The aim of this study was to assess risk factors to PTSD following childbirth incorporating a longitudinal design. Since the introduction of DSM-IV (APA, 1994) there has been an awareness in the literature that women can develop PTSD following childbirth. The first study in this thesis provides a comprehensive review of the literature in this area and the clinical implications of the disorder. The aim of the second study was to investigate the factor structure of a questionnaire measure (PLDQ) that has been used in past studies to assess women's perceptions of labour and delivery. The findings from this study indicate that the PLDQ consists of three internally reliable factors that can assess a woman's perception of pain, staff support/care and fear during labour and delivery. The scale can differentiate among women on these factors according to type of delivery. The aim of the third paper was to assess risk. factors to PTSD across time in the antenatal period, appraisal factors during delivery with the PLDQ, and maintenance factors in the postnatal period. There is an absence of studies in the literature that assess risk factors to PTSD over time. The results of this study indicate that postnatal depression (PND) and a negative appraisal of staff support and care during labour and delivery can predispose women to PTSD at 5-8 weeks following delivery. At 10 -14 weeks the relationship between PTSD and PND was still consistent. The clinical implications of the research are discussed for screening women at risk of PTSD following childbirth, assessment of a woman's appraisal of a difficult labour and delivery and the provision of support in the postnatal period.

No description available.

One of the crucial events during mammalian embryogenesis is the process of implantation. Implantation enables the embryo to invade the uterine endometrium and to gain access to the maternal circulation. The attachment reaction requires a highly coordinated dialogue between the implanting blastocyst and the receptive uterus, known as the embryo-uterine cross-talk. Since the blastocyst expresses multiple Wnt genes, in this study, we have characterized the role and regulation of the Wnt/-catenin pathway in embryo-uterine communication. Using a transgenic mouse that reports Wnt signalling through the canonical pathway, we have demonstrated that the Wnt/-catenin pathway was transiently activated in the regions of the uterine luminal epithelium apposed to the blastocyst at the time of implantation. Activation of this pathway within the endometrium depended on the presence of the blastocyst and required the oestrogen surge. We further demonstrated that activation of the Wnt/-catenin pathway was essential for proper implantation to occur. One possible mechanism that regulates the responsiveness of the luminal epithelium to Wnt is the regulation of components of the Wnt pathway. We show that there is dynamic pattern of expression of the components of the Wnt pathway at the time of implantation. Furthermore, we demonstrate that LIF signalling is required for the expression of a subset of these Wnt components in luminal epithelial cells at the time of implantation. Our results demonstrate that the LIF and Wnt signalling pathway form a network involved in coordinating the process of implantation As Wnt/ß-catenin signalling is essential for embryo attachment, we proposed / Le processus de l'implantation embryonnaire joue un rôle crucial lors du développement des mammifères. L'implantation de l'embryon est un processus extrêmement complexe au cours duquel l'embryon va d'abord s'apposer, puis adhérer à l'endomètre pour ensuite y pénétrer. Ultérieurement, il a été démontré que le blastocyste exprime plusieurs gènes de la famille Wnt. C'est pour cette raison que dans cette thèse, j'ai décidé caractériser le rôle et la régulation de la voie de signalisation Wnt/-catenine lors du dialogue materno-fœtal. Nous avons utilisé une souris transgénique qui permet de contrôler la voie de signalisation Wnt/-catenine. Ainsi, nous avons démontré que la voie de signalisation Wnt/-catenine était activée de façon transitoire dans les cellules épithéliales du lumen de l'utérus, dans la région adjacente au blastocyte au moment de l'implantation. L'activation de cette voie de signalisation dépend de la présence du blastocyste et de la sécrétion d'oestradiol. Nous avons également démontré que l'activation de la voie de signalisation Wnt/-catenine était essentielle au processus d'implantation embryonnaire. Par la suite, nous avons examiné la possible interaction entre la voie de signalisation Wnt et LIF. En effet, dans les souris mutantes pour le gène LIF, la voie de signalisation Wnt/-catenine n'est pas activée. Grâce à la technique de rt-PCR, nous avons caractérisé le profil d'expression des récepteurs Frizzled, des co-récepteurs LRP, des antagonistes sFRP et DKK et des gènes Wnt dans les souris mutantes pour le gène LIF et dans les souris de type sauvage. Nous avons démontré que les composa

Inaug.-diss.--Strassburg.

Senior Honors Thesis (Nursing)--Ohio State University, 2004. / Title from first page of PDF file. Document formatted into pages; contains 26 p. Includes bibliographical references (p. 23-24). Available online via Ohio State University's Knowledge Bank.

Thesis (M.S.)--Catholic University of America. / Includes bibliographical references.

Thesis (M.D.)--University of California, San Francisco, 2001. / Includes bibliographical references. Also available online.

Background: GDM is a state of glucose intolerance first diagnosed in pregnancy. It is a pre-diabetes state, predisposing both the mother and offspring to future risk of diabetes. GDM is associated with increased risk to macrosomia, adiposity, Caesarean Section (CS) delivery, shoulder dystocia, and neonatal hypoglycaemia. SA have a greater than two fold risk of both GDM and future diabetes risk compared to WC. However, despite having higher levels of hyperglycaemia in pregnancy, SA babies are amongst the smallest babies in the world. The mechanism behind this increased glycaemic risk in SA is complex, multifactorial and unclear. Disordered hypothalamic-pituitary-adrenal axis (HPA) has been linked to adult diabetes, obesity and metabolic syndrome in WC but has not been studied in SA. The current management of GDM is largely based on evidence from studies in WC and has been extrapolated to other ethnic groups such as SA. This includes: diagnostic criteria to define GDM, postnatal screening methods for postpartum glucose abnormalities, effect of GDM on offspring birth weight (BW) and fetal growth in GDM. Through this research we aim to explore the ethnic differences between SA and WC in the applicability of diagnostic criteria, post partum screening methods, effect of GDM on BW, fetal growth patterns in GDM and also examine ethnic differences in HPA activity as a potential mechanism underlying the increased glycaemic risk in SA in pregnancy. Methods: i. Retrospective analysis of a routinely collected multicentre data (n=14477) over a 3-year period was used to study the applicability of various GDM diagnostic criteria and post partum screening methods. A subgroup analysis of the above data set was used to compare fetal growth between SA and WC (177 WC and 160 SA). ii. A retrospective analysis of a large birth weight cohort (n=53,128) from Leicestershire between 1994 and 2006 was used to compare the effect of maternal diabetes and GDM on BW in SA and WC. iii. To examine fetal growth in SA, a retrospective case control analysis of serial fetal biometry was performed between GDM and control population from India. (178 controls and 153 GDM) iv. To explore underlying HPA dysfunction as a potential mechanism for increased glycemia in SA and ethnic differences in HPA behaviour a prospective cohort study comprising of high risk pregnant SA and WC women was performed. Diurnal salivary and urinary cortisol excretion was studied in relation to glycaemia in SA and WC (n=100, 50 SA, 50WC) Results: i. The newer IADPSG detects obese women with mild fasting hyperglycaemia. The benefits of treatment of hyperglycemia are not well established. The increase in detection rates of GDM with the new NICE and IADPSG criteria were uniform across ethnic groups in a selectively screened population. ii. Postnatal screening with oral glucose tolerance test (OGTT) is associated with poor uptake in all ethnic groups, which improves substantially with using HbA1c. SA were more likely to attend postnatal screening with HbA1c compared to WC. Screening for postnatal diabetes using FPG is more likely to miss women of non-WC ethnicity owing to the larger proportion of post-load glucose abnormalities. iii. The BW increase associated with maternal diabetes was lower in SA by 139g compared to WC. iv. Important ethnic differences in fetal growth were noted. SA fetuses had overall smaller measures of head and abdomen circumferences, but with disproportionately smaller abdominal circumference compared to WC, signifying early evidence of a head sparing growth restricted pattern. v. SA fetuses of GDM mothers showed early evidence of increased abdominal adiposity at 20 weeks with smaller measures of other fat free mass and skeletal growth compared to non-GDM controls vi. SA had higher cortisol awakening responses compared to WC. First trimester waking cortisol was an independent predictor of glycaemia in the third trimester. Despite significantly lower BMI, SA had similar glucocorticoid (GC) excretion to WC. Urinary GC excretion was independently predicted by maternal adiposity and not BMI in SA. Conclusion: This research addresses important gaps in the literature in gestational diabetes in SA. There are important ethnic differences in the impact of maternal diabetes and gestational diabetes on BW and fetal growth, and evidence of early increase in adiposity at the expense of lean body mass in SA. This research provides novel evidence to support the argument for ethnicity tailored management of GDM. Our research also provides novel evidence for disordered HPA activity as a possible mechanism for the increased glycemic risk in SA. Larger randomized prospective studies incorporating offspring outcomes in relation to HPA are needed.

Polycystic Ovary Syndrome (PCOS) is a complex disorder encompassing reproductive and metabolic dysfunction. Ovarian hyperandrogenism is an endocrine hallmark of human PCOS. In animal models, PCOS-like abnormalities can be recreated by in utero over-exposure to androgenic steroid hormones. This thesis investigated pancreatic and adrenal development and function in a unique model of PCOS. Fetal sheep were directly exposed (day 62 and day 82 of gestation) to steroidal excesses - androgen excess (testosterone propionate - TP), estrogen excess (diethylstilbestrol - DES) or glucocorticoid excess (dexamethasone - DEX). At d90 gestation there was elevated expression of genes involved in β- cell development and function: PDX-1 (P < 0.001), and INS (P < 0.05), INSR (P < 0.05) driven by androgenic excess only in the female fetal pancreas. β- cell numbers (P < 0.001) and in vitro insulin secretion (P < 0.05) were also elevated in androgen exposed female fetuses. There was a significant increase in insulin secreting β-cell numbers (P < 0.001) and in vivo insulin secretion (glucose stimulated) (P < 0.01) in adult female offspring, specifically associated with prenatal androgen excess. At d90 gestation, female fetal adrenal gene expression was perturbed by fetal estrogenic exposure. Male fetal adrenal gene expression was altered more dramatically by fetal glucocorticoid exposure. In female adult offspring from androgen exposed pregnancies there was increased adrenal steroidogenic gene expression and in vivo testosterone secretion (P < 0.01). This highlights that the adrenal glands may contribute towards excess androgen secretion in PCOS, but such effects might be secondary to other metabolic alterations driven by prenatal androgen exposure, such as excess insulin secretion. Thus there may be dialogue between the pancreas and adrenal gland, programmed during early life, with implications for adult health Given both hyperinsulinaemia and hyperandrogenism are common features in PCOS, we suggest that their origins may be at least partially due to altered fetal steroidal environments, specifically excess androgenic stimulation.

Partnership working has become something of a government imperative for tackling complex public health issues and is now more often the norm than the exception in health education and disease prevention work. The literature however, highlights that partnership working may be explained more by rhetorical appeal rather than any concrete evidence of effectiveness. There is little evidence from the literature examining the functioning, effectiveness or outcomes of partnership for health improvement. Partnership working was used within one such public health initiative (Healthy Respect) as a means of implementing and delivering a complex sexual health intervention programme to young people aged 10-18 years in Lothian. The main aim of Healthy Respect was to create an environment that would lead to long term improvements in the sexual health and wellbeing of young people through a multi-faceted approach which linked to education, information and services. This PhD study aimed to assess the extent and impact of partnership working in the Healthy Respect project; it aimed to examine the process and outcomes of partnership working for the organisations involved in the programme and to theoretically assess how this may impact on improving young people’s sexual health and wellbeing. The study used Healthy Respect’s logic model as a framework to examine the theory of how change occurred through partnership working in the project. A mixed method research design was used consisting of two postal surveys and in depth interviews with a sample of providers delivering sexual health education, information and services to young people in Lothian. Results suggest that Healthy Respect was only partially successful in working in partnership with some of the organisations involved in delivering sexual health education, information and services to young people. Partnerships were formed with approximately half of the providers. Those most engaged and working in partnership with Healthy Respect were from the NHS (including school nurses) and voluntary organisations which offered sexual health services to young people. Sexual health services also occupied a dominant position in the local networks of providers. Many providers linked with these services including secondary schools which offered Sexual Health and Relationship Education (SHARE). Other organisations most notably those from the Local Authority organisations were less willing to work in partnership with Healthy Respect. Many of the barriers (identified through the qualitative interviews with providers) to working in partnership with Healthy Respect came mostly from the Local Authority organisations and offered an explanation as to why partnerships with these organisations didn’t develop as planned. Results did suggest that where partnership work was taking place, this impacted on an organisations ability to deliver sexual health information, education and services to young people. However, partnerships with Healthy Respect were only formed with approximately 46% of the providers targeted, therefore not all organisations and subsequently young people would have benefitted from the Healthy Respect programme. The Healthy Respect programme was heavily reliant on partnership working to deliver the complex intervention. Yet results suggest that they were only partially effective in working in partnership with the organisations involved which may have led to them having little impact on the sexual health and wellbeing of young people (especially the most vulnerable). Partnerships take a long time to build and require a great deal of time and resources to be invested in them to work. However, the results of the study leave us with the fundamental question of whether all this time and effort should be applied to partnership working and interventions of this type for what could be very little impact on young people’s sexual health? This study has contributed to knowledge in the area of partnership working for health improvement. It defined what partnership was using a range of methods which moved beyond supportive attitudes and was able to examine and measure both the process and outcomes of partnership work in this project, something which few studies have been able to achieve.