Maternal obesity and diabetes increase the risk of delivering large for gestational age infants (LGA), who have higher risk of long term obesity or metabolic syndrome [1]. As the underpinning mechanisms of how fetal growth is regulated by the placenta remain unclear [2], this thesis has investigated placental responses to high maternal BMI and gestational diabetes. Spanish pregnant women recruited at 20 gestational weeks were classified according to pre-pregnancy BMI as control (BMI<25kg/m2; n=59), overweight (BMI=25-30kg/m2; n=29) or obese (BMI>30kg/m2; n=22), and gestational diabetes status (GDM) classified at 28 weeks. Maternal anthropometry and gestational weight gain (GWG) were measured during pregnancy. Placenta, cord blood, newborn antrophometry and infant weight were sampled or measured. Expression of genes involved in placental energy sensing pathways, folate transporters and DNA methylation was determined using real-time PCR, and placental triglyceride concentrations, lipid peroxidation and genomic DNA methylation patterns measured. Data were analysed according to their parametric distribution by Kruskal-Wallis or 1-way ANOVA. Despite lower GWG, a greater proportion of obese women exceeded recommended weight gain [3], had higher placental weight and increased numbers of LGA infants. Maternal hyperinsulinaemia and hyperglycaemia with obesity were accompanied by unchanged placental IGFR1 and ISR1 expression, similar cord blood glucose and triglyceride concentrations. Placental mTOR was halved with obesity, whilst SIRT1 and UCP2 gene expression were 1.8 and 1.6 fold upregulated respectively with no differences in TBARS concentrations. Hyperleptinaemia in obese women resulted in unchanged placental leptin and leptin receptor expression, but higher cord blood leptin and monocyte concentrations with placental hypermethylation of genes involved in the immune response. Lower folate concentrations in obese mothers led to similar cord blood folate, and decreased placental FRα, but raised DNMT1, mRNA expression. No major differences were observed with GDM, probably due to small sample size. In conclusion, it appears that the placenta can protect the fetus of obese women by increasing antioxidant capacity, compensating for maternal hyperglycaemia and lower folate. However, maternal obesity was associated with enhanced cord blood leptin and monocyte concentrations, increased placental weight and more LGA delivery, leaving infants at ongoing risk of increased adiposity and inflammation. Therefore, current studies are currently exploring these interacting aspects.

Computational and mathematical models have become increasingly important and have contributed to significant advances in our understanding of complex biological systems. We developed a mathematical model to characterise the expression profile of transmembrane electrogenic proteins of excitable cells. The cell of interest is the myometrium smooth muscle cell, which is the principal unit of electrical activity in the uterus. These cells remain quiescent throughout most of gestation, whereas just prior to and during labour they are able to generate spontaneous action potentials. A more detailed and comprehensive characterisation of these cells, in comparison to previous models, would furnish an appropriate tool for the development of therapeutics to manage preterm birth and other perinatal problems associated with uterine contractility, such as postpartum haemorrhage. The "conductome" can be defined as the totality of ion channels and ion transporters expressed by an electrically active cell, i.e., a list specifying the cell surface density and oligomeric composition of each of these species. Gene expression techniques can accurately survey the complete set of all mRNA species encoding electrogenic proteins (e.g., subunits of channels). The conductome is constrained by this transcriptome, but the link between the two is complicated by the facts that (i) presence of an mRNA species does not necessarily imply the presence at the transmembrane proteomics level; and (ii) subunits can combine in various ways to give rise to conducting channels with different properties. Every individual potential oligomeric channel complex was represented as a mathematical model on the basis of biophysical data taken from the literature; these data were obtained mainly using heterologous expression systems. We investigate the possibility of combining the behavioural information of the action potential with the detailed molecular data of the transcriptome. The general problem is that electrical behaviour does not necessarily lead to a unique solution. The question addressed here is to what extent the additional information provided by transcriptomics helps to constrain the solution space. We develop and apply a method to characterise the functional redundancy of electrically active cells. We use mRNA sequencing to determine which electrogenic species the cell is capable of expressing, combined with a least-squares parameter estimation procedure to determine the conductome from electrophysiological data. Moreover, we estimate the parameters associated with the gating kinetics from published data, so that the only remaining free parameters are the surface densities of the species on the list defined by the transcriptomics analysis.

<p> Every patient has a right to be treated with dignity, respect and high quality pain management (Olivier, et al., 2012). Pain continues to be inadequately treated by healthcare providers (Zuccaro, et al., 2012). The purpose of this DNP project was to determine if perinatal nurses&rsquo; intent to medicate pregnant women with chronic pain was affected by knowledge of pain, attitude, or demographics. This will explore the theoretical application of Ajzen&rsquo;s theory of planned behavior which suggests that attitude correlates with intention to act.</p><p> A quantitative, cross-sectional correlation study used a pencil and paper survey to measure knowledge about pain, attitudes, and intent to medicate pregnant women with chronic pain. One hundred perinatal nurses who worked in labor and delivery, mother baby, or the neonatal intensive care unit from four hospitals in northern New Jersey participated in the study. Each hospital provided a different level of perinatal care from community basic, to intermediate, intensive, and regional perinatal center.</p><p> Increased levels of education positively impact perinatal nurses&rsquo; knowledge of pain, attitude, and intent to medicate pregnant women with chronic pain. The perinatal nurse&rsquo;s intent to medicate was not statistically correlated to age, years of nursing experience, or level of perinatal care. The perinatal nurse&rsquo;s intent to medicate a pregnant woman with chronic pain is positively correlated to increased knowledge of pain (<i>r</i> (100) = 0.463, <i>p</i> &le; 0.001). Attitude scores were positively correlated with an increased intent to medicate a pregnant woman with chronic pain (<i>r</i> (100) = 0.583, <i>p</i> &le; 0.001).</p><p>

<p> Adolescent pregnancy and parenthood have been identified as national public health problems and are topics of intense debate in the United States because of their impact on maternal and child health and on the social and economic well-being of the nation. While many types of parenting programs are available to the adolescent mother, not one approach has emerged as the most effective to decrease subsequent pregnancies and to improve mother and child health. Using Husserl's Phenomenology as a philosophical underpinning, what it means to be a pregnant adolescent living in a group home was explored. Data were collected from volunteers who had lived in two group homes in a suburban county in the Mid-Atlantic area of the U.S. In-depth, one-on-one interviews using a semi-structured guide were completed with eight participants. Giorgi's steps for analysis of the verbatim transcripts were used to develop <i> essences and the essential structure</i> about the phenomenon understudy. The participants' ages when they lived in the group home ranged from 13-17 years; the time they lived in the group home was between one to two years and some adolescents, after delivery, lived in the group home from six months to two years. Three themes emerged, each with subthemes, describing the participants' experiences: <i>The environment with its rules and structure was experienced as either supportive or not in day-to-day living; Balancing adolescent expectations and needs impacted pregnancy and parenting; and Defining motherhood focused on the basics and was influenced by the participants' own mothering</i>. The study's fmdings were compared and contrasted with well-known nursing, individual development, and parenting theories and relevant research findings. Nurses who care for adolescents throughout their pregnancy and the postpartum period are uniquely positioned to influence their development as mothers. </p>

Introduction: The human endometrium undergoes cyclical changes of proliferation, differentiation and shedding. This cyclical process has been described as an inflammatory process. Menstrual abnormalities account for the morbidity of a large population of females in their reproductive age. Aberration in endometrial angiogenesis has been implicated in the mechanism of heavy menstrual bleeding (HMB). Although the precise mechanism for control the endometrial neoangionesis is not fully understood, vascular endothelial growth factor and other cytokines such as cyclooxygenases, prostaglandins, interleukin -8 and leukocytes have been implicated in both endometrial pathologies and angiogenesis dysregulation. In addition, heavy menstrual bleeding results from upregulation of the expression/synthesis of these local markers. Uterine fibroids are the most common benign tumor affecting the female reproductive tract. Heavy menstrual bleeding is the main presenting complaint of women with uterine fibroids. However, the mechanism by which uterine fibroids cause heavy menstrual bleeding has not been elicited yet. Therefore, the mechanism of action of different available treatments for this condition, including uterine artery embolisation is unclear. This thesis is based on the hypothesis that a) uterine fibroid changes the physiology of endometrium and we aimed to find out whether these markers work in a different way in heavy menstrual bleeding in those with uterine fibroids and those without., In addition I we wished to study whether uterine fibroid upregulate these local markers in heavy menstrual bleeding, whereas uterine artery emolisation down-regulates them. Methods: This thesis describes the use of endometrial samples, taken with a Pipelle sampler, collected from women with heavy menstrual bleeding both with uterine fibroids and also with normal uteri, to estimate the difference in the endometrial expression of the factors likely to be involved in the control of menstrual bleeding between the two groups. Results: The study found no differences between the expression of both either proteins or mRNA for the cytokines under investigation By using endometrium, myometrium and different types of fibroid tissue collected from women who had hysterectomies with the complaint of heavy menstrual bleeding, there was higher expression of VEGF, COX-2, PGE2 and IL8 proteins in fibroid than myometrial tissue. However, the level mRNA of expression for VEGF, COX-1, COX-2, IL8 and EP2 showed no differences between myometrial and fibroid tissue. In the same group, endometrial expression of these markers for women who had no hormonal therapy before operation compared with that for women who received gonadotropin releasing hormone agonists (GnRH), higher expression of VEGF mRNA in women who had GnRH agonists than those who had no any hormones. In fibroid tissue, GnRHdownregulated the expression of VEGF protein and other cytokines compared with those not on any hormonal therapy. In addition, the estimated serum levels of these factors, indicating a higher level of IL8 in the GnRH group than in the other group. Conclusion: It seems that theses markers play a role in HMB mechanism in both uterine fibroid and normal uteri group in same manner. In addition, they have a fundamental role in the growth of uterine fibroids as well.

Background: Young women with Polycystic Ovary Syndrome (PCOS) may have increased measures of cardiovascular risk. It is difficult to determine how much of this risk is due to PCOS itself and how much is due to obesity and insulin resistance,which are common in PCOS and are themselves associated with greater cardiovascular risk. Aims and Methods: The study aimed to determine if arterial stiffness, carotid intima-media thickness and diastolic dysfunction were increased in young women with PCOS independently of the effects of obesity. A cross-sectional study of women with PCOS and healthy volunteers aged 16-45 years was undertaken. Subjects had a comprehensive assessment of body composition (including computed tomography assessment of visceral fat), measurements of arterial stiffness (aortic pulse wave velocity; aPWV), common carotid intima-media thickness (ccIMT), diastolic function (longitudinal tissue velocity; e’:a’) and metabolic measures including an oral glucose tolerance test to assess insulin area under the curve (IAUC), a marker of insulin resistance. Results: After adjustment for age and body mass index, PCOS subjects had greater insulin response (IAUC) following glucose challenge (adjusted difference [AD] 35900 pmol min/l, P<0.001), higher testosterone (AD 0.57 nmol/l, P<0.001) and high molecular weight adiponectin (AD 3.01μg/ml, P=0.02) than controls. There were no significant differences in aPWV (AD -0.13m/s, P=0.33), ccIMT (AD - 0.01mm, P=0.13) or e’:a’ (AD -0.01, P=0.86). After adjustment for age, height and central pulse pressure, aPWV and e’:a’ were associated with log visceral fat and IAUC. After adjusting for log visceral fat, the relationships between aPWV or e’:a’ and IAUC were only party attenuated. There was no relationship between cardiovascular measures and adiponectin or testosterone. Conclusions: Insulin resistance and central obesity are associated with subclinical dysfunction in young women, but a diagnosis of PCOS does not appear to confer additional risk at this age.

Pre-eclampsia is a disorder of unknown aetiology that affects about 5% of Sri Lankan women during their pregnancy. It is most likely a multifactorial disorder that is caused by the interaction of genetic and environmental factors. Recent advances in genetics have resulted in a surge of investigations into genetic factors underlying pre-eclampsia. These studies have been conducted mainly in the white Caucasians in the West and the Japanese in the East. The investigations described in this thesis therefore were undertaken in a genetically distinct South Asian Sinhalese population in Sri Lanka and replicated in a white Caucasian population in Nottingham, UK. Four candidate genes; Epidermal Growth Factor (EGF) and Transforming Growth Factor Alpha (TGFA), which may play a role in placentation; Angiotensinogen (ANG), which is involved in blood pressure regulation; and 5,10-Methylenetetrahydrofolate reductase (MTHFR), which is an enzyme involved in folate metabolism, were examined. These investigations consisted of the following: Recruitment of 80 population volunteers each from the Sinhala, Sri Lankan Tamil and Moor racial groups in Sri Lanka, establishing the allele/haplotype frequency for the candidate genes in those volunteers and in 80 white Caucasian population volunteers, and comparing their allele/haplotype frequencies; recruitment of 180 Sinhalese women with pre-eclampsia and 180 normotensive pregnant Sinhalese women, establishing the allele/haplotype frequencies of the candidate genes in these women and in 74 white Caucasian women with pre-eclampsia and 81 normotensive pregnant white Caucasian women, comparing the pre-eclampsia phenotype of the Sinhalese with that of the white Caucasians, examining the association of the candidate genes with pre-eclampsia, and examining the association of the candidate genes with quantitative traits such as birth weight and blood pressure in normotensive pregnant women; and examining the functional effects of polymorphisms in the angiotensinogen gene on gene expression. The phenotyping results of the Sinhalese women reflect the severe morbidity associated with pre-eclampsia elsewhere, and highlight the severe perinatal mortality associated with pre-eclampsia in the Sinhalese. The population genetic results show considerable similarity between allele/haplotype frequencies of the Sri Lankan racial groups and considerable variation between them and the white Caucasians. The EGF gene was associated with pre-eclampsia in the Sinhalese and with the weight of babies at birth in both the Sinhalese and the white Caucasians. The TGFA, ANG and MTHFR genes were not associated with either pre-eclampsia or any quantitative trait. The angiotensinogen reporter gene expression studies revealed the possible existence of a repressor element in the 3' untranslated region of the angiotensinogen gene, but this finding needs confirmation by further investigations.

The study investigated the cost-effectiveness of caesarean section (CS) as the major component of Emergency Obstetric Care (EMOC) in a humanitarian context. Research was conducted from December 2007 until June 2008 in Bunia, in the north-east of the Democratic Republic of Congo. Methods A case-control study explored the factors determining whether a woman had a CS or a vaginal delivery. Cases (n=178) were randomly selected from women who had delivered by CS. Controls (n=180) were women who had delivered vaginally within two weeks of a case and were matched by place of residency. Face-to face interviews in the local language used a structured questionnaire about obstetric and socio-economic factors. Obstetric care was assessed during repeat visits to health structures using checklists. Provider cost of CS was calculated for four hospitals, of which one provided free emergency healthcare. Information about cost allocation to CS was collected from hospital managers, maternity staff, and administrators. Costs were verified with local entrepreneurs, international organisations and UN agencies. The social cost of maternal death was discussed in focus groups, which also obtained user cost information additional to the data from the case-control study. Results CS constituted 9.7% of expected deliveries in the Bunia Health Zone. During the study period, the humanitarian hospital performed 75% of all CS. There were no elective CSs in the study sample. The study found no evidence of obstetric surgery for non-medical reasons. Previous CS and prolonged labour during this delivery were the strongest predictive factors for CS. The risk increased with age of the mother and decreased with the number of children alive. Fifteen obstetric deaths were reported to the research team, three among them were women who had a CS. After adjusting the observed number for missed pregnancy-related and late post-partum deaths, the estimated number of maternal deaths avoided by humanitarian EMOC, compared to expected mortality without additional services, ranged from 20 to 228. Compared to recent estimates for the DRC, perinatal deaths avoided ranged from 237 to 453. Cost-effectiveness was expressed as cost per year of healthy life expectancy (HALE) gained. The estimated cost of adding one year of HALE by providing CSs in a humanitarian context ranged from 3.77 USD to 9.17 USD. Comparison of the cost of EMOC and the social cost of maternal death was complicated by the existence of local customs such as “sororate”. The user capacity to pay for health insurance was found to be low. Conclusion Caesarean sections as part of humanitarian assistance were cost-effective. To keep EMOC accessible during and following the transition from emergency relief to development, a change in the national financing policy for health services is advisable.

Recurrent miscarriage (RM) is stressful. One reason for this is because no causes can be found for the pregnancy loss in the majority of cases. Focus has been on the endometrium which undergoes decidualisation in preparation for implantation. Any problems in the finely organised interactions between the endometrium and invading trophoblast cells may contribute towards a miscarriage. Immunological mechanisms are thought to be one of the pathways involved as there is the need of maternal adaptation of her immune response to the semi-allogenic developing embryo. Uterine natural killer (uNK) cells are the most abundant in the endometrium during the window of implantation. They interact with trophoblast cells, and are involved in vascular remodelling, an important step in implantation. Hence, they have a biological plausibility of playing a major role in RM. Both peripheral NK (pNK) and uNK cells tests have been developed as assessments of immunological causes of RM. A systematic review performed showed inadequate evidence for both pNK and uNK cells tests as markers for adverse pregnancy outcomes. There were only twelve studies, with 446 patients reporting pregnancy outcomes. There was no accepted consensus of normality and methodology for analysing NK cells. The conclusion was the need for well-designed studies to assess the role of NK cell tests as a clinically useful marker for screening. This led to the conduct of the pilot phase of a RCT of prednisolone in early pregnancy in women with idiopathic RM and raised uNK cells density. The main aim of this trial was to assess feasibility of recruitment and tolerability of prednisolone. Secondary clinical outcomes included live birth, types of miscarriage, miscarriage karyotype, gestational age at delivery, birthweight and pregnancy complications (eg: pre-eclampsia, gestational diabetes, fetal abnormality, stillbirth, IUGR). 160 women were screened for uNK cells density and 40 were randomised, despite the majority (85%) desiring prednisolone if given a choice. There was a trend towards improved live birth rate with prednisolone treatment but this was not significant. There were equal numbers of biochemical, sac and fetal pregnancy losses in both groups. All completed treatment with main reported side effects in the prednisolone group of insomnia. There were no pregnancy complications. The analysis of uNK cells was found to be very time consuming. To accommodate potentially large numbers who will be screened in the definitive trial, an alternative, quicker and equally accurate method of analysing uNK cells was developed using the colour deconvolution and area measurement plug-ins of a public domain image analysis package, Image J. Women supported this trial. Randomisation was acceptable. The prednisolone was safe. UNK cell density is a valid biomarker of severe outcomes. There was a trend towards improvement in live birth rates. This trial paves the way for the development of an endometrial based test to screen for the subgroup of women with RM that could potentially benefit from individualised treatment.

The extensive assessment of bull’s reproductive potential prior to breeding is highly important and includes examination of general physical soundness, external and internal genitalia and semen quality. Breeding success depends on the efficient use of bulls with high breeding value but simultaneously semen quality imposes restrictions on the use of these bulls in AI. Several techniques have been devised to assess quality of either fresh or frozen-thawed semen. Among a variety of traditional parameters sperm concentration, sperm raw and post-thaw motility and sperm morphology are commonly used for routine semen assessment in the laboratory. In this study, we investigated differences in sperm metabolic activity relative to their motility that may reflect better the fertility of bulls from their non-return rates (NRRs). To investigate the relationship between mid-piece length and fertility of bovine spermatozoa, sperm biometry was performed on ejaculates obtained from 34 bulls representing six breeds: Holstein (yearlings and mature), Friesian, Belgian Blue, Aberdeen Angus, Charolais and Limousin. Significant differences (P<0.01) between ejaculates were found in 9/34 bulls, as well as differences (P<0.001) between individual bulls within the same breed. The average mid-piece length for Aberdeen Angus was 13.35μm, for Belgian Blues and Limousin around 13.8μm, and for Charolais 13.68μm: for dairy breeds (Holstein and Friesian) it was about 13.4μm. The mean value of mid-piece length for breed was compared with their 49 day non-return rate; a negative correlation was found in the dairy breeds, while in bulls from beef breeds this correlation was positive but very low: the small numbers of bulls involved prevented meaningful statistical relationships being established. To differentiate live and dead sperm and non-sperm-specific particles, a flow cytometry method was developed by labelling sperm with JC-1 and propidium iodide (PI) dyes and to determine maximum mitochondrial membrane potential (ΔΨm) at minimum incubation. This method entailed setting regional and logical gates to exclude dead sperm and other non-cellular components from live sperm present within an ejaculate. It was confirmed that spermatozoa of both fresh and frozen-thawed semen exhibited maximum high:low ΔΨm ratio after 40 min incubation. Flow cytometric dot plots of analyses of fresh and frozen-thawed spermatozoa incubated with JC-1 could identify a unified sperm population of membrane-intact cells, each population characterised by both low and high ΔΨm but to varying degrees suggesting that this flow cytometric method simplifies the determination of mitochondrial membrane potential using JC-1. This method serves two purposes: using this method, one could able to evaluate sperm ΔΨm as well as the proportion of live:dead. Changes in mitochondrial structure and integrity appear to be an important component associated with sperm motility and reduced fertility. The ΔΨm was assessed using JC-1 and PI in the presence of glycolytic and respiratory inhibitors. Mean high ΔΨm was significantly greater for control compared to the treatments in fresh and frozen-thawed semen. In samples treated with valinomycin (VAL) and iodoacetamide (IAM) ΔΨm was lowered significantly. The proportion of sperm with a high ratio of high:low ΔΨm was higher in control and 2-deoxy-D-glucose (DOG) treated samples representing more active mitochondria: in samples treated with VAL and IAM the ratio was reduced, representing loss in activity of mitochondria. Cryopreservation significantly decreases high:low ΔΨm ratio in control suggesting that lower mitochondrial activity may be associated with oxidative stress produced by reduced antioxidant levels due to the freeze/thaw cycle. The relationship between ZO2 (µl oxygen consumed /108 spermatozoa/hr) and mitochondrial function was assessed in fresh and frozen-thawed semen. Sperm oxygen consumption was greater in fresh compared to frozen-thawed semen. Insignificant positive correlations existed between ZO2 and ratio of high:low ΔΨm in fresh (r=0.82) and frozen-thawed (r= 0.49) semen suggesting that the ΔΨm measured in this way by flow cytometry can be used as an indicator of ZO2. Finally, the metabolic pathways by which spermatozoa produce energy to support their motility were investigated in fresh and frozen-thawed semen diluted in media containing glycolytic and respiratory inhibitors. Total and progressive motilities were not significantly different in sperm incubated with DOG and VAL but decreased significantly with IAM compared to control. This indicates that sperm can maintain a similar degree of motility when generating their energy exclusively from either glycolysis or mitochondrial activity. IAM significantly lowered sperm motility as well as mitochondrial activity (as described above) and was found to be an inhibitor of both glycolysis and respiration possibly linked with either modification of mitochondrial cysteine and/or glutathione levels. Sperm are considered in a state of hyperactivation/capacitation when their amplitude of lateral head displacement (ALH) increases and path straightness (STR) and linearity (LIN) decrease. In the present study higher ALH and lower STR and LIN were observed when spermatozoa were dependent on mitochondrial energy (DOG), whereas these estimates were reversed when they were on glycolytic energy (VAL) indicating that sperm hyperactivation and capacitation are associated with mitochondrial function. There was a positive correlation of sperm progressive motility, ZO2 and high:low ΔΨm ratio with bull NNRs suggesting that these sperm characteristics may be useful for predicting bull fertility. Furthermore sperm mid-piece length was significantly correlated with sperm average curvilinear velocity and amplitude of lateral head displacement. Since the mitochondria are localized on the sperm mid-piece, it is likely that its energy may contribute in high sperm velocity and also hyperactivation that helps sperm disengagement from oviduct epithelium and positioning at the site of fertilization.