Stress incontinence (SI) is more common in white women (61%) than in black African women (27%). Previous studies have demonstrated that collagen XVII is increased and the collagen I:III ratio is decreased in continent black women compared to white suggesting better adhesiveness and elasticity in the tissue of black women. We decided to examine this concept further and analyse the elastin content in paraurethral vaginal tissue of black and white women with or without stress incontinence. A further study was set up to examine if topical oestrogen could increase elastin and change associated components of white women with pelvic organ prolapse (POP). Oestrogen treatment has been shown to increase pro-mmp2 and new collagen formation in SI women, therefore it seemed possible that such treatment could affect the collagen and elastin components of POP favourably. The clinical symptoms of POP and surgical outcome may also be improved. The first study examined the elastin content by histochemistry in paraurethral vaginal tissue while the second study assessed how locally applied oestrogen (Vagifem) given over three months influenced the mRNA expression of MMP2, elastin and collagen XVII and also elastin, collagen I and collagen III protein content of vaginal skin from women with POP. In the racial comparison study black controls showed a highly significant increase in elastin content compared with white controls (p<0.01). For SI to occur in black women a severe insult that reduces elastin production appears to be necessary as black women with SI showed significantly lower elastin content compared with black controls (p<0.05). After application of topical oestrogen to white women with POP it was shown that mRNA for MMP2 is up-regulated (p<0.01) while that for ER alpha receptor is not (p=NS). The message for collagen XVII was down-regulated (p<0.01) while collagen I and III protein were increased significantly (p<0.001 in both cases). The mRNA for elastin was significantly increased (p<0.05) after treatment but the increase in elastin protein staining did not quite reach significance. In conclusion, black women have higher elastin content in vaginal tissue compared to white and this may contribute to the lower incidence of SI in black women. Topical oestrogen over a short period has remodelling effects on key factors of the extracellular matrix of vaginal tissue. Although significant rises in elastin mRNA were shown but not protein, this treatment over longer term application could enhance some of the changes seen. This research provides evidence that black women have beneficial characteristics of vaginal skin that could resist SI and POP. Oestrogen treatment with refinements for white women could mimic black characteristics and alleviate POP symptoms.

No description available.

Coordination of uterine contractions during labour is critical for successful delivery. The mechanisms underlying this coordination are not fully understood. Propagation of contraction signals has previously been observed to occur through transmission of electrical excitation waves. This thesis aims to examine the histological microarchitecture of the muscular layer of the uterus (myometrium) and determine how this structure affects the propagation of excitation by means of in silico three-dimensional reconstruction of the myometrium and numerical simulations of a spatially structured excitation-relaxation model. A key aim of the in silico reconstruction of the smooth muscle architecture of the myometrium is to identify structural features that correspond to the control of excitation behaviour in the myometrium. This examination is aided by analysis of excitation patterns observed in multi-electrode array recordings. The reconstruction is subsequently used as a basis for simulating electrical activity in the myometrium. Novel structural features are identified here that are located at the initiation points of electrical activity and are proposed to be the pacemaker sites in rat myometrium. Furthermore, boundary of low connectivity across the mesometrial border was observed in the rat, which corresponds to the termination of excitation waves observed in multielectrode array recordings. In addition, bridges of smooth muscle cells connecting the inner and outer layers of the myometrium were observed in both rat and human myometrium. Taken together these three features suggest a novel mechanism for control of contraction in the rat myometrium; an analogous mechanism is proposed for the human myometrium. The results presented in this thesis could provide an explanation for the patterns of excitation propagation observed in human and rat uteri. Further refinements of the methods used here are outlined and expected to generate a more detailed visualisation of the structures underpinning these mechanisms.

<p> A nutritional method commonly used to deliver feedings to premature infants is the use of a gavage tube. To measure for any undigested breastmilk or formula, a gastric aspirate is checked prior to the next feeding. There is a gap in practice as to what to do if these aspirates signify feeding intolerance. The project question centered on identifying evidence-based guidelines in the literature that would help to define best practices related to feeding intolerance of gavage-fed infants. The Johns Hopkins Nursing Evidence-Based Practice model and the Appraisal of Guidelines Research and Evaluation provided the frameworks for gathering and evaluating evidence as well as the process used in forming the practice guideline. The primary methods employed were a team approach that included a Neonatal Intensive Care Unit (NICU) Project Team and NICU expert opinion along with a literature review conducted by the doctor of nursing practice student. The NICU Project Team collected the NICU experts&rsquo; input via surveys they developed and distributed as well as e-mails to authors identified from the literature review. The surveys yielded a 76% response rate from the registered nurses and a 59% response rate from the medical providers. All data collected were shared and descriptive statistics were used to evaluate the data. One of the central research findings was that gastric aspirates should no longer be routinely obtained on stable infants and, if used in evaluating feeding intolerance, they must be used in combination with other indicators. An enteral feeding guideline was developed to reflect this finding that can be shared with other NICUs and nurseries in the United States and globally to decrease the morbidity and mortality of neonates.</p><p>

Pre-eclampsia affects about 5% of all pregnant women and is one of the most important pregnancy complications world-wide. Life threatening complications require an immediate medical management of pre-eclampsia. However, as the origin of this disease is still unexplained, diagnosis, treatment and management still pose a challenge. The aim of this thesis was to investigate the involvement of small metabolites and oxylipins in pre-eclampsia and the regulation of the vascular tone. A metabolomics analysis of maternal blood plasma enabled identification of a range of biomarkers. These were putatively identified as 12,13-epoxy-9-oxoODE, methionine sulfoxide, guanidoacetic acid, uric acid, p-cresol sulfate, hydroxyhexacosanoic acid as well as the bile acid isomers taurodeoxycholic acid, tauroursodeoxycholic acid and taurochenodeoxycholic acid. A targeted LC-MS/MS method was used to determine oxylipin levels in maternal plasma, fetal plasma, chorionic plate arteries and stem villi from healthy and preeclamptic subjects. Significantly differing oxylipin levels were found in maternal plasma, fetal plasma and chorionic plate arteries. Arachidonic acid, 5,6-DHET, 8-HETE, 11-HETE, 15-HETE, 9-oxoODE, 13-oxoODE were decreased and 13-HODE was increased in maternal blood plasma in late onset pre-eclampsia. In early onset pre-eclampsia 5-HETE was significantly increased in maternal plasma. In cord blood plasma, 9-oxoODE, 13-oxoODE, 9-HODE and 13-HODE levels significantly increased in late onset pre-eclampsia. In chorionic plate arteries, arachidonic acid, 14,15-DHET, 5-HETE and 15-HETE were increased in late onset pre-eclampsia. Gene expression studies were conducted to determine levels of CYP2J2, EPHX1, EPHX2, PPARA and PPARG in chorionic plate arteries. All genes were detected on RNA level in this tissue region and were stably expressed across healthy and preeclamptic subjects. Vascular effects of CYP P450 derived oxylipins were assessed in chorionic plate arteries and stem villous arteries. No effects were observed for the four EET (epoxyeicosatrienoic acid) isomers , four DHET (dihydroxyeicosatrienoic acids) isomers or 5-, 15- and 20-HETE (hydroxyeicosatetraenoic acids), except for a weak dilating effect of 8,9-DHET on stem villous arteries. In addition to this, PPAR-alpha agonist Wy14643 and PPAR-gamma agonist ciglitazone were examined for effects in the placental vasculature. Potent dilating effects were demonstrated for both compounds in chorionic plate arteries and stem villous arteries. In conclusion, this thesis demonstrated that pre-eclampsia is characterised by complex changes in levels of small metabolites and oxylipins. The identified biomarkers provide new insights into ongoing pathophysiological processes in the pre-eclamptic syndrome. The physiological significance of changed oxylipin levels needs still to be determined. However, as oxylipins are known ligands of PPAR receptors, which were demonstrated to be expressed in the placenta, the PPAR signalling pathway is a promising target for future studies in pre-eclampsia.

Background: Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance that occurs or is first recognised during pregnancy. The prevalence of GDM is 1-28% globally and 11% in China. Although GDM can cause severe maternal and neonatal outcomes, there is no consensus worldwide as to whether universal or selective screening of expectant mothers should be recommended. In 2010, The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommended that all pregnant women should be screened via a one-step universal screening approach for GDM, using a 75g oral glucose tolerance test (OGTT) with reduced thresholds. Despite ongoing debate over the efficacy and use of the IADPSG approach, China was the first country to adopt the new screening approach. A number of observational studies have shown that the new IADSPG approach is clinically more effective. However, reservations exist as to the associated increase in health costs and inconvenience to pregnant women. Aim: To assess and explore the best screening approach for GDM both globally and in China. Methods: The research involved three projects. Project I (Chapter 3) was a systematic review of the effectiveness and cost-effectiveness of universal versus selective screening for GDM, which followed a standard systematic review procedure for Diagnostic Test Accuracy studies. Project II (Chapter 4) was a Q methodology study to investigate the pregnant women’s attitudes towards and experience of the IADPSG one-step screening approach for GDM in China. A total of 30 pregnant women who visited the hospital for antenatal care in 2014 were recruited to participate in the study. The Q methodology study was undertaken using the FlashQ software and were analysed using the PQMethod software. Project III (Chapter 5) was a case-control study to establish and assess a risk score algorithm in order to improve the IADPSG approach for GDM screening in China. Medical records of 550 pregnant women (272 GDM cases and 278 controls) who had given birth in the year 2013 at the Chengdu First People’s Hospital were retrospectively collected and analysed. Univariable analysis and multiple logistic regression analysis were used to identify GDM risk factors and to formulate the risk score algorithm. A Receiver Operating Characteristic (ROC) curve was employed to assess the effectiveness of the risk score algorithm for GDM screening. Results: The systematic review (Chapter 3) included 28 effectiveness studies, four cost studies and one cost-effectiveness study. Seven out of the 28 effectiveness studies and the cost-effectiveness study favoured selective screening. The Q methodology study (Chapter 4) suggested that the participants agreed as to the importance and necessity of the IADPSG one-step GDM screening for all pregnant women. However, the non-GDM women felt somewhat burdened in undertaking the fasting and 2-hour oral Glucose Tolerance Test (OGTT) for GDM under the IADPSG approach. The participants also desired more information on GDM and OGTT both before and after the test. The case-control study (Chapter 5) identified age, height, body mass index (BMI), family history of diabetes, waist circumference, previous deliveries and blood pressure before 24th week of gestation to be risk factors for GDM in the Chinese population. Subsequently, a risk score algorithm was established, whereby the use of the risk score to select high-risk women for screening could help to exclude nearly half (45%) of non-GDM women from the OGTT while still diagnosing 80% of the GDM cases. Conclusion: Universal screening for GDM is recommended for areas where GDM prevalence is relatively high and where economic constraints circumscribing implementation of the approach do not exist. For areas where GDM prevalence is low, it is recommended that current practice, whether it is universal or selective screening, should be retained until more robust evidence emerges. The IADPSG one-step universal screening was viewed positively in terms of importance and necessity by participants of the study, and they felt that GDM screening is necessary to be undergone by every pregnant woman. At the same time, the non-GDM women also felt strongly that the two-hour OGTT requiring 3 blood samples over the test period was inconvenient and burdensome. Alternatively, the use of a risk score-based selective IADPSG approach was observed to be conducive to the exemption of nearly half (45%) of non-GDM women from the OGTT test while still diagnosing 80% of the GDM cases in China. A future validation cohort from other parts of China is required to affirm the effectiveness of this risk scoring algorithm.

Gestational diabetes mellitus (GDM), defined as glucose intolerance first identified during pregnancy, is an escalating problem worldwide which affects 5-20% of all pregnant women. It is associated with long-term consequences such as obesity, metabolic syndrome and type 2 diabetes in both the mother and affected offspring, the latter mediated in part by birthweight (“diabetes begets diabetes”). However, selective screening strategies based on established risk factors for GDM, accurately identify only around 60% of cases suggesting that there are other mechanisms involved. The aim of my thesis was to investigate the role of 2 novel biomarkers, vitamin B12 (B12) and glucagon-like peptide (GLP-1) in the development of GDM and related metabolic outcomes. A systematic review and meta-analysis showed that B12 insufficiency in pregnancy was in the order of 20-30% across the world and was associated with marginally higher, but significant, odds of low birthweight babies but these findings may be isolated to high-risk countries. In a local UK population, B12 insufficiency was independently associated with obesity, 2.6-fold higher risk of GDM and fetal macrosomia. A nationwide survey of women of child-bearing age confirmed that 12% were B12 insufficient with associated hyperhomocysteinaemia, despite apparently adequate dietary intakes of B12. This warrants urgent review of the recommended nutrient intake guidelines to optimise B12 status prior to conception. In the second part of my thesis, it was shown that overall GLP-1 response during a diagnostic glucose tolerance test is reduced in GDM women compared to controls, with a decrease in the early phase particularly predictive of post-prandial glucose levels. This potentially provides a novel mechanism to explain the delayed first phase insulin response which has been noted in GDM and T2D. Finally, to better understand how GLP-1 may exert a protective effect on the vascular complications of hyperglycaemia, a basic science project was carried out which demonstrated that liraglutide, a GLP-1 receptor agonist, enhanced the AMPK and phospho-AKT signaling pathways thereby contributing to the reduction of oxidative cell damage. In summary, this thesis supports the hypothesis there are multiple mechanisms which give rise to GDM (e.g. predominant insulin resistance or insulin secretion or combination of factors) and biomarkers such as B12 and GLP-1 can be clinically useful in identification of high-risk women. If proven in larger prospective studies, with measurements of the biomarkers from early pregnancy, these markers may be used to risk-stratify these women with the ultimate goal of reducing the transgenerational perpetuation of diabetes.

Pre-eclampsia is an important and serious condition affecting 2-8% of pregnancies worldwide and carries with it significant associated risk of morbidity and mortality for both mother and child. It is characterised by new onset hypertension after the 20th week of gestation with accompanying proteinuria. Resolution of symptoms should occur following delivery. Several pathophysiological mechanisms are common to both pre-eclampsia and cardiovascular disease, and the link between pre-eclampsia and cardiovascular disease later in life has been established. While the underlying pathophysiological mechanisms of pre-eclampsia are complex, endothelial dysfunction is a key component. Increased arterial stiffness and hypertension have also been documented. Endothelial dysfunction has been shown to extend beyond childbirth, into the postpartum period. Studies evaluating endothelial dysfunction at even longer time-points following an affected pregnancy have produced conflicting results. Results from biomarker studies have supported the concept of endothelial dysfunction throughout pregnancy and the postpartum period, but as more time elapses between index pregnancy and biomarker sampling, these results also vary. Cardiac imaging and electrocardiographic studies have also contributed to knowledge about the normal physiology of pregnancy and changes which are associated with hypertensive disorders of pregnancy during pregnancy, the postpartum period and beyond. The main focus of this thesis was to investigate the possible mechanisms behind the link between pre-eclampsia and future cardiovascular disease. The aim was to investigate women who were free from cardiovascular disease for any evidence of subclinical vascular damage long-term following a pre-eclamptic pregnancy. Overall women recruited to this study would be older than women who participated in the majority of previously published studies on this theme. Before embarking on the investigation of subclinical vascular damage in women with a history of pre-eclampsia, a link was confirmed between a history of pre-eclampsia and cardiovascular disease up to 30 years from time of index pregnancy. This was accomplished using record-linkage in a large Scottish cohort; the Generation Scotland Family Health Study (GS:SFHS). Following on from this, ECGs available in women with and without a remote history of pre-eclampsia in the GS:SFHS cohort were assessed for any obvious differences. There was a more leftward shift in the QRS-axis in these women and a trend towards a longer corrected QT interval (QTc) which approached statistical significance, but after adjusting for other co-variates, pre-eclampsia did not independently predict QTc. Investigations for subclinical vascular damage were carried out by means of non-invasive vascular function studies in women recruited from three different cohorts (blood pressure clinics, GS:SFHS and the previous Proteomics in Pre-eclampsia (PIP) study of women during pregnancy). Time since index pregnancy varied between 1-30 years. Flow-mediated dilatation (FMD) was performed to assess for endothelial dysfunction, pulse wave analysis (PWA) and pulse wave velocity (PWV) assessed arterial stiffness, and carotid ultrasound was performed to establish whether there was any evidence of atherosclerosis. After adjusting for other co-variates, I was able to demonstrate the presence of endothelial dysfunction many years after pregnancy in women with a history of pre-eclampsia in comparison with those who experienced a normotensive pregnancy. There was also a significantly higher presence of carotid plaque in women with a history of pre-eclampsia. To investigate whether the findings from the vascular study translated to findings in biomarker studies of women with a history of pre-eclampsia in comparison with controls, samples from the vascular studies cohort and from the wider GS:SFHS cohort were used. Markers of inflammation, angiogenesis, cardiac damage and collagen turnover were studied. A significantly higher vascular endothelial growth factor (VEGF) was detected in women with a history of pre-eclampsia. Pre-eclampsia is associated with an increased risk of cardiovascular disease, and endothelial dysfunction is evident later on in life. Larger studies are required to further investigate the vascular and biomarker results, and studies including more thorough cardiac assessment (such as echocardiography) in this population should also be considered. The studies described found no evidence of one single component to explain the relationship between pre-eclampsia and cardiovascular disease later in life. This is not unexpected as pre-eclampsia is a complex condition with multiple contributing factors and it is likely that the increased cardiovascular risk later in life is likewise multifactorial in origin.

Background Preterm labour and post-partum haemorrhage are leading causes of pregnancy morbidity and mortality. Previous work identified potassium channels expressed in myometrium and hypothesized modulation of channels with greater expression in MSMC than VSMC will influence contractility and avoid cardiovascular effects. By combining calcium channel blockers with potassium channel openers an enhanced tocolytic effect is anticipated. VU590 inhibits Kir 7.1 and it was hypothesised would elicit a contractile effect with therapeutic potential for post-partum haemorrhage. Aim To determine the effect of select potassium channel openers and a specific potassium channel blocker in myometrial contractility. Methods Human and murine myometrial strips were used in contractility organ bath experiments. Select combined doses were tested in myometrial small arteries using wire myography. Western blotting was carried out to determine the gestational and labour-state expression of potassium channels in human myometrium and myometrial small arteries. Results Pinacidil demonstrated a relaxatory effect on both myometrial and vascular smooth muscle. Riluzole reduced contractility alone and greater inhibition in combination with nifedipine than nifedipine alone. Riluzole appeared to have a mild effect on myometrial arteries. Kir 7.1 showed a trend of diminished expression by gestation and was downregulated in term and preterm labour states. VU590 elicited a significant increase contractility characterised by a prolonged contraction phase of up to 6.7±1.9 hrs (VU590 10 µM). A gestational-dependent effect was seen on murine myometrium. Conclusion The combination of nifedipine with potassium channel openers has a more potent effect on reducing contractility than either compound alone. Riluzole combined with nifedipine warrants further investigation for potential tocolytic therapy. VU590 augments spontaneous contractions profoundly in human myometrium in vitro and could have potential therapeutic benefits in the treatment of postpartum haemorrhage.

Optimizing maternal health and improving reproductive outcomes are widely acknowledged as major challenges in the health care system. Care during the antenatal period has been the focus of improving maternal health and reproductive outcomes. Yet, evidences have shown that antenatal care alone is not enough. Initiating care before conception or preconception care could be potentially effective to further improve maternal health and reproductive outcomes. Preconception care encompasses a range of health promotion, risk assessment, preventative and curative interventions for women of reproductive age to reduce risks that potentially affect reproductive outcomes. It aims to provide prospective parents information and support with regards to preconception interventions that are beneficial for the parents and future children. Primary care providers are often being urged to provide preconception care as part of primary care services. In support of preconception interventions, there has been increasing evidences for such interventions. However, existing reviews or studies of preconception interventions have been limited by being risk specific, for example; focussing on folate supplementation or women with diabetes. Adding to this, interventions were reported mainly carried out in the secondary care settings. There is still paucity of evidence that comprehensively evaluate the impact of providing preconception care as a systematic approach involving multifactorial risk factors and, in particular, in primary care. Preconception care involved a range of risk assessment; assessment of genetic risk is no exception. The aim of preconception care for genetic risks is to allow women or prospective parents the opportunity to have informed reproductive decisions of future pregnancies. However, experience of offering preconception care in addressing genetic risks is yet less explored. This thesis specifically sought to evaluate the potential impact of preconception care involving assessment of reproductive genetic risk. Further, this thesis also aims to provide evidence for effectiveness of preconception interventions on multifactorial risk factors in the primary care settings. As primary care providers especially GPs are increasingly being recognised to provide such care, it was thus important to explore their views. For this, this thesis aimed to explore the opinions and attitudes of GPs in the United Kingdom towards providing preconception care that involved assessment of reproductive genetic risk in current general practice. This study took place within the Primary Care Trusts of Nottinghamshire and Derbyshire. The findings from this thesis are expected to help inform a strategy for the implementation of preconception assessment of reproductive genetic risk in the general practice in the United Kingdom. The aim of this thesis was achieved by carrying out three components of work. These components of work involve three domains that could assist in the implementation; the interventions; the settings; and exploring attitudes and opinions. 1. The first component involved carrying out a systematic review of literatures on the effectiveness of preconception care interventions in the primary care settings. 2. The second component involved carrying out a systematic review of literatures on the effectiveness of preconception assessment of reproductive genetic risk. 3. The third component involved a postal questionnaire survey of GPs practicing in the Nottinghamshire, Nottingham City, Derbyshire and Derby City Primary Care Trusts, exploring their attitudes and opinions. A new questionnaire was developed as the study instrument for this study. The first component of work has synthesized the evidence of the effectiveness of preconception interventions in the areas of maternal knowledge of pregnancy-related risks; self-efficacy and health locus of control; risk behaviour modification (for example, folate and alcohol consumption); adverse pregnancy outcomes (for example, congenital anomalies and preterm birth); and psychological consequences. The review has identified that both risk specific interventions or interventions involved multifactorial risks, both demonstrated significant improvement in maternal knowledge, self-efficacy and health locus of control. There was positive evidence for risk specific interventions in the areas involving risk behaviour modification. However, the effects for adverse pregnancy outcomes and psychological outcomes remained unclear. The second component of work sought to find evidence the effects of preconception assessment of reproductive genetic risk. The scope of literature search included family history and ancestry assessment, pre-carrier test education or consultation and carrier testing or screening. It was not possible to draw clear conclusion regarding its effectiveness as only two studies involving assessment of cystic fibrosis and haemoglobinopathies were identified. Nevertheless, the studies have provided information on potential benefits of preconception assessment of reproductive genetic risks on reproductive decisions, knowledge and understanding of carrier risk as well as psychological benefits. The third component of work involved self-administered postal questionnaire survey. The impact of this survey is restricted due to low response rates. Nevertheless, the results of this survey indicated that a substantial proportion of GPs were already offering or providing preconception assessment on reproductive genetic risk opportunistically, in particular, with women planning pregnancy and women with known family history of genetic conditions. Even if they are not offering of providing preconception assessment on reproductive genetic risk at present, majority of them indicated that they are prepared to offer and provide the service, especially when consulting women planning a pregnancy or women at-risk. Their primary concern was how to reach these women as not many would come to consult GPs for preconception advice. This study has demonstrated that family planning clinic was the most preferred primary care setting to offer preconception assessment on reproductive genetic risk. In the United Kingdom, family planning clinics serve a large proportion of women of reproductive age group, thus, this setting may provide opportunities to introduce preconception care and reproductive risk assessment including genetics. While there is paucity of evidence from the systematic reviews in my thesis that could impact on the direction or implementation of offering preconception care addressing genetic risks, many factors other than scientific evidence can influence the implementation process. Observational studies have demonstrated potential benefits of preconception care specifically preconception assessment of genetic risk interventions such as early antenatal diagnosis to informed reproductive decisions. Broad interests from the international organization such as in the United States and Netherlands have a role in the implementation. Similarly, interest from the stakeholders in particular individuals of reproductive age groups and the primary care providers also may influence the development of the interventions. In this context, the GPs that participated in the survey have provided important information on opportunities and barriers, and potential ways to facilitate its development. Nevertheless, analysis of the data has identified some areas that were not fully addressed in this thesis and this is discussed in the final chapter.