around reproductive decision making. Indeed, many participants became trapped within these ways of knowing SMA and the internal contradictions they contained, whilst for others, the strategic privileging of one form of knowledge as ‘authentic’ over the other became the only way to escape some of these dilemmas, and clarify where their reproductive responsibilities lay.

A poor maternal diet leads to offspring with a greater risk of developing chronic diseases later in life. This thesis considered whether a low protein diet during pregnancy in sheep affected the development of the fetal kidney, and how this impacted upon adult renal function when challenged by obesity. Pregnant ewes were fed either a control diet or a diet that was isocaloric but contained only 50% of the protein, in either early or late gestation. The effects of the diet were assessed on the ewe, day 65 fetuses (0.44 gestation), and two year old offspring which had been subjected to an obesogenic environment (ab libitum feed and reduced exercise). Few effects were observed on the ewe, confirming that the nutritional insult was relatively mild. Fetal renal vasculature (assessed by vascular corrosion casts) was not different between groups, although the microvasculature was significantly reduced in the early protein group, as evidenced by CD34+ staining of endothelial cells. This was accompanied by a reduction in angiogenic factors compared to control animals. Protein-energy malnutrition in the ewe led to reduced urea in maternal and fetal plasma, along with a concomitant reduction in ornithine in the fetal plasma and amniotic fluid. Other amino acids were relatively unaffected. In the adult sheep there were no effects on long-term renal function in the group fed low protein late in pregnancy, despite the lambs having lower birth weights and a period of postnatal catch up growth compared to the other groups. However, the group fed low protein during early pregnancy had reduced nephron number, microalbumuria and reduced renal function as assessed by gamma scintigraphy. There was also evidence of microvascular rarefaction which may have been exacerbated by obesity. This study did not reveal any consistent sex-specific effects of the maternal low protein diet. This study emphasises the importance of diet quality rather than quantity, and the importance of consuming a well-balanced diet during pregnancy to protect against future chronic diseases.

Background. In vitro studies have shown that ER+ acquired tamoxifen resistant MCF7 breast cancer cell lines can show elevated levels of EGFR expression with an increase in its subsequent signalling pathway(s) and that these are growth inhibited by gefitinib, an EGFR tyrosine kinase inhibitor. This thesis examines the effect of gefitinib on tamoxifen resistant human breast cancer in the clinical setting and in an ‘in-vivo’ mouse model. Patients and Methods. This phase 2 clinical study recruited 54 patients. 28 were oestrogen receptor positive and had progressed on tamoxifen treatment(acquired resistance), the other 26 (48.1%) were oestrogen receptor negative(de novo resistance). Patients were given a loading dose of 1000mg gefitinib on Day 1 and then gefitinib 500mg as a once daily oral dosing until evidence of disease progression. Clinical data were recorded. Sequential tumour biopsies were taken pre-treatment, after 8 weeks therapy and at the development of resistance and analysed immunocytochemically to identify predictive factors for response to treatment and also to see the effect of treatment and resistance on tumour biology, encompassing monitoring steroid receptors, EGFR, HER2 and IGFR, downstream kinases MAPK and AKT, and the proliferation marker Ki67. In parallel with the clinical study, ER+ acquired tamoxifen resistant MCF7 xenografts (TAMR) were grown in nude mice in the presence of tamoxifen and treated with gefitinib 50mg per day orally (designated 3 treatment) or tamoxifen alone (designated control) and monitored for impact on tumour growth. Results. In the phase 2 study gefitinib treatment was well tolerated with an overall clinical benefit rate of 33.3% (n=18/54). Pre-treatment oestrogen receptor positivity was associated with tumour response to gefitinib (p=0.015, longer TTP (p = 0.015), and with clinical benefit (CB) in 53.6 % of the ER+ acquired tamoxifen resistant patients. In contrast, the clinical benefit rate was minimal in the steroid receptor negative patient cohort (11.5%). All patients in this series expressed detectable levels of EGFR, but high pre-treatment levels of EGFR predicted a poorer outcome (p=0.075) Only patients achieving CB had a significant fall in Ki67 staining as measured at 8 weeks versus pretreatment levels (p=0.024), and that Ki67 levels were lower in CB than PD patients at this time. We observed lower levels of EGFR phosphorylation at this time point in some CB patients. Further examination of the CB pts who showed a >10% decline in EGFR phosphorylation revealed decreases in phosphorylation of MAPK and also in Ki67. TAMR xenografts expressed high levels of EGFR as previously observed in vitro. Their growth was significantly inhibited by gefitinib (p=0.039) over the study period while after only 2 weeks of gefitinib treatment tumours showed a decrease in the level of Ki67 staining (p = 0.068). Conclusion. Acquired tamoxifen resistance in vivo both in patients and in a xenograft model appears to be in part mediated through EGFR pathway signalling and this can be blocked and growth inhibited with gefitinib. In ER 4 negative tumours the effects of gefitinib were less striking, suggesting alternative signalling pathways are dominant in promoting their growth despite obvious overexpression of EGFR.

Breast carcinoma is the most frequent type of cancer affecting women. Among the recently described molecular and phenotypic classes of breast cancer, human epidermal growth factor receptor 2 (HER2)-positive tumours are associated with a poor prognosis. HER2 status is currently assessed in routine breast cancer reporting using immunohistochemistry (IHC) in addition to in situ hybridisation (ISH) in borderline cases. The ability of HER2 gene status to predict response to targeted therapy (Trastuzumab) is well documented. However, prognostic information provided by IHC expression categories and prognostic value added by using ISH in borderline cases remains unclear. HER2 plays an important role in cancer progression being targeted to provide predictive and prognostic information. Moreover, HER2 is related to cancer resistance against a variety of therapies; however, trastuzumab has proved successful in treatment of this subgroup. Nevertheless, patients may acquire resistance to this drug after a period of treatment, which indicates that other molecular mechanisms might influence success of this therapy. Dimerisation between members of the HER family may contribute to resistance against treatments due to different combinations that trigger different downstream pathways. This is promoted by ligands, which are expressed as transmembrane precursor protein molecules and have a conserved epidermal growth factor-like domain. Through resistance to trastuzumab, other drugs are being developed to interact in different domains of HER2 protein. The study of interaction between receptors/ligands will characterise specifically their signalling pathway and understand which strategy to acquire. The main aim of this thesis was to assesses the status of HER2 protein (IHC), HER2 gene (chromogenic ISH) and HER heterodimers (in situ proximity ligation assay (PLA)), including HER2/EGFR, HER2/HER3 and HER2/HER4, in two BC series prepared in tissue microarray format; a series of consecutive primary operable BC cases (n = 1858) including HER2+ trastuzumab naïve cases (TrN, n = 221), the second series of HER2+ trastuzumab adjuvant treated cases (TrT, n = 143). Therefore determining the biological characterisation of these biomarkers by associating against clinicopathological parameters, survival outcome and understand the trastuzumab therapy value. There was excellent overall concordance between HercepTest negative (scores 0/1+) and positive (3+) with CISH positive/negative (defined as HER2/Chr17 copy number ratio of ≥ 2; p < 0.001). Kaplan-Meier analysis for breast cancer specific survival (BCSS) and disease free interval (DFI) revealed statistically significant differences between HER2 positive and negative cases detected by HercepTest and CISH (p < 0.001). Interestingly, it was identified that HercepTest 2+ non-amplified cases were not significantly different with those amplified 2+ or 3+ cases with respect to their behaviour (BCSS and DFI). The results revealed an inverse association between the HER heterodimerisation status and hormone receptor status (p < 0.001), and a significantly worse outcome amongst cases revealing high levels of all heterodimers (p < 0.001). Among ER+ cases, the heterodimers high levels were significantly associated with worse prognosis (p < 0.001) overall. However amongst the two HER2+ populations dimerisation status did not show an association with patient outcome. The overall concordance between HercepTest and CISH analysis for HER2 status was excellent. All HercepTest 2+ cases identified were observed to have poor outcomes similar to those HercepTest 3+ cases regardless of gene amplification status. In the current clinical environment cases exhibiting IHC 2+ and non-amplified gene HER2 status will not be offered targeted HER2 therapy but do exhibit aggressive clinical behavioural characteristics. Even though those patients with high levels of the HER2 truncated form, p95HER2, have shown poor outcome, this biomarker does not reveal any extra findings comparing with the HER2 expression results. Beside HER2, EGFR is the only monomer that reveals prognostic value amongst the breast cancer patients. Tumours exhibiting high levels of HER heterodimerisation have an adverse prognosis, however in the context of HER2+ breast cancer no association with clinical outcome was observed regardless of use of trastuzumab treatment. HER2/HER3 heterodimerisation status assessed in multivariate analyses has shown that this protein-protein interaction is associated with a poor prognostic outcome, which needs further investigation and assessment of clinical utility to use in the future in breast cancer treatment decision. Further quantification analysis of dimer/ligand complex using PLA of other HER family members may be useful to identify subset of patients associated with distinct outcome, response to treatment and relationships with HER signalling related biomarkers.

This study explores the nature of competence required to fulfil the role of the midwife, learning to become competent, and professional learning beyond registration. The research was undertaken through a qualitative, case study approach, exploring competence as a phenomenon, as experienced by thirty-nine student midwives as they went through the final stages of pre-registration midwifery education programmes, were assessed to be competent, and took on the role of the midwife. The views of the thirty-nine participants of competence and of their own capability, development and learning, were compared with the views of teachers, assessors, other midwives, and supervisors of midwives, working with participants. Also explored are the characteristics of the expert and the characteristics of good and bad midwives. The case is made early on in the thesis that a definition of competence is required for midwifery to develop as a profession, to protect the public, and to facilitate midwife development pre and post registration. Towards achieving this, the research begins to construct a model of midwifery competence as an integrated, holistic concept. The research explores the relationship between the various components and dimensions in the integrated model and the factors involved in being competent across contexts and from situation to situation. Factors involved in the maintenance of competence over time and in learning beyond registration are identified by exploring the nature of learning beyond registration and the characteristics of good and bad midwives.

Progesterone has been shown to be neuroprotective in a number of central nervous system injury models, including cerebral ischaemia. There is still a lack of understanding behind progesterone’s neuropotective properties, and the purpose of this project is to clarify some of these issues. Osmotic mini-pump infusion was hypothesised to more effective in delivering progesterone to the target organ of the brain, when compared to a bolus intraperitoneal injection. Progesterone pharmacokinetic profiles were compared between different dosing regimes. Intraperitoneal progesterone injection had a short half-life in both plasma and brain, while osmotic mini-pumps delivered higher concentrations of progesterone in plasma and particularly in brain, over a longer period, which supports the hypothesis. It was hypothesised that progesterone will reduce NO production and cell death in in vitro. Progesterone reduced nitric oxide production after challenging microglia with LPS, which supports our hypothesis and the nuclear progesterone receptor was found not to have a major role in nitric oxide attenuation. Neither of the microglial cell lines, BV-2 and HAPI cells produced elevations in NO formation in ischaemic conditions. The in vitro oxygen and glucose deprived model of ischaemia, reduced viability in both microglial and neuronal cells. Also, high pharmacological concentrations of progesterone exacerbated ischaemic injury, which does not support the hypothesis of progesterone in reducing cell death. Progesterone administration, via osmotic mini-pump infusion, was hypothesised to have a better outcome compared to vehicle treatment. After the onset of experimental stroke, progesterone delivery via osmotic mini-pump with loading dose was found to be beneficial in terms of neurological deficit score in adult male mice, which supports the hypothesis. Also, we hypothesise that co-morbidity can affect the efficacy of progesterone treatment in outcomes. Aged animals have an increased sensitivity to experimentally induce stroke and did not display, in the outcomes measured, any benefit from progesterone treatment. NOD/ShiLtJ mice had severe symptoms, resulting in high mortality after surgery and are not recommended as a model of diabetes for experimental stroke. Hypertensive BPH/2 mice are a potential hypertensive model and had better functional outcomes after treatment with intraperitoneally administered progesterone, compared to non-treated hypertensive animals in our small preliminary study. This supports our hypothesis that co-morbidity can affect the efficacy of progesterone treatment in outcomes. The gold-standard for assessing intervention effects across studies within and between subgroups is to use meta-analysis based on individual animal data. We hypothesise meta-analysis would reveal progesterone to reduce lesion volume, but also discover other effects in different subgroups of animals. Progesterone significantly reduced lesion volume, it also appeared to increase the incidence of death following experimental stroke. Furthermore, this negative effect appears to be particularly apparent in young ovariectomised female animals. These findings support the hypothesis that progesterone reduces lesion volume and progesterone having other effects in different subgroups. This investigation has clarified some issues and expanded our understanding on the neuroprotective properties of progesterone. However, these findings indicate further investigation is still required before progesterone can be considered for use in clinical trials as a neuroprotectant in stroke.

The bacteria Ureaplasma has long been associated with a wide range of adverse health implications, including preterm birth, preterm premature rupture of the membrane and lung disorders, such as bronchopulmonary dysplasia in neonatal infants, but still, little is known about the pathogenic properties of Ureaplasma and possible direct association with adverse health complications. Estimated prevalence of Ureaplasma colonisation in sexually active adults is between 40 – 80%, therefore further understanding of its pathogenic properties and its ability to initiate an immune response is crucial. Specifically selected human cell-lines were examined in vitro to determine whether an innate immune response could be activated by Ureaplasma infection. If inflammatory immune responses were detected in human cell-lines, pathogenic properties of Ureaplasma would be confirmed, and its role in pregnancy and neonatal complications could be supported. Using a range of techniques, activation of immune response pathways were examined, as too were the production of detrimental pro-inflammatory cytokines that would strengthen the suggested associations of Ureaplasma infection with the above-mentioned complications. Myeloid-derived leukocytic monocytes, human bronchial epithelial cells and human amniotic epithelial cells were examined, as these would be the most relevant cell lines to determine if Ureaplasma could induce preterm birth, preterm premature rupture of the membrane and bronchopulmonary dysplasia. All cell lines studied showed immune response and inflammatory cytokine production after stimulation with Ureaplasma. This supports that Ureaplasma is capable of causing tissue damage in neonatal respiratory tracts that may lead to bronchopulmonary dysplasia and damage to the amniotic and chorion membranes that may lead to preterm premature rupture of the membrane. Ureaplasma was detected at the cell surface of human amniotic epithelial cells (HAECs) by TLR2 and TLR2/6 heterodimers. Results suggest that Ureaplamsma multiple banded antigen (MBA) is the strong ligand for TLR2 and TLR6 and stimulation of HAECs with MBA alone caused an immune response. TLR9 was responsible for the detection of internalised Ureaplasma, which is also able to initiate an immune response and inflammatory cytokine production. v Ureaplasma stimulation results in the production of the inflammatory cytokines TNF-α, IL-8 IL-6 via the NF-κB signaling pathway. Production of the potent inflammatory cytokine IL-1β was also observed, which would suggest the formation of inflammasome complexes. NLRs were investigated to find which NLR inflammasome were activated. It was shown that genetically knocking down NLRP7 significantly reduced the amount of IL-1β that was produced after Ureaplasma stimulation, suggesting that NLRP7 inflammsones are activated by Ureaplasma. Reduction in IL-1β was also observed, but to a lesser extent, when NLRP3 was knocked down. We decided to investigate the role of NLRP7 further and found a novel immune pathway, where NH3 causes activation and formation of the NRLP7 inflammasone. NH3 is produced as a bi-product of urease activity, which an essential process for Ureaplasma. The addition of a potent urease inhibitor to HAECs being stimulated with Ureaplasma significantly reduced the production of IL-1β, strongly supporting that NH3 plays a significant role in the detection of Ureaplasma infection and is responsible for causing the tissue damage that contributes to preterm premature rupture of the membrane leading to preterm birth. This investigation strongly supports that Ureaplasma is responsible for causing preterm birth and health complications in neonates, and that more robust treatment and monitoring of Ureaplasma is required, especially in pregnant women. These undertakings will hopefully reduce the rates of preterm birth and the associated health implications, in addition to reducing rates of bronchopulmonary dysplasia in neonates.

For many centuries, malaria has remained the most common parasitic disease in sub-Saharan Africa potentially placing 32 million pregnancies at risk each year. Malaria in pregnancy (MiP) in malaria endemic Africa is mostly asymptomatic or paucisymptomatic, yet associated with maternal anaemia and intra-uterine growth retardation resulting in low birth weight (LBW) which is an important risk factor for infant mortality (chapter 1). In Mali, several observational studies have determined the risk and consequences of malaria in pregnancy. However, national estimates of the burden of MiP and its potential impact are lacking. This thesis describes the results of a series of surveys conducted in different malaria transmission settings countrywide from 2005 to 2010, to quantify the burden and consequences of MiP in Mali (chapter 2). Results demonstrate that the risk of malaria infection at delivery was generally high ([average prevalence 11.6%]) and showed marked diversity between regions and transmission settings. Coverage of intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) and impregnated treated bednets (ITNs) was low (30.4% and 60.7%) and indicated important miss opportunities for the control of PAM. To prevent the disease and its consequences in pregnancy, the World Health Organization recommends IPTp using SP and use of an ITN. For IPTp, the recommended regimen consists of at least 2 doses of SP given during the second and third trimesters for HIV negative women and at least 3 doses for HIV-positive women not receiving cotrimoxazole. However, there are concerns that the 2-dose regimen, which provides at most 12 weeks of prophylaxis, leaves many women unprotected for as much as half of the 20-26 pregnancy weeks after quickening. Re-infection with the 2-dose regimen is common, especially during the transmission seasons and amongst women who complete their last dose early in the third trimester. A trial was therefore conducted to compare the standard 2-dose regimen versus 3 doses using SP, hypothesizing that the third dose may add significant benefit over the 2-dose regimen in preventing placental malaria and other birth outcomes (chapter 3). The study concluded that IPTp-SP with 3-doses was superior to the standard 2-dose regimen and resulted in better birth outcomes. The results of this trial were then combined with 6 similar trials as part of a meta-analysis assessing if 3 or more doses of IPTp-SP are more effective than the current standard 2-dose regimen. The pooled results suggested a marked benefit of adding extra SP doses over the standard 2-dose regimen in both regions of high and low SP resistance as measured by the prevalence of dihydropteroate synthase K540E mutations (chapter 4). Although studies from western Africa favour the use of IPTp-SP, SP resistance is now a serious threat to the longevity of IPTp with SP in parts of eastern and southern Africa where the quintuple dihydofolate reductase (N51I, C59L, S108N) /dhps (A437G, K540E) mutation is saturated in many places. In order to get a better understanding of the impact of SP resistance on IPTp effectiveness, this thesis also determined the in vivo response of parasites in asymptomatic parasitaemic pregnant women who received IPTp-SP and the effectiveness of IPTp-SP on birth parameters in West-Africa (chapter 5 & 6) Overall, the study concluded that SP resistance in Mali and Burkina Faso is low and that the IPT-SP is associated with clinically relevant improvements in birth outcomes in Mali.