Maternal obesity is associated with adverse effects for mothers and offspring. The primary aim of this thesis was to assess food intake and physical activity (PA) using validated self-administered questionnaires, and whether these were associated with gestational weight gain (GWG) and birthweight (BWT), in severely obese (body mass index, BMI≥40kg/m2) compared with lean pregnant women (BMI 20-25kg/m2). The secondary aims were to validate self-reports against food diary (FD) and accelerometry; to assess the prevalence of under or over-reporting of energy intake; and to carry out a pilot study to assess total energy expenditure, as well as self-reporting accuracy, by using doubly-labelled water (DLW) technique, in subgroups of participants. Pregnant women were recruited from an ongoing study of severe obesity in pregnancy at the Royal Infirmary of Edinburgh, UK. Assessments were done in early (12-20 weeks) and late (28-32 weeks) pregnancy. A subgroup of women also completed questionnaires on appetite, general nutrition knowledge, and eating behaviours. All results were adjusted for age, parity, ethnic origin and deprivation category score. Self-reported total energy intake was not significantly different between obese and lean during early (median 2,444 vs 2,312 kcal/day) and late (2,173 vs 2,354 kcal/day) pregnancy. However when validated with FD, the relative validity of the food frequency questionnaire was lower in obese compared to lean. Under-reporting of total energy intake was higher in obese compared to lean (49% vs 15%, P<0.01) through comparison of selfreported energy intake with estimated total energy expenditure, and this was supported by the DLW pilot study results. The DLW also showed possible over-reporting of PA by the obese group. Obese women reported significantly lower appetite than lean throughout pregnancy (P<0.01). They also had lower scores in general nutrition knowledge, but these were no longer significant after controlling for confounders. Obese women had significantly higher scores of restrained and emotional eating behaviours than, and similar scores of external eating behaviours to, lean. Appetite, nutrition knowledge, restraint and emotional eating behaviours scores were not associated with food intake in either obese or lean. On the other hand, increased intakes of total calories and fats were influenced by increasing score of external eating behaviour in both groups. Obese women reported doing similar amounts of total PA but significantly less of vigorous and sports and exercise activities than lean (P<0.05). Accelerometry showed obese women had lower average activity counts/day, although they did have significantly greater energy expenditure in light-intensity activity than lean (P<0.01). Obese women had less GWG than lean (Mean ± SD, 5.3± 52 vs 10.8±3.7kg, P<0.001). Increased GWG was associated with increased self-reported total energy intake in lean, but this was not seen in obese. GWG was not associated with PA in either group. BWT was not significantly different between obese and lean (3,547±549g vs 3,567±516g). In lean, increased BWT was associated with increased energy intake and total PA. BWT in obese was not associated with diet but with increased with PA in early pregnancy. In conclusion, self-reported methods were less reliable in assessment of diet and PA in severely obese compared to lean pregnant women. These exploratory studies found that obese women did not appear to have the same factors as lean women affecting GWG and BWT, though this may be complicated by the poor reliability of self-reports. Therefore, quantitative assessments such as measurement of serum micronutrient levels (to evaluate nutritional status), and accelerometry (to assess physical activity) may be necessary in this poorly understood population.

Alloresponses to blood group antigens result from antigen mismatch between donor and recipient during blood transfusion or transplantation and between mother and fetus during pregnancy. During pregnancy, antigen mismatch can result in haemolytic disease of the newborn (HDN), a disease characterised by the development of potentially harmful alloantibodies, which cross the placenta and mediate the destruction of fetal erythrocytes. This project investigates examples of clinically important alloresponses to blood group antigens and, more specifically, characterises the ymphocytes that either drive or regulate these responses. The main aims or this project were to first map alioreactive T-helper cell epitopes and secondly to clone using a novel method, IL-10 secreting blood group specific regulatory cells. The work focussed on two major antigens, the kell (K) 1 and Rhesus (Rh) D antigens.

Women face a number of physical, emotional and psychological challenges following an HIV positive diagnosis during pregnancy. Psychological challenges, such as maternal anxiety and low mood, have been associated with disruptions to mother-infant bonding in the general population. Despite significant numbers of women receiving an antenatal HIV diagnosis in the UK each year, there remains a limited understanding about the experiences of this group in bonding with their babies. This Grounded Theory study aimed to explore the experience of mothers in bonding with their baby following an HIV diagnosis during pregnancy. The study explored the perceived challenges to mother-infant bonding, and the factors mothers felt helped them to manage this process following diagnosis. Ten mothers diagnosed antenatally at a London sexual health service were interviewed about their experiences. Data analysis led to a theoretical model of mother-infant bonding following a maternal HIV positive maternal diagnosis. The model comprised four theoretical codes: facing barriers to bonding; feeling disconnected from the baby; developing a special bond; and strengthening and moving on. These codes were comprised of challenges to mother-infant bonding, as well as factors relating to maternal strength and resilience. The model used a chronological structure, with processes plotted from the point of antenatal diagnosis through to following the infant HIV testing process after birth. Challenges with bonding were experienced primarily during the early stages after birth, with maternal resilience and positivity about the future developing towards the end of infant testing. Circular relationships, in which positive and negative processes fed into and influenced each other, were highlighted throughout. The findings highlight important areas for development in clinical practice, including more targeted psychological support for women following an antenatal diagnosis, and the provision of timely information regarding mother-to-child transmission. Clinical implications from this study are discussed alongside suggestions for future research.

Introduction: Adequate calcium and vitamin D are needed for maternal and fetal health. Many pregnant women are not consuming enough calcium and are at high risk for vitamin D deficiency. Objectives: To 1) investigate the nutrition-related knowledge, opinions, and clinical practices of family physicians (FPs) towards prenatal calcium and vitamin D; and 2) determine the prevalence of meeting a predefined cut-off serum 25-hydroxyvitamin D concentration ([25-OHD]) for vitamin D sufficiency (≥ 75 nmol/L) in a cohort of pregnant women with gestational diabetes mellitus (GDM). Methods: Part 1: 500 surveys were mailed out to randomly selected FPs across Manitoba. Part 2: data were collected via retrospective chart review of 35 pregnant women with GDM attending a teaching hospital in Winnipeg, Manitoba between January 1, 2010 and December 31, 2013 and having one serum [25-OHD] measurement during their pregnancy. Results: Approximately one-third of FPs are discussing calcium and vitamin D requirements and supplements with their prenatal patients. The top three perceived barriers to delivery of calcium and vitamin D advice were more urgent issues, lack of time, and forgetting to do so. The mean serum [25-OHD] was 52.5 ± 24.1 nmol/L (range 14-109 nmol/L). Over half of women (51.4%) were vitamin D deficient ([25-OHD] < 50 nmol/L), and 28.6% of women were insufficient ([25-OHD] 50-74 nmol/L). Conclusions: Physicians would benefit from more training in nutrition. Multiple barriers exist that prevent FPs from providing calcium and vitamin D advice. Women with GDM have a high prevalence of vitamin D deficiency in our study. / February 2016

Background Physiological and psychological changes appear during pregnancy, these affect the well-being of the pregnant woman. Physical activity and exercise has shown positive effects to improve and maintain health.  Aim To investigate the experience of women accomplished physical activity and physical exercise during pregnancy. Design and method The investigation has a descriptive qualitative design. Five women participated in semi-structured interviews. The data processing consisted of a qualitative content analysis with an inductive approach. Results The informants described positive experiences with physical activity and exercise during pregnancy. The participants felt more prepared for childbirth, improved self confidence and more energy. However, to maintain the level of physical activity, it was necessary to adjust the actual physical activity. The decrease in mobility, lead to an increase of mental stress. It was difficult to prioritize between exercise and work. The questioning attitude from family members and others made the woman feel insecure. Conclusion The informants described positive experiences from exercising during pregnancy and also its difficulties. This study can contribute to a better understanding for women who would like to stay active during pregnancy.

M.Cur

Aim: To explore how pregnant women experience fetal movements in late pregnancy. Specific aims were:  to study women’s experiences during the time prior to receiving news that their unborn baby had died in utero (I), to investigate women’s descriptions of fetal movements (II), investigate the association between the magnitude of fetal movements and level of prenatal attachment (III), and to study women’s experiences using two different self-assessment methods (IV). Methods: Interviews, questionnaires, and observations were used. Results: Premonition that something had happened to their unborn baby, based on a lack of fetal movements, was experienced by the participants. The overall theme “something is wrong” describes the women’s insight that the baby’s life was threatened (I). Fetal movements that were sorted into the domain “powerful movements” were perceived in late pregnancy by 96 % of the participants (II). Perceiving frequent fetal movements on at least three occasions per 24 hours was associated with higher scores of prenatal attachment in all the three subscales on PAI-R. The majority (55%) of the 456 participants reported average occasions of frequent fetal movements, 26% several occasions and 18% reported few occasions of frequent fetal movements, during the current gestational week.  (III). Only one of the 40 participants did not find at least one method for monitoring fetal movements suitable. Fifteen of the 39 participants reported a preference for the mindfetalness method and five for the count-to-ten method. The women described the observation of the movements as a safe and reassuring moment for communication with their unborn baby (IV). Conclusion:  In full-term and uncomplicated pregnancies, women usually perceive fetal movements as powerful. Furthermore, women in late pregnancy who reported frequent fetal movements on several occasions during a 24-hour period seem to have a high level of prenatal attachment. Women who used self-assessment methods for monitoring fetal movements felt calm and relaxed when observing the movements of their babies. They had a high compliance for both self-assessment methods. Women that had experienced a stillbirth in late pregnancy described that they had a premonition before they were told that their baby had died in utero.

This study revisits the effect of duration by residence in relation to smoking during pregnancy. It contributes to the literature by incorporating a health inequity perspective, and discusses whether immigrants tend to converge with Swedish women’s smoking. The study is based on Swedish Medical Birth Register and includes 1 1864 52 pregnancies between 1991 and 2012. Logistic regression was performed to attain crude and adjusted Odds Ratios and 95 % confidence intervals. Immigrants’ are divided by categorizing countries of origin depending on levels of Human Development (IHDI). Overall immigrant women show low levels of smoking during pregnancy when they arrive to Sweden, by duration of residence levels of smoking increase and converge with smoking patterns of Swedish women. I found that there are differences in smoking patterns depending on IHDI of the country. Immigrant women of higher categories of IHDI show higher levels of smoking although the increase of smoking is higher among immigrant women from categories of lower IHDI. However, immigrant women’s smoking during pregnancy is affected by duration of residence, and the increased smoking is associated with health inequalities related to their country of origins IHDI, and by socioeconomic inequalities in Sweden.

<p>Sexual conflict occurs when female and male fitness interests diverge. In a social system characterized by aggressive sexual coercion and the risk of infanticide, female chimpanzees (Pan troglodytes) respond to this conflict by exhibiting an exaggerated sexual swelling that advertises sexual receptivity while concealing the exact timing of ovulation. Sexual swellings impose significant costs, yet can persist into pregnancy. Records from long-term studies of eastern chimpanzees (P. t. schweinfurthii) in Gombe National Park, TZ, and Kibale National Park, UG, provide data on postconception swellings, while data on group composition and behaviors such as mating, grooming, and aggression are drawn from the Gombe database only. Throughout, I use linear mixed models to simultaneously test multiple effects while controlling for repeated measures of individuals. In Chapter 1, I tested whether variation in females’ vulnerability to infanticide and aggression predicted the amount of swelling during pregnancy. In Chapter 2, I examined female-male relationships across reproductive states to ask whether females can better gain benefits and avoid costs by affiliating promiscuously with all males, or by investing in relationships with preferred males. Finally, I analyzed metabolites of reproductive hormones using urine samples from pregnant females in both populations to build a hormonal profile of postconception swellings. Swellings during pregnancy increase female-male association, and are caused by the same basic hormonal mechanism as preconception swellings, though they occur in a very different hormonal milieu. Females at greater risk of infanticide and intrasexual aggression swell more during pregnancy. Females mate promiscuously before conception, but during pregnancy and lactation, preferentially groom with males that are likely to protect them from aggression and infanticide. Based on these and other findings, I conclude that postconception swellings in chimpanzees are an adaptive response to sexual conflict.</p> / Dissertation

Excessive release of syncytiotrophoblast vesicles (STBM) from the placenta into the maternal circulation may cause the inflammatory response, endothelial dysfunction and activation of the coagulation system characteristic of pre-eclampsia (PE). Consequently, other cell types including platelets, leukocytes, red blood cells (RBC) and endothelium may be activated to release cellular vesicles which exacerbate the disease. This thesis aimed to develop methodology for enumerating and phenotyping STBM and the other vesicle types to determine whether they could be used as biomarkers for PE. In vitro derived STBM and vesicles from the other cells of the vascular compartment were examined to select a suitable panel of antibodies to analyse these same vesicle types in plasma samples from non-pregnant (NonP), normal pregnant (NormP) and PE women. Our flow cytometer was shown to detect microvesicles ≥290nm, hence smaller nanovesicles and exosomes could not be detected by this method. Therefore, a novel technique for analysing both microvesicles and nanovesicles, Nanoparticle Tracking Analysis (NTA), was explored and was found to be able to detect vesicles as small as 70nm. The origins of the vesicles that change in pregnancy are not yet known. Flow cytometry and NTA were used in parallel to determine the size, number and phenotype of STBM and other cellular vesicles in NonP, NormP and PE women. Flow cytometry showed that majority of vesicles were derived from platelets, followed by RBC vesicles, leukocyte vesicles and STBM. NTA showed that the total number of vesicles in plasma was significantly elevated in NormP and late-onset PE women compared to NonP controls, and the vesicles were smaller in size. Similarly, flow cytometry showed differences in the composition of vesicles between pregnant and non-pregnant women, demonstrating that pregnancy affects vesicle release. However, no differences were found between NormP and PE women. This was probably due to the majority of samples studied being from late rather than early-onset PE. Thus, although this is the most comprehensive analysis of circulating vesicles in pregnancy to date, their use as biomarkers for PE remains an open question.