No description available.

Preterm birth is a major clinical problem, worldwide 15000000 babies are born prematurely each year. Inappropriate myometrial function is a major cause of preterm labour. Preterm labour is the result of multiple pathological processes involving several underlying mechanisms. In all cases, a quiescent uterus in pregnancy changes to one that can produce coordinated, forceful contractions, following an increase in uterine conductivity and contractility, and cervical remodelling to facilitate cervical dilatation. Currently there are several biochemical and clinical tests available to assist in the prediction of preterm birth. Many of these have a very high negative predictive value but their positive predictive value remains low. One in five women in the UK requires induction of labour. The outcomes of this process are again difficult to predict. Both of these areas of obstetrics would benefit from improvements in prediction of clinical outcomes. Previously, phospholipase C like 1 (PLCL1) was identified as a novel intracellular protein found to be significantly downregulated in both the myometrium with the onset of spontaneous labour using sequencing techniques (Chan et al., 2014). It acts as an IP3 chelator, uncoupling phospholipase C from myometrial contractions, maintaining myometrial quiescence and therefore regulating a common pathway to inflammatory, oxytocin or prostaglandin mediated labour. We aimed to develop a clinical test utilising PLCL1 as a quiescence or susceptibility marker to other stimuli to premature labour and to determine if this marker could determine sensitivity to prostaglandins and syntocinon during the induction of labour process. During a prospective observational cohort study, patients were recruited from a preterm prevention clinic throughout mid-pregnancy, and from the antenatal ward when attending for induction of labour at term. Cervical cytobrush samples were taken to obtain cervical epithelial cells. A novel assay was developed to quantify PLCL1 from these samples. There have been various challenges in the process, including the small and varying number of cells obtained, problems with interference from cervical mucus with protein quantification and difficulty adequately lysing our cells to release the protein. We have demonstrated the presence of PLCL1 in cervical cytobrush samples using immunocytochemistry, SDS-PAGE, and western blotting and ELISAs. We have developed a method to isolate our cervical cells from the cervical mucus, lyse these cells and quantify PLCL1 using an ELISA. Our findings demonstrate that PLCL1 is a promising novel protein which could be utilised in the prediction of preterm birth and outcomes of induction of labour. As a susceptibility marker, PLCL1 could be used in conjunction with other markers.

Embryo donation (ED) and double donation (DD) are fertility treatments whereby resulting children are raised by parents to whom they are genetically unrelated. The main similarity between ED/DD and adoption is the lack of genetic parent-­child relationships, and the main difference is the presence of the gestational link in ED/DD families, which provides an option of concealing genetic origins. This thesis consists of one large study followed by three subsidiary studies, with the overall aim of exploring the disclosure of genetic origins in the UK and Brazil, and the support available to assist parents with this process. In Study I, 36 ED/DD parents, and 27 adoptive parents were interviewed to determine if and how they disclosed to their children, and identify the support that they received to manage this process. In Study II, 30 UK-­based infertility counsellors completed an online survey to ascertain how they engage in disclosure-­related issues with patients seeking embryo donation/double donation treatment. In Study III, 19 Brazilian parents, who conceived a child using donated sperm or eggs, completed an online survey to explore if and how they disclosed to their children, and whether they felt supported with this process. In Study IV, 24 Brazilian fertility professionals completed an online survey to determine how they engage with parents seeking treatment with donated gametes. Overall, adopters were more confident in the process of adoption revelation, and received more support in order to achieve this, compared to ED/DD parents. Findings highlight the complex nature of disclosing donor conception, and identified that Brazilian parents experience similar challenges compared to those in the UK. Disparities were found in the disclosure-­related support provided both across and within these two country contexts. From these results, recommendations for how parents could be better supported with disclosure-­related issues are given.

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.