Several reports have linked vitamin D deficiency with an increased risk of gestational diabetes mellitus (GDM). Both of these conditions are alarmingly common in Saudi Arabia, and pose additional risk of developing future metabolic disease. This study, therefore, investigates the vitamin D status amongst pregnant Saudi women, and the potential influence of vitamin D deficiency on metabolic dysfunction, such as GDM. A total of 578 pregnant women (28.8 ± 5.4 years) were recruited for this study during their first trimester of pregnancy (8-12 weeks) and followed up in their second trimester (24-28 weeks), where data were collected from 297 [51.3% (297/578); 28.9 ± 5.3 years] women. The study collected socio-economic, anthropometric and biochemical data, along with dietary intake, physical activity and sun indices. The findings of this study indicate that during the first trimester 81% of women being vitamin D deficient, dropping to 77% in the second trimester. It was also noted that being younger in age, multiparous, having a lower level of education, being a housewife, and living in West Riyadh were all associated with vitamin D deficiency during the first trimester (p < 0.05), and this further corresponded to reduced sun exposure (p < 0.001). In contrast, physically active pregnant women, women adequately exposed to sunlight at noon (p < 0.001), and residents of North Riyadh all had significantly higher circulating vitamin D levels (p < 0.05). Furthermore, low levels of high-density lipoprotein cholesterol (HDL-cholesterol) during early pregnancy were also associated with an increased risk of vitamin D deficiency (p < 0.05). Ultimately, compared with the first trimester, circulating vitamin D levels were significantly higher in the second trimester, after adjustment (p < 0.001). Among the pregnant women studied here, it was subsequently found that 33% developed GDM in the second trimester. Vitamin D deficiency in early pregnancy was associated with significantly higher risk of GDM, and this risk persisted after adjusting for confounding risk factors with regard to both vitamin D deficiency and GDM [odds ratio (OR) 3.97, confidence interval (CI) 1.12-14.15, p = 0.033]. In addition, significantly higher random blood glucose levels, higher glycated haemoglobin (HbA1c), and low HDL-cholesterol in early pregnancy were observed in the GDM subjects, compared to those without GDM (p < 0.05). Furthermore, vitamin D deficiency in mid-pregnancy increased the risk of metabolic syndrome and low HDL-cholesterol, thus pointing to the role of vitamin D in the probability of developing cardiometabolic disease. In summary, a high prevalence of vitamin D deficiency was observed amongst the subjects in this study, namely pregnant Saudi women. Moreover, hypovitaminosis D in early pregnancy was identified as a significant risk factor for the development of GDM. The present study, therefore, suggests that maintaining optimal levels of vitamin D during pregnancy may be a useful intervention in preventing the development of GDM and metabolic syndrome. Along with vitamin D supplementation, lifestyle modification also appears to be critical for maintaining optimal vitamin D levels during pregnancy, thus avoiding pregnancy-related complications.

This thesis examines women’s experiences of postnatal care in hospital and on postnatal debriefing. The objectives were to determine what postnatal debriefing is; to understand reasons why some women attend such services; identify the views of women and staff towards this and finally explore women’s feelings about their birth experience to identify possible links between this and the need for women to talk to a professional. A case study utilised secondary data sources to identify women’s experiences of care on the postnatal ward. This was followed by a critical literature review of postnatal debriefing which adopted meta-ethnography to analyse the varied research papers retrieved. The literature review was published in a peer-review journal. Finally the fourth research component followed a sequential mixed methods approach. This included a survey to a convenience sample of 447 women following birth and qualitative interviews with 16 women. The findings of the case study showed that women felt unsupported on the hospital postnatal ward and the environment unconducive to recovery. The critical review of the literature showed that postnatal debriefing enabled women to have their birth experiences validated by talking and being listened to and being provided with information. Results from the main research study show that women with a high Impact of Events Score (IES) are more likely to want to talk following their birth experience and more likely to rate their experience of birth more negatively compared with those with those with a low IES. Five themes were identified in the qualitative analysis that illuminated women’s reasons for needing to talk about their birth experience. Women found the postnatal debriefing service of value. Maternity providers should consider offering a postnatal debriefing service to help meet women’s postnatal support needs in advance of further research in this area.

Maternal obesity significantly increases the risk of a prolonged and dysfunctional labour resulting in emergency caesarean delivery. As the mechanism(s) remain to be eludicated, a translatable animal model is warranted. Recently, Elmes et al (2011) illustrated the potential of the high-fat, high-cholesterol (HFHC) diet animal model to investigate maternal obesity associated uterine dystocia, but it remains to be fully evaluated. The aim of this thesis was to evaluate this animal model by assessing the effect of a HFHC diet upon uterine contractility, and to highlight the potential mechanism(s) responsible. All female Wistar rats were sustained on a control (CON) or HFHC diet prior to and during pregnancy and labour, with tissue collected from these animals upon term delivery of the 1st pup. Uterine contractility was assessed through ex vivo contractility studies and in vivo intra-uterine telemetry surgery. Chronic exposure to a HFHC diet resulted in an aberrant asynchronous multiphasic spike bundle contraction phenotype ex vivo, with HFHC animals displaying a prolonged duration of labour up to 12 hours longer than CON animal’s in vivo. These results are reflective of human clinical studies, highlighting the efficacy and translatability of this animal model, but the mechanism(s) remain to be identified. Enzyme-linked immuno-sorbent assay and western blotting revealed that HFHC animals displayed significantly increased circulating progesterone at term, coupled with a decrease in uterine contractile-associated protein (CAP) expression including connexin-43 and caveolin-1 at the onset of term-labour (TL). Further to this, chronic exposure to a HFHC diet significantly increased circulating cholesterol, which could alter uterine myocyte membrane fluidity and compromise the expression and function of their integral CAP’s including the oxytocin receptor (OXTR); OXTR expression was increased at TL but HFHC animals displayed a protract response to this uterotonin ex vivo. Feeding of a HFHC diet significantly increased circulating oleic acid and decreased arachidonic acid, which could explain lower plasma concentrations of the utertonin prostaglandin F2α identified during a previous pilot study, and offer another potential mechanism by which maternal obesity could compromising the outcomes of labour. This thesis has highlighted the efficacy and translatability of this animal model in the study of maternal obesity associated uterine dystocia, and offered insights into the mechanism(s) responsible.

This thesis examines the working milieu of midwives in the urban west midlands, primarily Birmingham and Coventry, between 1794 and 1881. Adopting a microhistorical approach, and by integrating sources including a midwife’s register, lying-in charity and poor law records, the thesis argues that developments in midwifery provision over the period mainly arose from local factors and circumstances, however some metropolitan influences can also be discerned. Reasons for the relatively late introduction of midwifery training in the locality, and the minimal interest by local midwives are considered, alongside evidence of midwives’ awareness of the varying reputation of their occupation. This research indicates that midwives worked for a range of clients including charities, the poor law and private clients, and midwifery could be combined with other strands of caring work, or even work unrelated to caring. The analysis illustrates the existence of full-time, sustained midwifery careers and of midwives who achieved a middle-class lifestyle, and a degree of status within their localities. Combined with the evidence of entrepreneurial approaches to midwifery, the thesis argues that these provincial midwives should be integrated into the historiography of businesswomen.

The core promoter is the ultimate target of all transcriptional regulatory processes. The recently discovered diversity of core promoters and basal transcription factors suggests a regulatory role in differential gene expression. However, the direct contribution of the core promoter remains poorly understood. I investigated core promoters and their putative role in differential gene regulation using the zebrafish embryo as an in vivo model system. To analyse the functional requirement for the general transcription factor TATA-box binding protein (TBP), a diverse set of promoters was tested for their TBP dependence. This analysis revealed a differential requirement of TBP for promoter activity. To further explore the roles of core promoters the ability of various core promoters to interact with tissue-specific enhancers was investigated. A high-throughput pipeline combining automated imaging with custom-designed software for registration of spatial reporter gene activity in thousands of zebrafish embryos was developed. The technology was applied in a large-scale screen analysing the tissue specific activities of 202 enhancer - core promoter combinations. A variety of interaction specificities observed suggests an important role of the core promoter in combinatorial gene regulation. Overall, these findings indicate that the core promoter significantly contributes to differential transcriptional regulation in the vertebrate embryo.

In the ambulatory assessment of women with abnormal uterine bleeding, the main aim is to reach a diagnosis and thereby allow appropriate treatment. Excluding endometrial pathology, particularly carcinoma and hyperplasia, is of paramount importance. However there is no consensus as to which set of investigations should be used (hysteroscopy, ultrasonography and endometrial sampling). There is a lack of good quality research evidence on the accuracy of the various diagnostic tests in predicting endometrial lesions. This dearth of relevant evidence prompted the research presented in this thesis to address and answer the following research questions: • What is the accuracy of outpatient miniature hysteroscopy / ultrasonography in the identification of premalignant and malignant endometrial lesions? • What is the relative significance of hysteroscopic and ultrasonographic evidence of endometrial atrophy in relation to an insufficient sample on outpatient endometrial biopsy? • What is the risk of premalignant and malignant pathology among endometrial polyps? What is the significance of various risk factors associated with endometrial polyps? • What is the feasibility of multivariable analysis to evaluate combinations of diagnostic tests in the diagnosis of endometrial disease? Findings and Conclusions Positive hhysteroscopy is accurate in ruling in endometrial cancer and hyperplasia (the LR was 51.1 (95% CI 7.9-326.9). Using endometrial thickness >4mm at ultrasound scan, ultrasound is accurate in ruling out endometrial cancer and hyperplasia (the LR was 0.14 (95%CI 0.02-0.64). Insufficient sample on endometrial biopsy was more common among cases with hysteroscopic finding of endometrial atrophy (adjusted OR= 4.79, 95% CI 1.05-21.91, p=0.04) and less common among cases with sonographic endometrial thickness above 5mm (adjusted OR=0.19, 95% CI 0.07-0.53, p=0.001). Therefore insufficient sample may be considered a substitute to absence of pathology provided the hysteroscopic and sonographic endometrial assessment is consistent with endometrial atrophy. Hyperplasia was more frequent in endometrial specimens with polyps than in those without (9.7% vs 4.8%, OR=2.1, 95% CI 0.85-5.2), but the rate of carcinoma in the two groups was not statistically different (4.8% vs 3.2%, OR=1.5, 95% CI 0.46-5.0). Tamoxifen treatment was associated with endometrial polyps (adjusted OR= 8.16, 95% CI 2.01-33.2, p=0.003) but hormone replacement therapy was not (adjusted OR=1.35, 95% CI 0.65 – 2.81, p=0.42). The true clinical value of a test lies in the added information over and above what was already known from the history and examination. It is feasible to develop a stepwise multivariable analytic approach to explore the added value of tests (hysteroscopy or ultrasonography) over and above history when predicting endometrial hyperplasia or cancer. This analytic strategy needs to be applied in larger datasets to draw clinical conclusions.

The female reproductive tract acts not only as a complex mediator of sperm function and selection but animal data suggests that it alters protein expression after exposure to sperm, implying two-way communication. We have used single-cell fluorescence imaging to observe [Ca2+]i signalling in human female reproductive tract cells upon initial contact with sperm and in sperm during binding and release events. Parallel experiments were also performed on a model human oviductal cell line, OE E6/E7 and a control, human foreskin fibroblasts. Upon exposure to sperm, tract cells generated [Ca2+]i signals through mobilisation of thapsigargin-sensitive intracellular Ca2+ stores. The percentage of significant [Ca2+]i responses varied in different anatomical regions of the female tract. Furthermore, [Ca2+]i signalling was observed upon exposure to sperm-conditioned media suggesting signalling factors may be shed or secreted by sperm. Human foreskin fibroblasts were unresponsive to sperm. Co-culture of sperm with tract explants induced post-translational modification of sperm proteins through NO-dependant S-nitrosylation. We have also provided initial evidence for [Ca2+]i alterations in sperm during binding to and detachment from oviductal explants. We conclude that sperm can elicit [Ca2+]i signals in female tract cells upon initial contact though mobilisation of intracellular Ca2+ stores. This may reflect events upstream of reported gene and protein expression changes. In addition, human sperm interaction with oviductal epithelium is likely to be important in modulating sperm function during migration and associated events through the female reproductive tract.

Previous studies have associated intracellular calcium ([Ca2+]i) oscillations in vascular smooth muscle cells (SMC) with vasomotion in multiple species. In normal and pre-eclamptic pregnancies, there is strong evidence to suggest that the intrauterine environment is hypoxic. The aim of this study was to investigate whether ATP and [Ca2+]i oscillations play a role in modulating vasomotion during hypoxia in human umbilical blood vessels. The results obtained from in vitro studies using firefly luciferase assay and quinacrine staining indicated that human umbilical artery and vein endothelial cell (HUAEC, HUVEC respectively) constitutively released ATP and, in HUVEC at least, the release was accentuated by hypoxia (7.6 mmHg O2, 30 min). This release is dependent on the PI3K/ROCK pathway, and on normal vesicular transport. Further, application of ATP to human umbilical artery SMC induced dose-dependent [Ca2+]i oscillations, which was mediated by P2Y4 receptor. Moreover, ex vivo data from freshly isolated umbilical artery rings showed that acute hypoxia increased the frequency of vasomotion. It is therefore proposed that the findings of the present study is important in the understanding of the behaviour of human umbilical vessels in normal pregnancy, but may also have implications in the pathophysiology of complicated pregnancy such as pre-eclampsia.

Advances in technology have led to the miniaturisation of hysteroscopes without compromising optical performance. This development has facilitated the routine use of diagnostic hysteroscopy in an outpatient setting without the need for general anaesthesia. Further developments have expanded hysteroscopy from a simply diagnostic intervention to an operative one with a plethora of hysteroscopic surgical procedures. The work in this thesis has adopted a mixed methodological approach to rigorously evaluate patient selection, feasibility and efficacy of office hysteroscopy. Based on the results of this thesis we recommend: 1) Women with recurrent PMB should be investigated with either hysteroscopy or saline infusion sonography. 2) Vaginoscopy should probably be used in preference to other techniques to introduce the hysteroscope into the uterine cavity. 3) Women who have a uterine cavity >9cm or dysmenorrhoea should be warned they are more likely to require further intervention after endometrial ablation. 4) There appears to be no difference between the effectiveness of bipolar radiofrequency ablation and thermal balloon ablation at five years of follow up. 5) Women who present with abnormal uterine bleeding and an endometrial polyp should have it removed. 6) The hysteroscopic morcellator should be used in preference to bipolar resection for endometrial polyp removal.

Background:   Porphyrias are inherited disorders with impaired heme biosynthesis. Acute intermittent porphyria (AIP) is the most common porphyria in Sweden. AIP attacks may be life-threatening. Female sex hormones are regarded as important precipitating factors. Hepatocellular carcinoma (HCC) is a severe complication in the older AIP population. The aim of the thesis was to describe the clinical expression of AIP in women, experience of hormonal contraception and hormonal replacement therapies (HRT) and of pregnancies. Secondly, we evaluated gonadotropin-releasing hormone (GnRH) agonist treatment for prevention of menstrual-cycle-related AIP attacks. Thirdly, we evaluated whether an altered sex-steroid metabolism was present in AIP women compared with controls. Finally, we evaluated the benefit of screening for HCC in AIP in a 15-year follow-up study. Methods and results: In a retrospective population-based study in northern Sweden, 166 female AIP gene carriers ≥18 years of age participated. Manifest AIP (MAIP) was reported in 55%; 82% had severe attacks and 39% had menstrual-cycle-related attacks. Hormonal contraceptives were used by 94, and 12 reported that this precipitated AIP attacks. HRT and local vaginal treatments in menopause did not precipitate AIP attacks. Only 10% reported impairment of AIP symptoms during pregnancy. In the retrospective follow-up study of GnRH-agonist treatment, 11 of 14 women improved during treatment. Porphyria attacks were triggered in two women after estradiol add-back and in 5 of 9 women after progesterone add-back. In the sex-steroid metabolism study, levels of s-progesterone, estradiol, allopregnanolone and pregnanolone during the menstrual cycle in 32 AIP gene carriers were compared with 20 healthy controls. Progesterone metabolism in the AIP group differed from controls. In the AIP group levels of allopregnanolone, but not pregnanolone, were significantly lower. In the prospective HCC screening study AIP gene carriers aged &gt;55 years were included. On average 62 subjects participated during 15 years. HCC was diagnosed in 22 of 180 eligible AIP gene carriers in the region (male:female, 12:10, 73% MAIP). The annual incidence of HCC was 0.8%. The risk of HCC was 64-fold higher than in the general population over 50 years of age in this region, and even higher for AIP women (93-fold). Increased 3- and 5-year survival was seen in the regularly screened AIP group. Liver lab tests were not useful in HCC screening. Conclusion: The clinical expression of AIP in women is pronounced and menstrual-cycle-related attacks are common. Hormonal contraceptives can induce AIP attacks and caution is recommended. GnRH-agonist treatment can ameliorate menstrual-cycle-related attacks of porphyria. Dose findings for GnRH-agonists and add-back regimes, especially for progesterone, are intricate. Progesterone metabolism in the AIP group differs from that in healthy controls. HCC screening in AIP gene carriers &gt;50 years of age enables early diagnosis and a possibility for curative treatments. Annual HCC screening with liver imaging is recommended in AIP gene carriers &gt;50 years of age.