Aim: To develop an intervention that could be facilitated by midwives to improve symptoms of mild to moderate anxiety in pregnant women Background: Many women experience symptoms of anxiety during pregnancy. Severe anxiety is associated with negative health outcomes for women and babies. Psychological interventions may be beneficial for pregnant women with mild to moderate symptoms of anxiety. Interventions require evaluation in pregnant populations to strengthen the evidence base. Methods: An intervention was developed according to the Medical Research Council theoretical and modelling phases for developing complex interventions. The study comprised three phases: 1. systematic reviews exploring the effectiveness and acceptability of interventions for pregnant women with anxiety; 2. development of an intervention which comprised individual support from midwives, peer group discussion and self-help resources; 3. a feasibility study of the intervention. Data collection comprised baseline and post-intervention self-report anxiety measures and semi-structured interviews conducted post-intervention. Data analysis used descriptive statistics for the quantitative data and template analysis for the qualitative data. Findings: Ten women participated in the feasibility study. Two midwife facilitators and two midwifery support worker co-facilitators were recruited and trained to facilitate the intervention. Women reported that the intervention was acceptable and beneficial. The findings highlighted how the intervention could be improved to maximise participant recruitment and improve the benefit derived by pregnant women with symptoms of anxiety. Facilitators provided positive comments about their involvement and said they felt prepared to deliver the intervention. Areas were identified where the training of intervention facilitators, study manuals and use of self-help resources could be enhanced to improve performance and fidelity of the intervention. Conclusions: Midwives have the potential to facilitate supportive interventions to enhance the current provision of emotional support in pregnancy. Minor refinements to the intervention are recommended prior to further testing. The next stage of development should be to conduct a randomised pilot trial. This should determine robust research methods and procedures for conducting a main trial to assess the effectiveness of the intervention on self-report symptoms of anxiety in pregnant women.

Portfolio Abstract Introduction The psychological experience of giving birth has been found to have a long-lasting impact upon the wellbeing of the woman and the mother-infant interaction (Ayers, Eagle, & Waring, 2006). Research has been carried out to investigate what influences the psychological experience of giving birth and contributes to these longlasting consequences. The interaction between the woman and the health professional has been shown to influence the psychological experience of birth (Ford & Ayers, 2011; Söderquist, Wijma, & Wijma, 2006). Despite these findings, obstetricians are a relatively neglected health profession within the birth research literature. Furthermore, obstetricians’ involvement or ability to contribute towards positive birth experiences has not been fully researched. Women have either emphasised the importance of the support they received from obstetricians or criticised the lack of support they received (Howarth, Swain, & Treharne, 2012; Simkin, 1991; Simkin, 1992; Waldenström, Hildingsson, Rubertsson, & Rådestad, 2004). The role of any caregiver during labour and birth is suggested to be important for influencing the psychological experience of birth (Anderson, Melvaer, Videbech, Lamont, & Joerhensen, 2012). However, obstetricians attend medically complex births where there may be mother of baby medical complications. Such births have attracted debate in the research literature. Complex medical births are argued to constitute a risk factor for negatively influencing the psychological birth experience and impacting upon the long-term wellbeing of the mother and infant-mother interaction (Anderson et al., 2012). However, other research has suggested that complex births are not always a risk factor for experiencing birth negatively and that the psychological (Nilsson, Thorsell, Hertfelt-Wahn & Ekström, 2013; Simkin, 1991, Simkin, 1992). Objectives The objective of this research project was to investigate the way obstetricians talk about giving birth, or ‘obstetric discourse’ and how obstetricians ‘constructed’ a positive birth experience. This research project aims to initiate the thorough investigation of spoken obstetric discourse, so that future research may build upon these findings. Previous literature has investigated the discourse about birth via interviews without obstetricians being the primary sample (Douché & Carryer, 2011) and has considered the discourse produced by obstetricians more broadly from published documents (Kitzinger, 2007; Licqurish & Evans, 2015) . However, there has been a lack of investigation about the spoken discourse of obstetricians. By adding focus to spoken obstetric discourse this study may potentially add variance to the data. Discourse is argued to be influenced by the context in which it takes place. Therefore research moving forward in this area may benefit from including varied contexts. Discourse analysis strives to highlight variance rather than a similarity (Potter & Wetherell, 1987). Striving to highlight similarities is argued to be invalid and accused of omitting potentially useful data from the research literature (Potter & Wetherell, 1987). Methodology The underlying theory and the accompanying methodology of discourse analysis was used to meet the objectives of this research project. A social constructionist epistemological stance was taken towards the gathering of knowledge in this research project. A social constructionist epistemology is compatible with discourse analysis due to the shared assumptions about language constructing experiences. From this theoretical framework, language is an important target for analysis because it is argued to shape human experience in terms of constricting or enabling what may be said, done or felt (Willig, 2013). More specifically, language is argued to create reality rather than accurately describe it. This study used a hybrid model of discursive psychology and Foucauldian discourse analysis. This involves analysing local discursive techniques such as disclaimers, contrasting and inferences about internal states, while also analysing wider social influences and the discourses available to the participants. For example, the discourse of medicine may be argued to be an available discourse for those who work in the field of medicine to draw upon to influence their own discourse. Obstetric discourse in the form of spoken language was gathered from semi-structured interviews with eight practising obstetricians. Results The findings of the analysis suggested that the participants constructed a positive psychological birth experience in varied ways and used multiple rhetorical devices when doing so. The results are reported in two broad categories; the participants’ contrast of ‘obstetric births’ with so called ‘ideal births’ and the use of claims about women’s internal states during labour. The participants’ responses to questions about positive birth experiences were to construct ‘obstetric births’ and ‘ideal births’ in contrast with one another. The births that obstetricians attended were constructed using medical discourse, which emphasised medical complications and medical interventions. This category of birth was presented as a challenging birth type within which to facilitate positive psychological experiences. Obstetric births were contrasted with what were termed ‘ideal births’. Ideal births were described as medically ‘normal’ births that did not require an obstetrician’s intervention. These births were associated with midwifery and presented as a category of birth within which interpersonal relationships between the woman giving birth and the midwife may facilitate a positive psychological birth experience. The rhetorical device of contrasting appears to function here to emphasise difference and key features of obstetric births. The participants made claims about the internal states of women in labour. Internal mental states are not analysed to ascertain whether they are accurate or not within a discourse analysis methodology. Claims were made about women’s experience of pain and anxiety. Such claims are viewed as discursive devices that have certain functions within the discourse. Within this study, inferences about internal mental states appeared to have a possible function to present the women in labour as less able to communicate and difficult to have a discussion with. Communication was presented as a factor that may facilitate a positive psychological birth experience. A function of these claims about internal states may be to construct positive births as difficult to facilitate with women during labour due to their internal mental states. Discussion The results of this analysis are considered in light of discourse analysis theory and the writings of Foucault. Discourse analysis has been described as a ‘theory-method’ because it makes certain claims about how language creates reality (Potter, 1997). Further consideration is given to the appropriateness of applying other psychological theories from Menzies Lyth’s (1960) research into social defences. Suggestions for further research and the possible clinical implications of this study are considered.

Introduction Approximately one in five women experience abdominal pain and/or vaginal bleeding in early pregnancy. This usually prompts referral to an Early Pregnancy Assessment Unit where an ultrasound scan will be performed. Following the ultrasound, either a certain or uncertain diagnosis will be made. Certain diagnoses may be positive, i.e. a viable intrauterine pregnancy, or negative, i.e. a non-viable or ectopic pregnancy. Uncertain diagnoses occur when there is ambiguity regarding either the location or the viability of the pregnancy. Up to 25% of women attending an Early Pregnancy Assessment Unit are given such a diagnosis at their initial visit. All women with a diagnosis of either a pregnancy of unknown location or uncertain viability need to be followed-up until a definitive diagnosis can be made. At present this is haphazard and protracted, commonly taking up to two weeks to resolve and requiring multiple visits for various different investigations. This takes a considerable amount of time and costs a not insignificant amount of money. Furthermore, in the time taken to make a definitive diagnosis, a stable woman with an unknown miscarriage or ectopic pregnancy may become unstable and require immediate resuscitation, life-saving blood transfusion and/or emergency surgery. Aims The aim of this PhD was to develop methods to minimise the number of women given uncertain diagnoses in early pregnancy, or to at least minimise the duration of uncertainty if the diagnosis is unavoidable. Several different studies were undertaken in an attempt to accomplish this. Studies We initially undertook a prospective cohort study to determine the levels of anxiety generated by uncertain diagnoses in early pregnancy was undertaken. Women with uncertain diagnoses were found to be significantly more anxious (as measured using the standardized short form of Spielberger’s state-trait anxiety inventory) than their counterparts given certain diagnoses (23±0.79 versus 14±6.6), even if these certain diagnoses were not associated with an ongoing pregnancy. This study served to further justify the main objective. We then performed a systematic review and meta-analysis to identify and determine the diagnostic accuracy of various different ultrasonographic features to predict (a) an intrauterine pregnancy prior to visualization of embryonic contents and (b) a tubal ectopic pregnancy in the absence of an obvious extra-uterine embryo. This study identified the double decidual sac sign as a potential marker to be able to accurately differentiate a true gestation sac from a pseudosac with a sensitivity of 82% (95% CI, 68-90%), specificity of 97% (95% Ci, 76-100%), positive likelihood ratio of 30 (95% CI, 2.8-331) and negative likelihood ratio of 0.19 (95% CI, 0.10-0.35). The quality of the studies included in the meta-analysis however precluded the use of the double decidual sac sign in clinical practice without further validation As a consequence, we carried out a prospective study following STARD guidelines to determine the diagnostic accuracy of the double decidual sac sign to predict an intrauterine pregnancy prior to visualization of embryonic contents using modern, high-resolution transvaginal ultrasound. This study found that the double decidual sac sign predicted an intrauterine pregnancy with a sensitivity of 94% (95% Ci, 85-98%), specificity of 100% (95% CI, 16-100%) and overall diagnostic accuracy of 94% (95% CI, 88-100%). The positive and negative predictive values are 100% (95% CI, 94-100%) and 33% (95% CI, 4.3-78%) respectively whilst the positive likelihood ratio was infinite and the negative likelihood ratio was 0.06 (95% CI, 0.02-0.16). These results suggest that the meta-analysis under-estimated the ability of the double decidual sac sign to differentiate between a true gestation sac and a pseudosac. Subsequently, we conducted a study incorporating off-line analysis of ultrasonographic images to determine the inter- and intra-observer reliability of the double decidual sac sign to predict an intrauterine pregnancy prior to ultrasonographic visualization of embryonic contents. This involved fifteen observers from around the United Kingdom remotely assessing a selection of two-dimensional images from 25 of the diagnostic accuracy study participants. There was significant (p < 0.01) agreement amongst the observers but the level of agreement was only ‘fair’, reflected by kappa statistics of 0.25, 0.33 and 0.21. Following a period of focused training, the inter-observer reliability significantly increased demonstrated by kappa statistics of 0.70, 0.63 and 0.53. The intra-observer reliability ranged from ‘substantial’ (K=0.65) to ‘almost perfect’ (K=0.92). These results demonstrate that the double decidual sac sign has the potential, after training, to be both reliable and precise, making it a very useful ultrasonographic sign in clinical practice. Finally, we undertook a prognostic research study, following REMARK recommendations, investigating the ability of five serum biomarkers to predict pregnancy outcome in women with pregnancies of uncertain viability. Candidate biomarkers included Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), soluble FMS-like Tyrosine Kinase-1 (Flt-1), serum TNF-Related Apoptosis Inducing Ligand and Interleukin-15. Serum concentrations of Ang-2 and Flt-1 were significantly lower in pregnancies of uncertain viability that were subsequently proven to be viable than those that were subsequently proven to be non-viable (Ang-2 1510pg/ml versus 2365pg/ml and Flt-1 103pg/ml versus 202pg/ml). Furthermore, there were statistically significant (p < 0.01), linear (p-value for trend < 0.01) associations between Ang-2 and Flt-1 concentrations and subsequent pregnancy viability such that women with a pregnancy of uncertain viability and Ang-2 concentrations greater than or equal to 2666pg/ml were 64% less likely to have a viable pregnancy than those with Ang-2 concentrations less than or equal to 1382pg/ml and women with a pregnancy of uncertain viability and Flt-1 concentrations greater than or equal to 142pg/ml were 50% less likely to have a viable pregnancy than those with Flt-1 concentrations less than or equal to 87pg/ml. These findings suggest that Ang-2 and Flt-1 may be useful in the prediction of pregnancy viability in cases of uncertainty. Discussion One of the biggest challenges in early pregnancy ultrasonography is accurate differentiation between a true gestation sac and a pseudosac. Pseudosacs, although rare, are strongly suggestive of an ectopic pregnancy, hence it is an important distinction to make, ideally as soon as possible. Both appear initially as intrauterine fluid collections or ‘empty sacs’. Whilst experts may claim that it is not difficult to differentiate between the two structures, in clinical practice, many of the individuals undertaking the scans in early pregnancy do not claim to be experts. Traditional teaching has always been to wait until either a yolk sac or fetal pole are visualized within the sac before confirming a definite intrauterine pregnancy. Although safe, inherent with this approach is that an intrauterine fluid collection is visible using transvaginal ultrasound from around day 28 but a yolk sac is not visible until at least day 35. If an ultrasound is undertaken during this time, an ‘empty sac’ will be seen and uncertainty will ensue. Application of the results from the studies described above could potentially revolutionize the care of women with diagnostic uncertainties in early pregnancy. Firstly, the confirmation that uncertain diagnoses in early pregnancy are highly anxiogenic, means that Early Pregnancy Assessment Units can now justify the allocation of resources to help alleviate this distress. This is crucial if we are to improve the holistic nature of the care provided to women with complications of early pregnancy. / Furthermore, the discovery that the double decidual sac sign can accurately predict an intrauterine pregnancy prior to visualization of embryonic contents (and therefore effectively exclude an ectopic pregnancy) means that we can rationalise follow-up, improve consistency and minimise error in the management of women with ultrasonographic evidence of an empty sac in early pregnancy. Although it could be argued that utilization of the double decidual sac sign does not minimise the number of women given uncertain diagnoses in early pregnancy, merely swap concerns regarding location to ones regarding viability, in clinical practice it is the potential consequences of pregnancies of unknown location that are most hazardous, both because of the immediate threat to health and the future threats to fertility. Furthermore, if the findings from our prognosis study are confirmed, and appropriate threshold levels for our biomarkers determined, it may be possible to minimise the duration of uncertainty for women with pregnancies of uncertain viability to hours rather than weeks. Using a combination of approaches therefore, we have achieved the overall aim of this thesis in minimising diagnostic uncertainties in early pregnancy, the clinical benefits of which are multifold. Not only does it reduce anxiety for women, but also prevents unnecessary investigations from being performed in those with an intrauterine pregnancy and minimise morbidity and mortality, permit earlier, potentially less invasive intervention and possibly preserve future fertility for women with an ectopic pregnancy.

This thesis describes the development of a novel system to grade the ‘difficulty’ of an embryo transfer (ET) procedure. A systematic review of the prevalence of ‘difficult’ ET has revealed marked heterogeneity across the literature with no real consensus ‘definition’ or ‘grading system’ available for clinicians to use. A new systematic approach to grading ET procedures has been proposed and tested. It has the ablity to predict IVF outcomes accurately and has proven to be reliable. The ‘difficult’ ET procedure has been shown in this thesis to be detrimental to IVF outcomes when a fresh single blastocyst is transferred. All embryos of different qualities are affected to some degree by a difficult ET, but it appears that high quality blastocysts are proportionally more affected than the lower quality embryos, which have a lower potential to implant, though the mechanism is not clear. The embryo transfer time (ETT) is fundamental in determining the implantation potential of a single blastocyst. Once the ET procedures takes longer than ‘120-seconds’ and ETT is prolonged, there is a significant impact on both pregnancy and clinical pregnancy rates. The detrimental impact of increasing ETT on pregnancy rates was found to be independent of an embryo’s quality. The ETT appears to be a more accurate way to predict IVF outcomes than a stratified grading scale, though combining a descriptive scale with ETT may offer the optimum grading system. This thesis has shown that embryo cooling during ET loading and discharging may be significant. The morphokinetic data evaluated in developing mouse embryos has suggested that embryo hatching may be affected by embryo cooling, but further work is needed to confirm this effect. The ‘novel’ grading system proposed here combines both ETT with a systematic grading system and is based on strong evidence acquired in this work. It has been shown to be reliable and easy to use but it remains for this ‘new’ system to be tested and integrated into clinical practice.

Background: Perinatal mental illness, especially depression, is a leading cause of maternal morbidity and mortality in high-income countries. In the United Kingdom (UK), mental illness commonly presents to and is treated at primary care level; however there are no up-to-date estimates of the burden of different mental illnesses in women in and around pregnancy. The potential impact of mental illness with or without psychotropic medication on the risk of non-live pregnancy outcomes is unclear. In this context, the safety of psychotropic drugs, especially antidepressants, remains controversial. Aim and objectives: To estimate the clinical burden of depression, anxiety and serious mental illness (defined as bipolar disorder, schizophrenia and other related psychotic disorders) presenting to and/or being treated in UK primary care, and to investigate the effects on pregnancy outcomes while trying to differentiate the effects of psychotropic medication from mental illness itself. Methods: Women aged 15-45 years from 1990 to 2009 were identified from The Health Improvement Network, a UK primary care database. Coding of mental illness diagnoses and psychotropic drug prescriptions were examined by separately assessing the proportions of women with recordings of diagnoses, symptoms, and drug prescriptions over the study period. Three separate studies were then carried out. A cross-sectional study was firstly conducted to estimate the prevalence and diagnostic overlap of mental illnesses before, during and after pregnancy and the variation by maternal age, socioeconomic status and other maternal factors. The second study examined the risks of non-live pregnancy outcomes (defined as perinatal death, miscarriage, and termination) in women with no history of depression and anxiety, a diagnosis of such illness prior to pregnancy, illness during pregnancy or illness during pregnancy with use of medication (stratified by medication type). Multinomial logistic regression models were used to compare risks of non-live outcomes across these groups, adjusting for important socio-demographic and lifestyle characteristics. The third study examined the risks of major and system-specific congenital anomalies in children born to women with depression or anxiety that was untreated or treated with psychotropic medication. Logistic regression with a generalised estimating equation was used to compare risks of major congenital anomalies in children exposed and unexposed to psychotropic medication during the first trimester of pregnancy, adjusting for important socio-demographic, lifestyle and chronic comorbidity in the mother. Results: There were 344,042 women who had one or more singleton pregnancies identified between age 15 and 45 from 1990 to 2009. Recording of mental illness and prescriptions of psychotropic drugs increased considerably over the study period. There was high prevalence and overlap of different maternal mental illnesses, especially depression and anxiety, during and after pregnancy, and the prevalence was generally highest in younger, socioeconomically deprived women who had smoked before childbirth, were outside the normal range of BMI and had other chronic medical conditions, such as diabetes. Socioeconomic deprivation was associated with increased risk of all mental illnesses, although the impact of deprivation was more marked in older women. Those aged 35-45 in the most deprived group had 2.63 times the odds of antenatal depression (95% confidence interval [CI] 2.22-3.13) compared with the least deprived; in women aged 15-25 the increased odds associated with deprivation was more modest (odds ratio [OR]=1.35, 95%CI 1.07-1.70). Similar patterns were found for anxiety and serious mental illness. Women with antenatal exposure to antidepressant or anti-anxiety drugs showed the greatest increased risks for non-live pregnancy outcomes, relative to those with no history of depression or anxiety, although women with prior (but currently un-medicated) illness also showed modest increased risks. Compared with un-medicated antenatal morbidity, there was weak evidence of an excess risk in women taking tricyclic antidepressants (TCAs), and stronger evidence for other medications. The absolute risks of major and system-specific congenital anomalies were small in the general population (269 per 10,000 children for major congenital anomalies). Compared with un-medicated antenatal depression or anxiety (278 per 10,000 children for major congenital anomalies), the use of antidepressants during early pregnancy was associated with excess risks, especially for selective serotonin reuptake inhibitors (SSRIs) (290 per 10,000 children for major congenital anomalies). Compared with children born to women with no depression or anxiety, there was an increased risk of heart anomalies in children with antenatal exposure to SSRIs (adjusted OR=1.25, 95% 95%CI 1.02-1.53), particularly in those exposed to paroxetine (adjusted OR=1.89, 95%CI 1.24-2.88). Children exposed to sertraline and escitalopram also had similar increased risks, although fewer women were exposed to these drugs. No increased risks of major congenital anomalies were found in children exposed to TCAs or benzodiazepines; however, the risks of right ventricular outflow tract anomalies were notably higher for all drug classes. Conclusion: Strong socioeconomic inequalities in perinatal mental illnesses occur and persist with increasing maternal age. Women with depression or anxiety have higher risks of miscarriage, perinatal death and therapeutic terminations than women without these diagnoses and the risks are even higher if prescribed psychotropic medication during early pregnancy than if not. There is also an increased risk of congenital heart anomalies in children exposed to paroxetine and other SSRIs during the first trimester compared with those who are unexposed, although the absolute risk is small. There could be other associated factors also related to depression, anxiety or use of medications, which yet unlikely fully explain the observed excess risks. Whilst medicated depression or anxiety could be a marker of more severe illness than un-medicated ones, my findings indicate there may be some specific drug effects Targeting detection and effective interventions to women at risk of mental illness during pregnancy may reduce inequity and avoid substantial psychiatric morbidity, and subsequently reduce the need for further psychotropic treatment. GPs and other health care professionals should take a cautious approach when managing mental illness in pregnant women. The findings in this thesis provide vital information for this purpose, namely helping communicate the magnitude of risk of major congenital anomalies to women with the use of different psychotropic drugs in the context of the baseline risk in the general population.

This retrospective cohort study, examined pregnancy and birth related outcomes for 32,895 births between 1st January 1992 and 31st December 2001 in two maternity units in the East Midlands. The study compared seven outcomes in younger teenagers (<16 year), older teenagers (17-19 years) and a comparison group (20-25 year olds). The sample included 1105 births to younger teenagers, 6923 to older teenagers and 24867 to the comparative group. 14824 were to primiparous women and 18071 were to multiparous women of which 1711 births to multiparous women were rapid repeat births (<18 months of a previous birth). Results showed that compared to those in their early 20s, primiparous teenagers had an increased risk of antepartum haemorrhage (APH) (<16, OR=1.67,95% CI 1.262 to 2.227; 17-19, OR=1.48,95% CI 1.253 to 1.751) and low Apgar score (<16, OR=1.36,95% CI 1.102 to 1.669; 17-19, OR=1.15, 95% CI 1.023 to 1.297) but were less likely to have an instrumental birth (<16, 0R=0.64,95% CI 0.499 to 0.819; 17-19, OR=0.708,95% CI 0.622 to 0.807) or perineal trauma (<16, OR=0.63,95% CI 0.534 to 0.745; 17-19, OR=0.667, 95% CI 0.608 to 0.734). Teenagers had a similar statistical risk as the comparative group for lower segment Caesarean section (LSCS), low birth weight (LBW) and premature birth. Compared to those in their early 20s multiparous older teenagers had a reduced risk of both instrumental (OR= 0.711, 95% CI 0.555 to 0.912) and perineal trauma (OR=0.863, 95% CI 0.752 to 0.99 1) but in younger teenagers there was a similar risk. Multiparous teenagers were at an increased risk of premature birth (<16, OR=1.934,95% CI 1.153 to 3.243; 17-19, OR=1.227,95% CI 1.043 to 1.442) but for LSCS, low Apgar score and low birth weight a similar statistical risk was found as the comparative group. When comparing multiparous teenagers with primiparous teenagers, multiparous teenagers had a reduced risk of instrumental birth (OR=0.429, 95% CI 0.339 to 0.541), perineal trauma (OR=0.668, 95% CI 0.595 to 0.750), low Apgar score (OR=0.782,95% CI 0.664 to 0.921) and LBW (OR=0.760, 95% CI 0.587 to 0.982) but an increased risk of premature birth (OR=1.269, 95% CI 1.061 to 1.517). For the remaining outcomes both primiparous and multiparous teenagers had a similar statistical risk. Teenagers having a rapid repeat birth had a reduced risk of instrumental birth (OR=0.32, 0.110 to 0.931) but an increased risk for premature birth (OR=1.617 95% CI 1.150 to 2.272). For APH, Apgar score and LBW teenagers having a rapid repeat birth had a similar statistical risk to those who had not. In conclusions teenagers should not be treated as a homogenous group and outcomes should be investigated separately for age groupings and parity as teenagers birth well and only APII and neonatal complications are worse in some groups of teenagers.

Increasing the uptake of elective single embryo transfer is necessary to achieve the 10% HFEA limit for multiple IVF births in 2011. This thesis aims to explore patients’ and clinicians’ attitudes to eSET and to promote effective decision making regarding embryo transfer. Study 1 compared neurobehavioural outcomes between twins and singletons in a prospective study of infants born very preterm (n=233). Despite having older (p=0.025) and higher social class (p=0.023) mothers, twins had the same risk of cognitive impairment at 2 years as singletons. In study 2, a 44 item Attitudes to Twin Pregnancy scale (ATIPS) was developed and administered to a sample of clinicians, medical students and conference delegates (n=411). Item analysis reduced ATIPS to 2 short subscales. A-Twin (12 items) assessed perceptions of risks and benefits associated with a twin birth (α=0.7). A-SET (8 items) assessed attitudes to eSET (α=0.53). Study 3 explored the reliability and validity of ATIPS-R in IVF patients. Exclusion of 2 A-SET items increased alpha to 0.8. Female patients (n=100) had more positive attitudes to a twin birth than clinicians (p=<0.001). Less than a third of patients felt that a twin birth was risky for infants and over 80% of doctors agreed that a twin birth was worth any risks to infants. First cycle IVF patients were more positive about eSET (p=<0.001) than women undergoing repeat cycles. Study-4 developed a decision aid and evaluated its impact in a pilot randomised controlled trial (n=8). Lower decisional conflict in patients at embryo transfer was associated with more positive attitudes to twins at baseline (p=0.024) and less positive attitudes to eSET, (p=0.04). Although the attitudes of patients receiving the DA did not change, partners became more positive towards eSET (p=0.024). Conclusion: Patients and clinicians underestimate the risk of a twin birth for infants and would benefit from educational interventions to promote eSET. The ATIPS-R is a useful measure for assessing the effectiveness of such interventions. Abbreviations: SET- single embryo transfer; HFEA- Human fertility and embryology authority; IVF- In vitro fertilisation; A-Twin- attitude to risks and benefits of twins; ATIP- attitude to twin IVF pregnancy; A-SET attitude to single embryo transfer; eSET- elective single embryo transfer; DET- double embryo transfer; RCT – randomised control trial; DA- decision aid.

A method for measuring human platelet Angiotensin II (All) binding was validated, and characterisation studies involving 67 non-pregnant subjects were performed. Platelets were found to possess high affinity binding sites with many of the characteristics of receptors. No correlation was found between platelet All binding and the rise in intracellular free calcium after ex vivo All infusion, thus formal validation of the binding sites as receptors was not achieved. In 25 non-pregnant subjects, there was an inverse correlation between platelet All binding and simultaneously measured plasma All (P<0.02). In 10 ovulatory subjects, platelet All binding diminished in the luteal phase of the menstrual cycle (P<0.02). In a pilot cross-sectional study of platelet All in normotensive pregnancy, incorporating 125 pregnant/postnatal patients, platelet All binding was significantly lower in 1st trimester patients as compared to non-pregnant subjects (P<0.001). Platelet All binding remained low throughout pregnancy. Higher values, approximating to the non-pregnant level, were found 6 weeks postnatally. These findings were confirmed in a longitudinal study .of 30 pregnant women, with a diminution in platelet All binding being suggested by 5-8 weeks gestation (p= 0.02). Inverse correlations in pregnancy between platelet All binding and the components of the renin-angiotensin system were found (P<0.01). There were also significant correlations between platelet All binding and the levels of serum sodium, urea and osmolality (P<0.01). When platelet All binding was measured in 67 patients with established hypertension in pregnancy, binding in patients with pregnancy induced hypertension (PIH) was significantly higher than in normotensive primigravidae (P<0.0001). No differences in binding were found in the puerperium. In a prospective comparison of platelet All binding and the All sensitivity test in predicting the development of PIH, involving 34 subjects, platelet All binding was a more effective discriminant than any of the parameters derived from the All sensitivity test. There was a significant correlation between platelet All binding and the slope of the curve relating the diastolic pressor response to infused All (P<0.01).

Hypothesis: This thesis set out to test the hypothesis first proposed by Baker et al (1995) that Vascular Endothelial Growth Factor (VEGF) may be involved in the alteration in endothelial function that is observed in the disease of pre-eclampsia. Aims: To investigate concentrations of VEGF in plasma from non-pregnant, and normal pregnant women and women with pre-eclampsia. To investigate uterine and placental expression of VEGF in non-pregnant, normal pregnant women and women with pre-eclampsia. To investigate some of the vascular adaptations that occur in pregnancy and pre-eclampsia within the uterine and systemic circulations. To investigate the effect of plasma from women with PE and VEGF on i) An in vitro endothelial cell culture model. ii) An in vitro isolated vessel model. To characterise the mechanism whereby VEGF causes any alteration in vascular function.

Preeclampsia and fetal growth restriction (FGR) are common and costly obstetric complications. Both conditions are associated with immediate and remote mortality and morbidity for the mother and the offspring. Impaired placentation and aberrant maternal systemic responses are implicated as pathophysiological mechanisms in preeclampsia and FGR. Both preeclampsia and FGR are known to have a clear genetic basis. This study has investigated the roles of several candidate genes including those previously associated with diabetes (TCF7L2, FTO, PPAR-g, CDKN2B-AS1 and KCNJ11), and epidermal growth factor (EGF). Functional consequences of variants within the EGF gene were also investigated. A bidirectional association between type 2 diabetes (T2D) and preeclampsia is consistently reported, whereby each condition is associated with an increased risk of the other. Furthermore, fetal growth restriction, which complicates 30% of preeclamptic pregnancies, predisposes the offspring to an increased risk of type 2 diabetes and coronary artery disease (CAD) later in life. 11 single nucleotide polymorphisms (SNPs) reproducibly associated with T2D in the TCF7L2, FTO, PPAR-y, CDKN2B-AS1 and KCNJ11 genes were investigated as susceptibility loci for preeclampsia and fetal growth restriction in a maternal case control study. The study group consisted of 448 white western European women with preeclampsia, 673 controls with no evidence of preeclampsia, 243 women with pregnancies complicated by FGR, and 570 controls with no evidence of growth restriction. A maternal haplotype on the T2D region of the CDKN2BAS1 gene on chromosome 9p21 was found to be a risk variant for fetal growth restriction (P=O.005).The other 9 investigated SNPs in TCF7L2, FTO, PPAR-y, and KCNJ11 showed no association with growth restricted pregnancies. None of the SNPs investigated showed an association with preeclampsia. These findings suggest that some maternal diabetogenic risk variants are associated with an altered risk of FGR pregnancy but not preeclampsia. The results require replication in a larger sample and fetal-maternal gene interactions merit investigation. Epidermal growth factor (EGF) is described as a major regulator of the placentation process. It also helps to maintain an adequate blood supply to the growing fetus through its effects on umbilical vessel tone. Investigating the role of two genetic variants of the EGF gene in susceptibility to preeclampsia and FGR showed that the maternal variants, rs4444903 in the 5'UTR and rs2237051 in exon 14 of the EGF gene has no effect on the risk of preeclampsia or FGR pregnancy. The G allele of the SNP rs4444903 was associated with higher systolic blood pressure measures in the control group. The G allele of the rs4444903 and the A allele of rs2237051 have been associated with increased risk for FGR and lower birth weight in a previous study from our laboratory. This led to investigations to characterize the functional consequences of the two SNPs in the EGF gene on transcription, translation and ribonucleic acid (RNA) splicing using a variety of methods. These experiments have shown that the G allele of rs4444903 was transcriptionally more active than the A allele in hepatocellular carcinoma (HepG2) and more active than EGFP on its own in choriocarcinoma (Jeg-3) cell lines using a luciferase reporter gene assay. There was no effect of this variant on translational efficiency in the cell lines investigated using reporter gene assays, or in a cell free environment using an in vitro translation assay. DNA-protein interaction was investigated using nuclear extract from HepG2 cells to further define the mechanism by which the G allele exerts its higher transcriptional activity. Initial experiments suggest that the Sp1 transcription factor interacts with and represses the A allele of the rs4444903 SNP. The study also demonstrated no evidence of higher activity of the G allele on EGF expression in vivo using term placental tissues. It was expected that higher EGF expression as a function of genotype at rs4444903 SNP may lead to down regulation of the EGFR in the placenta, which was not confirmed in this study. SNP rs2237051 in exon 14 of the EGF gene is in strong linkage disequilibrium with rs4444903, and disrupts a predicted exon splicing enhancer region. This polymorphism was investigated using a minigene assay, but there was no evidence that it affected splicing of exon 14. Taken together, these findings provide no evidence that EGF genetic variants alter the risk of preeclampsia or FGR though functioning.