The first half of this thesis addressed the clinical question of whether the phenotype of peripheral immune cells is affected by the normal menstrual cycle and whether there are differences in women with recurrent unexplained miscarriage. In chapter 2, a mid-luteal type 1 shift was demonstrated in NK^dim and cytotoxic T cells in the menstrual cycle. In addition, women with recurrent miscarriage had increased numbers of type 1 (IL-18R+) cytotoxic lymphocytes and an increased number of NK^dim and NK^bright cells in the mid-luteal phase of the cycle. The shift to type 2 immunity seen in normal pregnancy has been previously identified from the second half of the first trimester. In chapter 3 this type 2 shift was seen in NK and T cells as early as 9 days post implantation. ST2L (the ligand for IL-33 and a marker of type 2 cells) was consistently up regulated at this very early stage post implantation in women who were pregnant. The second half of this thesis investigated IL-33 and ST2 in normal and pathological pregnancy. In chapter 4 it was shown that circulating IL-33 did not change over the course of pregnancy but that sST2 (the soluble decoy receptor) increased significantly in the 3rd trimester of normal pregnancy. Both IL-33 and ST2 were variably expressed by the pre-implantation human blastocyst, as well as by the 1st and 3rd trimester placenta. Finally, chapter 5 showed a potential role for ST2 in pre-eclampsia, an inflammatory disease of pregnancy. sST2 was significantly elevated in the third trimester in women who went on to develop pre-eclampsia even prior to the onset of disease. Using an in vitro model of placental perfusion, it was shown that sST2 can be secreted by the placenta, suggesting that sST2 may play a significant role in pregnancies complicated by this disease.

Objectives To examine the associations of Intimate partner violence (IPV) with stress-related sleep disturbance (measured using the Ford Insomnia Response to Stress Test [FIRST]) and poor sleep quality (measured using the Pittsburgh Sleep Quality Index [PSQI]) during early pregnancy. Methods This cross-sectional study included 634 pregnant Peruvian women. In-person interviews were conducted in early pregnancy to collect information regarding IPV history, and sleep traits. Adjusted odds ratios (aOR) and 95% confidence intervals (95%CIs) were calculated using logistic regression procedures. Results Lifetime IPV was associated with a 1.54-fold increased odds of stress-related sleep disturbance (95% CI: 1.08–2.17) and a 1.93-fold increased odds of poor sleep quality (95% CI: 1.33–2.81). Compared with women experiencing no IPV during lifetime, the aOR (95% CI) for stress-related sleep disturbance associated with each type of IPV were: physical abuse only 1.24 (95% CI: 0.84–1.83), sexual abuse only 3.44 (95%CI: 1.07–11.05), and physical and sexual abuse 2.51 (95% CI: 1.27–4.96). The corresponding aORs (95% CI) for poor sleep quality were: 1.72 (95% CI: 1.13–2.61), 2.82 (95% CI: 0.99–8.03), and 2.50 (95% CI: 1.30–4.81), respectively. Women reporting any IPV in the year prior to pregnancy had increased odds of stress-related sleep disturbance (aOR = 2.07; 95% CI: 1.17–3.67) and poor sleep quality (aOR = 2.27; 95% CI: 1.30–3.97) during pregnancy. Conclusion Lifetime and prevalent IPV exposures are associated with stress-related sleep disturbance and poor sleep quality during pregnancy. Our findings suggest that sleep disturbances may be important mechanisms that underlie the lasting adverse effects of IPV on maternal and perinatal health.

Eclampsia is a hypertensive disorder of pregnancy and a leading cause of maternal death. The primary explanation for eclampsia is that it represents a form of hypertensive encephalopathy (HTE) with neurological symptoms including headaches, nausea, vomiting, visual disturbances, and seizures. The etiology of HTE involves an acute increase in arterial blood pressure that exceeds the autoregulatory capacity of the brain leading to forced dilatation of cerebral vessels, decreased cerebrovascular resistance, hyperperfusion, blood-brain barrier (BBB) disruption, and vasogenic cerebral edema formation. Due to the central role of the cerebral circulation in mediating these symptoms, a better understanding of how pregnancy affects the cerebral circulation is important to the treatment and prevention of eclampsia. A central goal of this dissertation was to determine pregnancy’s effect on cerebral blood flow (CBF) autoregulation, edema formation, and BBB permeability during acute hypertension. Women with eclampsia often seize at lower blood pressures than HTE patients. We hypothesized that pregnancy may predispose the brain to eclampsia by lowering the pressure of autoregulatory breakthrough and enhancing cerebral edema formation. Using an in vivo model of HTE, we found that the pressure of autoregulatory breakthrough was not different between nonpregnant (NP) and late-pregnant (LP) rats; however, cerebral edema formation was significantly increased only in LP animals. Nitric oxide synthase inhibition significantly increased the upper limit of autoregulation in both NP and LP animals and attenuated cerebral edema formation in LP animals. BBB permeability during acute hypertension was not different between these groups. Magnesium sulfate (MgSO4) is widely used to treat eclampsia despite an unclear mechanism of action. A second goal of this dissertation was to determine the cerebrovascular effects of MgSO4 during pregnancy. Specifically, we investigated the effect of MgSO4 on in vitro resistance artery vasodilation and in vivo BBB permeability during acute hypertension. We hypothesized that dilation to MgSO4 would be greater in mesenteric than cerebral vessels. MgSO4 elicited concentration-dependent vasodilation in all arteries, as determined by measuring lumen diameter of isolated and pressurized arteries, however, mesenteric arteries were considerably more sensitive than cerebral arteries. In addition, there was no effect of pregnancy on MgSO4 sensitivity in mesenteric arteries, whereas pregnancy decreased sensitivity to MgSO4 in cerebral arteries. We further hypothesized that MgSO4 would decrease BBB disruption during acute hypertension, thereby protecting the brain in eclampsia. Using an in vivo model of HTE, we showed that MgSO4 treatment decreased BBB permeability during acute hypertension in LP rats, with the greatest effect observed in the posterior cerebrum. In conclusion, this dissertation determined CBF autoregulation and cerebral edema formation during pregnancy, and also the effect of MgSO4 on cerebral resistance artery vasodilation and BBB permeability during acute hypertension in LP rats. Although pregnancy did not influence autoregulatory breakthrough, cerebral edema formation was enhanced in LP animals and this may potentiate neurological symptoms in eclampsia. In addition, MgSO4-induced cerebral vasodilation is likely not a primary mechanism of eclampsia treatment, rather MgSO4 may limit edema formation by attenuating BBB permeability during hypertension.

Delay discounting is considered by many to be a risk factor for substance use disorders and other health-related behavior problems. While these health-related behavior problems are often treated with incentive-based interventions, little is known about whether delay discounting (DD) moderates response to that treatment approach. The present study examined how response to incentive-based smoking-cessation treatment varied as a function of baseline DD scores among pregnant women participating in randomized controlled clinical trials examining the efficacy of financial incentives. Women were assigned to a condition wherein they earned vouchers exchangeable for retail items contingent on abstinence from recent smoking or to a control condition wherein they received vouchers of comparable value but independent of smoking status. Individual differences in DD of hypothetical monetary rewards were measured at the study intake and follow-up assessments. We examined whether individual differences in baseline scores on that instrument predict antepartum and postpartum smoking status using logistic regression, and if sustaining abstinence caused changes in DD scores from intake to 24-weeks postpartum. We did not see any significant main effects of DD or interactions of DD with treatment on antepartum or postpartum smoking status. Treatment condition, baseline smoking rate (cigs/day), a history of quit attempts pre-pregnancy, and educational attainment were all associated with increased odds of abstaining from smoking at the late-pregnancy antepartum assessment, and treatment condition was the only significant predictor of abstaining from smoking at 24-weeks postpartum, three months after the treatment formally ended. We saw no discernible evidence that sustained abstinence from smoking was associated with post-treatment decreases in DD. Overall, we saw no evidence that being a steeper discounter is associated with a lack of success in quitting smoking in either treatment condition. Being assigned to the incentives condition was the only predictor of antepartum and postpartum abstinence. The observed associations of a lower baseline smoking rate, higher educational attainment, and a history of having attempted to quit smoking previously with increased odds of success in achieving antepartum smoking abstinence is consistent with results from previous reports on predictors of response to this treatment underscoring the reliability of these relationships.

Telemedicine offers an alternative referral strategy for fetal cardiology but is currently only used for ‘high-risk’ pregnancies. A case-study of a cost-consequences analysis comparing telemedicine to direct referral to a perinatal cardiologist is initially presented, which highlights that for high risk women for whom telemedicine was considered no cardiac anomalies were missed using either referral method. In the light of a review of the literature on the economics of telemedicine, three of the key methodological issues (of selection bias, of patient costs and using quality-adjusted life years (QALYs)) are explored to demonstrate how the case study analysis could be improved. Pregnant women were selected for referral based on their characteristics and risk factors; thus the cost and effects for the two groups may have been biased. Various methods identified in the literature are applied to the case study to reduce selection bias, but the analysis presented is unable to determine which method is best, given a number of limitations including the small sample size. The analysis is extended to include estimated total patient costs. However, when patient costs are added to the total costs of pregnancy, they did not substantially increase the overall cost. The results presented provide a guideline for future researchers and pregnant women of the likely costs during pregnancy. Given that the majority of missed cardiac anomalies were amongst low risk women, a decision analytical model is developed looking at the lifetime costs and QALYs of introducing telemedicine screening for pregnant women whose unborn babies are at a low risk of congenital heart disease. The analysis shows that offering telemedicine to all low risk women is the dominant strategy. The thesis demonstrates, within the constraints of existing data, that it would be cost-effective to provide telemedicine as part of an antenatal screening programme for all low risk women, and this would help prevent future ‘missed anomalies’.

Within the past twenty years, a great deal of research has addressed pregnancy and childbirth in the United States. Often, however, prior studies have focused on white middle-class women and have neglected the experiences of women of color and low-income women. Teen mothers have also been marginalized in past research. With few exceptions, the limited research that does exist on African American teen mothers is usually framed around the "teen pregnancy crisis" in the U.S; seldom are teens included in studies dealing with the overall issue of medicalization. In an effort to understand the extent to which the medical model of childbirth shapes teens' understandings and experiences of prenatal care, this paper analyzes in-depth interviews with 40 pregnant or parenting African American adolescents attending a Teen Parenting Program. The analysis focuses on teens' accounts of their experiences with the patient provider relationship and their interpretations of and responses to the medicalization of pregnancy and birth contextualized in teens' encounters with medical providers during pregnancy. Overall, the adolescents accepted the medical model of pregnancy and childbirth. There were, however, acts of resistance and defiance of medical authority.

Purpose: The objective of this study was to determine if regular volunteering during adolescence was associated with a delay in first pregnancy until adulthood. Method: Data for this analysis were drawn from Wave III of the National Longitudinal Study of Adolescent Health (Add Health). Logistic regression was used, controlling for demographic characteristics and pregnancy intention, to estimate the independent contribution of volunteering during adolescence to a delay in first pregnancy until after age 18. Results: One-third of respondents reported regularly volunteering during adolescence. Volunteering significantly differed among those who had a teen pregnancy compared to those who delayed pregnancy until adulthood (chi-square 6.52, p-value 0.012). In the adjusted analysis, respondents who reported regularly volunteering during adolescence were nearly 60% more likely to delay their first pregnancy until adulthood compared to those who did not volunteer. Conclusions: This analysis is the only one known to have examined volunteering alone, not as part of a multiple component prevention program. Its findings suggest that incorporating volunteering opportunities may make pregnancy prevention programs more successful. In addition, increasing the number of the kinds of volunteering opportunities that are already available may confer some protection against adolescent pregnancy.

The purpose of this study was to examine the relationship between history of parental substance abuse and substance use and psychiatric severity measures in a sample of treatment-seeking, pregnant women who meet DSM-IIIR criteria for lifetime opioid and cocaine abuse and/or dependence (N=260). The study examined whether a dose-response relationship was observed between number of parents affected by substance use problems (0, 1, and 2) and degree of women’s substance use and psychiatric severity. Results did not support a dose-response relationship between density of parental problems and substance use and psychiatric severity. However, some differences in severity were seen at different levels and types of parental density. Overall, the present study supports the need to further examine parental history of substance abuse as a potential risk factor for more severe substance use and psychiatric problems. Study findings have important implications for the screening and treatment of substance dependence during pregnancy.

Welfare of women during pregnancy and maternity The main aim of this thesis is to identify and analyse key issues within the current welfare system for woman during pregnancy and maternity. This will then allow recommendations to improve Czech legislation. The reason of choosing this theme is my deep interest in this sphere. The thesis discusses a broad range of issues over eight chapters; each chapter examines different aspects of the issue. First Chapter simply defines basic terminology associated with the subject. Chapter Two deals with the history of women's welfare during pregnancy and maternity and describes how legislation for those women has evolved over the past years. Chapter Three puts women's welfare in an international and constitutional context. Chapter Four examines the two main subdivisions of legislation. Part One is concerned with doses of the health insurance system. Part Two deals with doses of the state social support. Chapter Five looks at women's welfare during pregnancy and maternity in labour law. Chapter Six illustrates the approach to imprisoned women and their rights during pregnancy and maternity. Chapter Seven looks at the relevance of substitute family care within the sphere of welfare. The final chapter highlights the key differences between Czech and Slovak...

Background: The theme of the position and experiences of pregnant women in the context of methadone maintenance treatment has not yet been thoroughly examined, the aim was to contribute to break the taboo concerning this topic and help to destigmatize these women. Goals: To map the situation of pregnant women in MMT and to alert to therapeutic specificity of these women. Methods: Semi-structured interview and analysis of the medical documentation were used to obtain the data, observation method, qualified estimate and clinical case reports. Data were processed through content analysis. File: The research group consists of 7 patients who were treated in the Department of Adictology 1st Faculty of Medicine, Charles University and General University Hospital in Prague, who gave birth to at least one child between 2004 and 2014. Results: The analysis shows that during their pregnancy women reduce the use of illicit drugs and tobacco. Despite these pregnancies are usually not planned, it was observed that in these women the pregnancy occured in a situation when the respondents were stabilized in both the treatment and in their social situation. The experience of pregnancy played a stimulating role for dose reduction or direction to abstinence. The reasons are usually the confrontation with the NAS of their child...