MCur / Department of Advanced Nursing Science

This project is concerned with method development in mass spectrometry (MS)-based proteomics in order to find putative biomarkers for early pregnancy ofdomesticated dogs. It is of importance for dog breeders to know whether the dogsbecome pregnant post-mating. Unlike humans, dogs are not known to possess aspecific hormone that indicates fetal development; therefore other biomarkers mustbe investigated. The approach of choice in this project was to look at proteins throughMS-based proteomics. For this purpose, serum samples from 11 pregnant dogs (case,different breeds) and 7 non-pregnant dogs (control, all beagle dogs) were sampledbefore-hand at the Swedish University of Agricultural Sciences. Each dog wassampled Day 1, Day 8, Day 15, Day 22 and Day 29 after optimal mating. Twodifferent proteomics approaches were conducted: Bottom-up (“Shotgun”) proteomicsand targeted proteomics (“targeted analysis”). In this study, Label-free Quantification(LFQ) was employed, which is a relative quantitative technique. The massspectrometer of choice was the Quadrupole-Orbitrap QExactive plus massspectrometer coupled to a nano-Ultra Performance Liquid Chromatography (UPLC).Method optimization was done with respect to concentration of samples prior to MSanalysis, as well as different LC-gradients. From shotgun screening experiments, itwas possible to identify 252 proteins. Ultimately, 9 proteins were investigated usingtargeted final analysis: CRP, SERPINC1, CP, PROS1, SERPING1, A2M, AGP,SERPINA1 and HP. For targeted final analysis, 21 peptides were considered.Calibration curves were constructed using 8 of the 21 targeted peptides; 1 peptide perprotein, except for HP which had 2 peptides per protein. The SERPINA1 and CPproteins had no appropriate peptides for targeted final analysis and were thusexcluded. It was confirmed that CRP was up-regulated in case dogs compared tocontrol dogs. The other investigatedproteins showed no significant signs of regulation. In order to improve the results; itwould be desirable to include more dogs in the study which would benefit thestatistics of protein regulation. However, the use of isotopic labeled standards andemployment of a Parallel Reaction Monitoring (PRM) method should be prioritizedfor obtaining absolute quantitative data.

This thesis explores the discovery, investigation and prosecution of, as well as the men and women involved as suspects and witnesses in, cases of suspected new-born child murder and concealment of pregnancy in Scotland between 1812 and 1930. The study utilises pre-trial and other legal documents relating to these cases to outline both the continuities with other studies and aspects of the subject that are peculiar to Scotland during the period. An examination of the pre-trial documents not only reveals the various responses to suspicions of pregnancy and murder by the local community, it also shows that in a number of cases investigators harboured suspicions that members of the community were involved, either as an accessory to a crime, or withholding evidence. However, this information is largely ignored by prosecutors, and the vast majority of those tried were the victims’ mothers, an outcome that this thesis argues was a combination of a number of legal and medico-legal processes and procedures. This thesis also argues that the information provided by the pre-trial evidence can provide a more nuanced understanding of these ‘crimes’ – particularly at a local level – that is otherwise obscured by official statistics, that in turn can be used to challenge the prevailing historical consensus that has developed around certain aspects of the subject. The first chapter provides the legal and medico-legal contexts. Chapters Two and Three look at the discovery of, and responses to, the signs of pregnancy, recent delivery and of the bodies of new-born infants. Chapter Three argues that whilst communities were quick to observe the signs of pregnancy, they were less inclined to inform the authorities of their suspicions until after the signs of delivery, or a body, had been discovered. Chapter 4 looks at the profiles of suspects, and also at the geography of the ‘crimes’, and Chapter 5 looks at those men and women suspected of being an accessory to murder, and of helping to conceal a pregnancy or an infant’s death. This chapter reveals that the pretrial documents reveal that in a number of cases investigators suspected relatives, friends, the victims’ fathers, and in some cases even doctors and midwives, to be involved in various ways in cases of suspected new-born child murder. As such it provides a strong challenge to the historiographical consensus that new-born child murder was a sex-specific crime, carried out by the victim’s mother, acting alone. Chapters 6 and 7 explore the role of the police and medical witnesses respectively, both prior to a formal accusation, and during the official investigation. Chapter 7 also includes a detailed look at the medical reports pertaining to the examination of suspects and the post mortem examination of the victims. The final chapter looks at the witnesses and evidence presented at the trial, focusing in particular on the medico-legal issues that made it difficult for prosecutors to secure a successful murder conviction. The chapter argues that whilst these issues could be part of a wider culture of sympathy towards new-born child murder suspects, the evidence from the verdicts and sentencing can also demonstrate a hardening of judicial attitudes over the period.

Fetal exposure to excess glucocorticoids has been proposed as a key determinant of pregnancy outcome, as well as a predictor of long term health of the offspring through a phenomenon known as ‘developmental programming’. Obesity and ‘stress’ during pregnancy are two potential sources of altered fetal exposure to glucocorticoids. One in five pregnant women is obese at antenatal booking, and maternal obesity increases risk of offspring complications including higher birth weight, potentially leading to long-term programming effects on the offspring. Likewise, maternal anxiety during pregnancy has been identified as a programming factor, increasing the risk of psychopathology in the offspring. This thesis tests the hypothesis that in humans this association is mediated by altered action of glucocorticoids, by examining circulating levels of maternal glucocorticoids during pregnancy and through measurement of key genes in the placenta regulating fetal glucocorticoid exposure. Serum cortisol levels were measured at 16, 28 and 36 weeks gestation in n=173 class III obese (BMI 44.0±4.5kg/m2) and n=107 lean (BMI 22.8±1.6kg/m2) pregnant women. Serial corticosteroid binding globulin (CBG) concentrations were measured in a subset (n=39 lean, 26 obese) and free cortisol levels calculated using Coolen’s equation. CRH concentrations were measured at the same time points in obese (n=20) and lean (n=22) pregnant women Salivary cortisol was measured in samples collected at bed-time, waking and 30 minutes after waking. mRNA levels of candidate genes regulating glucocorticoids and fetal/placental growth including 11-beta hydroxysteroid dehydrogenase type 2 (11βHSD2), which inactivates cortisol, insulin-like growth factor 2 (IGF2) and glucocorticoid receptor (GR) were measured in first trimester (n=32), second trimester (n=15) and term (n=60) placental samples. DNA methylation of key regions controlling the expression of the IGF2, GR and 11βHSD2 genes was measured by pyrosequencing in first trimester and term samples. Levels of mRNAs encoding 11βHSD1, 11βHSD2, GR and MR were measured in term placentas collected from women from Helsinki, Finland in whom anxiety during pregnancy had been prospectively assessed using validated questionnaires. Term placental samples from a subset of the obese and lean women who had also completed stress questionnaires during pregnancy were used to examine replication of findings. Cortisol levels rose similarly during pregnancy in obese and lean but were significantly lower throughout pregnancy in obese women (p<0.05). The diurnal rhythm of cortisol was maintained. CBG levels also increased, though this change was lower in obese (1.21-fold (±0.9) vs 1.56-fold (±0.07), p<0.01). In obese women, lower calculated free cortisol at 16 weeks gestation was associated with higher birth weight after adjustment for other factors (r=-0.46, p<0.05). Placental mRNA encoding 11βHSD2 increased in association with increasing obesity in early pregnancy (r=0.44, p<0.01) and was highest in term placenta in obese women with macrosomic (>4000g) offspring (p<0.05). Placental transcript abundance of GR also increased in association with increasing obesity in early pregnancy (r=0.38, p<0.05), but was lowest in term placenta from obese with macrosomic offspring (p<0.05). IGF2 mRNA abundance was lower in the placentas of obese women with macrosomic offspring at term compared to both lean women and obese women with normal weight offspring (p<0.01). Methylation results are reported. Placental mRNA levels encoding 11βHSD1 (which converts inactive cortisone to active cortisol) at term was found to positively associate with maternal anxiety measured in the first trimester of pregnancy in a group of pregnant Finnish women (β=0.3, p<0.05). Findings were similar in the replication sample in lean women only (β=4.6, p<0.05). Lower circulating and bioavailable cortisol levels in early pregnancy, together with a greater placental ‘barrier’ to maternal glucocorticoids represent key mechanisms contributing to higher birth weight in offspring of obese women. Regeneration of active glucocorticoids in placenta and increasing placental sensitivity to glucocorticoids increases fetal glucocorticoid exposure and offers insight into the biological mechanisms underlying adverse offspring effects of maternal prenatal anxiety.

In May 2002 the National Institute for Clinical Excellence (NICE) made the recommendation that all pregnant women with an RhD negative blood type should be offered routine antenatal anti-D immunoglobulin (Ig) prophylaxis (RAADP). Midwives were the key professional group who would be involved in administration of anti-D Ig and yet they had little input to formation of policy and contributed little to the evidence base that informs policy and practice. A midwifery perspective is however important and relevant, and forms the basis of this work. The thesis comprises three distinct, but related, pieces of research: a survey conducted in 2005 to determine implementation of RAADP at UK maternity units; secondary analysis of anti-D Ig errors involving midwives that were reported to the Serious Hazards of Transfusion (SHOT) scheme in 2007/8; and focus group interviews conducted in 2010 to explore midwives’ views on issues that impact the care provided for women with an RhD negative blood type. The aim of the RAADP survey was to establish current {2005} policy in the United Kingdom in relation to the NICE recommendation for RAADP (NICE, 2002). The survey formed the foundation on which to build the thesis by determining that by 2005 RAADP had become an integral aspect of maternity care within the UK. However it also found that there were significant variations within local policies and among the information that was provided to pregnant women and healthcare professionals. The aim of the survey was to determine implementation of policy and not to explain findings, raising important questions which were used to inform the subsequent research. The second piece of research was secondary analysis of existing anti-D Ig error reports collated by SHOT. The analysis was unique in that it included only those errors involving midwives. The findings highlight both individual and organisational impact on errors, building on the findings of the RAADP survey. The research identified proximal errors, trigger events and fallible practices providing a framework within which the common pathways to error involving anti-D Ig can be understood. This will allow midwives to better understand and improve the care they provide. This piece of research also raised further questions about midwifery practice and those questions informed the focus group research. The focus group research aimed to consolidate the findings of the previous research by gaining direct input from midwives. Two focus group interviews were held, with clinical midwives as participants. The research found that the midwives and the organisations within which they worked provided care in line with policy and procedure at the apparent expense of a woman centred approach. This appeared to be linked to the midwives’ understanding of their responsibility, accountability and the education and information that underpinned the care they provided. The other important finding from the focus group research was that the midwives regarded RAADP as a less important intervention than they did anti-D Ig given following a potentially sensitising event (PSE) during pregnancy or given following delivery. When considered as a whole body of work, this research provides unique and valuable insight to midwifery involvement in the care of women with an RhD negative blood type. The research highlights the challenge of achieving government objectives for individualised, woman centred care within the present framework of clinical governance and evidence based care. In doing so it also raises questions about how individual midwives and the midwifery profession have engaged with medical colleagues and policy makers to maintain a midwifery context to the care they provide. Although the research findings relate to care provided for women with an RhD negative blood type the findings are pertinent to other aspects midwifery practice, particularly those originating within the medical profession that are now a routine part of midwifery care.

Thesis (MCur)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: The alarming rate of teenage pregnancies among South Africans became a driving force for the researcher to investigate this particular phenomenon. The goal of this study was to explore and describe the experiences of pregnant teenagers about their pregnancy. Guided by the research question “ What are the experiences of pregnant teenagers about their pregnancy?” a scientific investigation was undertaken. The objectives set for the study were to determine their experience of their current pregnancy; to determine their knowledge of contraceptives; and to explore their experience regarding the services delivered by the health care workers. A phenomenological descriptive design with a qualitative approach was the most suitable scientific method to describe the experiences of pregnant teenagers who attend an antenatal clinic in Chatsworth, Kwazulu Natal. An interview guide or protocol that includes a list of open-ended questions based on the objectives, the literature review, and the professional experience of the researcher was designed and used to explore during each interview. The final sample consisted of ten participants. Experts in the field of nursing and research methodology were consulted to determine the feasibility and content of the study, to evaluate the research process and outcome. The researcher collected the data personally. Data was collected by means of individual interviews. The researcher did the transcription of the interviews. Ethical approval was obtained from Stellenbosch University and the relevant health authorities. Informed written consent was obtained from the participants. Parental permission was obtained for participants under the age of 18 years. Participants younger than 18 years of age also completed an assent form. Data that emerged from the data analysis was coded and categorised into sub-themes and themes. The researcher compiled a written account of the interpretations that emerged from the data analysis. In addition, member checking was done with each participant after individual interviews, to validate the transcribed data. The conceptual framework for this study was adapted from Maslow (1968). The findings suggest that there is a need for parental intervention as far as teenage pregnancy is concerned, financial difficulties associated with poverty was identified as one of the major contributing factor to teenage pregnancy, and attitudes of providers of contraceptives led to teenagers, not using contraceptives in some cases. It is recommended that services at the clinic be improved; health care workers undergo extensive training and education regarding teenage health and sexuality needs. Furthermore review and revitalisation of education programs at schools, to meet the needs of teenagers, which are constantly changing according to the times, are recommended. The involvement of parents and the community in combating issues surrounding teenage pregnancy is vital. Further research is recommended to find solutions to alleviate this problem of teenage pregnancy. All stakeholders need to work together to remedy this social problem as it is not an issue that can be dealt with in isolation. / AFRIKAANSE OPSOMMING: Die veronrustende voorkoms van tienerswangerskappe onder Suid-Afrikaners was die motiverende faktor vir die navorser om die studie te onderneem. Die doel van die studie was om die ervaringe van swanger tieners ten opsigte van hul swangerskap te identifiseer en te beskryf. Die wetenskaplike ondersoek is gelei deur die navorsingsvraag, “wat is die ervaringe van swanger tieners betreffende swangerskap?” Die doelwitte vir die studie was om te bepaal: die ervaringe van die huidige swangerskap; kennis betreffende voorbehoedmiddels sowel as die ervaring ten opsigte van die dienste soos gelewer deur die gesondheidswerkers. 'n Fenomenologiese, beskrywende ontwerp met 'n kwalitatiewe benadering is as die mees geskikte wetenskaplike metode beskou om die ervaringe van swanger tieners wie 'n voorgeboorte-kliniek in Chatsworth, KwaZulu-Natal bywoon, te beskryf. Die navorser het gebruik gemaak van 'n vooraf opgestelde onderhoud gids, protokol bestaande uit 'n lys van oop vrae gebaseer op die doelwitte, die literatuuroorsig en die professionele ervaring van die navorser. Die finale steekproef was tien deelnemers. Kundiges op die gebied van verpleging en navorsingsmetodologie is geraadpleeg ten opsigte van die haalbaarheid, inhoud van die studie sowel, as om die proses en uitkoms van die navorsing te evalueer. Die data is persoonlik deur die navorser versamel. Data is ingesamel deur middel van individuele onderhoude. Transkripsie van die onderhoude is deur die navorser self-gedoen. Etiese goedkeuring is vooraf verkry vanaf die Universiteit van Stellenbosch sowel as die betrokke gesondheidsowerhede. Ingeligte skriftelike toestemming is verkry van die deelnemers sowel as van die ouers in geval van minderjaige tieners. Tydens die data-analise is data gekodeer en in temas en sub- temas kategoriseer. 'n Skriftelike verslag is saamgestel ooreenkomstig die interpretasie uit die data-analise. Die navorser het na transkripsie met elke onderskeie deelnemer gekontroleer ten einde geldigheid van die data te verseker. Maslow (1968) se teorie is gebruik as konseptuele raamwerk vir die studie. Die bevindinge dui daarop dat daar 'n behoefte is aan ouerlike tussentrede betreffende tienerswangerskappe. Finansiële probleme in verband met armoede is ïdentifiseer as een van die groot bydraende faktore tot tienerswangerskappe, sowel as dat houdings van diegene wat kontrasepsie verskaf daartoe kan lei dat tieners nie wil gebruik maak van voorbehoedmiddels nie. Dit word aanbeveel dat die dienste by die kliniek moet verbeter; gesondheidswerkers uitgebreide opleiding en onderrig moet kry ten opsigte van tienergesondheid en seksualiteit behoeftes. Hersiening en vernuwing van opvoedkundige programme by skole om in die voortdurende veranderende behoeftes van tieners, te voldoen. Die betrokkenheid van ouers en die gemeenskap in die bestryding van kwessies rondom tienerswangerskappe is noodsaaklik. Verdere navorsing word aanbeveel om oplossings te vind om hierdie probleem van tienerswangerskappe aan te spreek. Alle belanghebbendes moet saamwerk om hierdie sosiale probleem op te los.

Thesis (MA)--University of Stellenbosch, 2001. / ENGLISH ABSTRACT: Pregnancy has evolved from being predominantly understood as a medical phenomenon to what psychoanalytic theorists would regard as a holistic experience encompassing both physiological and psychological changes. According to psychoanalytic theorists, pregnancy is a transitional phase and a time of susceptibility and flux for most women. This often results in psychic turmoil where boundaries between conscious and unconscious process become more permeable. The pregnant woman's dreams and fantasies create an inner working model of relationships and this in tum provides a template of how her relationship with her baby will be experienced and conducted. This link to the unconscious increases insight into the process occurring between the woman and her evolving relationship with the fetus and provides the health professional with clues for early intervention. However care should be taken by health-care professionals to communicate the psychological processes during pregnancy within the cultural framework of the pregnancy mother for positive outcomes to be achieved. / AFRIKAANSE OPSOMMING: Die wyse waarop swangerskap verstaan word het ontwikkel vanaf grotendeels mediese verskynsel na wat die psigoanalitiese teoretici sal beskou as 'n holistiese ervaring wat beide die fisiologiese en die sielkundige veranderinge insluit. Die psigoanalitiese teoretici beskou swangerskap as 'n oorgangs fase en 'n periode van vatbaarheid en veranderlikheid vir die meeste vroue. Dit gee dikwels aanleiding tot psigiese wanorde waar die grense tussen bewustelike en onbewustelike prosesse meer deurdringbaar word. Die swanger vrou se drome en fantasië skep 'n innerlike werkende model van verhoudings en op sy beurt voorsien dit templet van hoe haar verhouding met haar baba ervaar en hanteer sal word. Hierdie band met die onbewustelike verleen insig in die proses wat tussen die vrou en haar ontwikkelende verhouding met die fetus voorkom en voorsien die gesondheids werker van leidrade vir vroeë intervensie. Die gesondheids werker moet egter versigtig wees om die sielkundige prosesse gedurende swangerskap binne die kulturele raamwerk van die swanger moeder te interpreteer om sodoende positiewe uitkomste verkry.

published_or_final_version / Obstetrics and Gynaecology / Master / Master of Philosophy

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Obstetrics and Gynaecology / Doctoral / Doctor of Philosophy