Regulation of the growth and differentiation of trophoblast cells is critical for successful embryo implantation and placentation. Cytokines are key players in these processes, as well as modulating the maternal immune response to prevent rejection of the conceptus. This thesis focused on the investigation of the cytokine interleukin (IL) - 33 and its receptor, ST2. ST2 has two isoforms, a functional cell surface receptor (ST2L) and a soluble decoy receptor (sST2). Previous work in this laboratory had shown that the human placenta expresses both IL-33 and sST2 at term. The aim of this thesis was to investigate IL-33 and ST2 in early pregnancy, the time when trophoblast is at its most active, with a view to better understanding their role. IL-33 and ST2 mRNA and protein were examined in 14 first trimester placentas from 6-12 weeks of gestation. IL-33 was localized to cells in the villous stroma, whereas ST2 was present in the syncytiotrophoblast, villous cytotrophoblast and the invasive extravillous cytotrophoblast of the cell columns. Secretion of sST2, but not IL-33, by the placenta was found. Investigation of pre-implantation embryos showed the presence of ST2, but not IL-33 protein. Decidualized endometrium was investigated as a potential source of IL-33 and sST2 at the maternal-fetal interface and, although mRNA for both was present, no protein could be found. The key finding was that sST2, rather than ST2L, was the predominant isoform in the placenta. This led us to reconsider the hypothesis that IL-33/ST2 interactions in the placenta are important for successful pregnancy and raised the possibility that they may have independent roles. Using trophoblast cell lines as a model, it was shown that sST2 binds to trophoblast cells, significantly inhibits their proliferation and stimulates their invasion in vitro. This is the first report of this novel role for sST2 in pregnancy. Thus these studies have shown that sST2 may play an important role in implantation and placentation through controlling trophoblast invasion.

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

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.

Endometriosis is a common cause of subfertility and pelvic pain, affecting up to 10% of women of reproductive age. It is characterised by the presence of endometrial-like tissue outside the uterus. The development of the disease is still poorly understood and, currently, the diagnosis relies on visualisation of typical lesions during surgery. There is great interest in identifying biomarkers to assist in diagnosis and disease management. Blood vessel development is known to be a crucial feature of endometriosis, but the mechanisms involved in angiogenesis are not well described for this disease. Most vessel development relies on the proliferation and migration of pre-existing endothelial cells. However, there may also be roles for cells derived from peripheral blood (circulating angiogenic cells) and surrounding stromal cells. In this thesis, the contribution of these different cell types to vessel development in endometriosis is assessed. In chapter 2, a robust protocol was optimised to identify circulating angiogenic cells (CACs) with flow cytometry. The reliability of the protocol was verified, and the level of these cells was found not to fluctuate with the menstrual cycle in healthy women (P=0.279, F=1.359, 3 d.f.). In chapter 3, levels of CACs in women with and without endometriosis were found to be equivalent (0.0835% ± 0.0422 compared to 0.0724% ± 0.0414), demonstrating that they have no use as a disease biomarker. In chapter 4, isolation and culture of endothelial cells from the endometrium was attempted. However, a pure culture of endometrial endothelial cells could not be obtained, which may be due to contamination by other cell types or cellular transdifferentiation. Finally, in chapter 5, the contribution of endometrial stromal cells to vessel development was considered. Stromal cells were found not to differentiate towards an endothelial cell phenotype, but were able to participate in tube formation assays. However, the presence of endometriosis did not influence this behaviour.

<p>De senaste åren har antalet kejsarsnitt på humanitär indikation ökat i Sverige. Den vanligaste bidragande orsaken till detta är förlossningsrädsla. Med förlossningsrädsla menas att man känner ångest och fruktan inför sin förlossning.</p><p>Syftet med denna litteraturstudie är att belysa faktorer som kan påverka upplevelsen av förlossningsrädsla samt vilket behov av stöd förlossningsrädda kvinnor behöver. Metoden som användes var en systematisk litteraturstudie som omfattade 16 vetenskapliga artiklar. Vid granskningen av dessa artiklar bildades två huvudkategorier, dessa var; upplevelser och stöd. Resultatet visade att den vanligaste upplevelsen vid förlossningsrädsla var rädsla för smärta och oron för sin och sitt barns hälsa och välmående. Förlossningsförloppet var också något som orsakade rädsla hos vissa kvinnor. Mest utsatta för förlossningsrädsla var kvinnor som led av dålig självkänsla och tvivlade på sin prestationsförmåga. Kvinnans tidigare erfarenheter spelade en stor roll vid upplevelsen av förlossningen. Den bästa vård förlossningsrädda kvinnor kan få är stöd från sin omgivning och vårdpersonal. Den mest framgångsrika behandlingsmetod enligt denna litteraturstudie var terapi.</p><p>En slutsats blev att det är viktigt att upptäcka kvinnans förlossningsrädsla i ett tidigt stadium och att omvårdnaden är individualiserad.</p>

<p>Bakgrund: Ordet abort kommer från det latinska ordet aboriri som betyder att förgås eller att gå ned. Ungefär hälften av alla kvinnor i Sverige gör någon gång en abort. Enligt den svenska abortlagen har kvinnan ett fritt val till abort och måste själv komma fram till det bästa beslutet. I denna process förtjänar hon stöd och respekt, oavsett hur hon valt att hantera sitt moderskap. Syfte: Syftet med denna litteraturstudie var att belysa kvinnors upplevelser samt behov av omvårdnad vid inducerad abort. Metod: Studien genomfördes som en litteraturstudie där 16 artiklar inkluderades och som granskades. Resultat: Resultatet visade att de vanligaste orsakerna till att kvinnor genomförde en inducerad abort var på grund av ekonomiska skäl, en ostabil relation och arbetsförhållanden. Kvinnors upplevelser vid inducerad abort var att de kände både positiva och negativa känslor. De positiva var bland annat; lättnad, ökad självkänsla och personlig mognad. De negativa känslorna var bland andra; skuld, oro och nedstämdhet. När det gällde behovet av stöd från vårdpersonalen kände de att personalen var stöttande och informativa men även att de kunde vara kalla och ignorerande. Slutsats: Det behövs mer forskning inom området, behov av stöd till kvinnor som genomgår en inducerad abort, för att vårdpersonalen ska kunna bemöta kvinnorna på bästa möjliga sätt.</p>

De senaste åren har antalet kejsarsnitt på humanitär indikation ökat i Sverige. Den vanligaste bidragande orsaken till detta är förlossningsrädsla. Med förlossningsrädsla menas att man känner ångest och fruktan inför sin förlossning. Syftet med denna litteraturstudie är att belysa faktorer som kan påverka upplevelsen av förlossningsrädsla samt vilket behov av stöd förlossningsrädda kvinnor behöver. Metoden som användes var en systematisk litteraturstudie som omfattade 16 vetenskapliga artiklar. Vid granskningen av dessa artiklar bildades två huvudkategorier, dessa var; upplevelser och stöd. Resultatet visade att den vanligaste upplevelsen vid förlossningsrädsla var rädsla för smärta och oron för sin och sitt barns hälsa och välmående. Förlossningsförloppet var också något som orsakade rädsla hos vissa kvinnor. Mest utsatta för förlossningsrädsla var kvinnor som led av dålig självkänsla och tvivlade på sin prestationsförmåga. Kvinnans tidigare erfarenheter spelade en stor roll vid upplevelsen av förlossningen. Den bästa vård förlossningsrädda kvinnor kan få är stöd från sin omgivning och vårdpersonal. Den mest framgångsrika behandlingsmetod enligt denna litteraturstudie var terapi. En slutsats blev att det är viktigt att upptäcka kvinnans förlossningsrädsla i ett tidigt stadium och att omvårdnaden är individualiserad.

Bakgrund: Ordet abort kommer från det latinska ordet aboriri som betyder att förgås eller att gå ned. Ungefär hälften av alla kvinnor i Sverige gör någon gång en abort. Enligt den svenska abortlagen har kvinnan ett fritt val till abort och måste själv komma fram till det bästa beslutet. I denna process förtjänar hon stöd och respekt, oavsett hur hon valt att hantera sitt moderskap. Syfte: Syftet med denna litteraturstudie var att belysa kvinnors upplevelser samt behov av omvårdnad vid inducerad abort. Metod: Studien genomfördes som en litteraturstudie där 16 artiklar inkluderades och som granskades. Resultat: Resultatet visade att de vanligaste orsakerna till att kvinnor genomförde en inducerad abort var på grund av ekonomiska skäl, en ostabil relation och arbetsförhållanden. Kvinnors upplevelser vid inducerad abort var att de kände både positiva och negativa känslor. De positiva var bland annat; lättnad, ökad självkänsla och personlig mognad. De negativa känslorna var bland andra; skuld, oro och nedstämdhet. När det gällde behovet av stöd från vårdpersonalen kände de att personalen var stöttande och informativa men även att de kunde vara kalla och ignorerande. Slutsats: Det behövs mer forskning inom området, behov av stöd till kvinnor som genomgår en inducerad abort, för att vårdpersonalen ska kunna bemöta kvinnorna på bästa möjliga sätt.

The key functions of the mammalian ovary are the production of fertilizable oocytes and thesecretion of steroid hormones. At the time of birth the human ovary is composed of basic unitstermed primordial follicles. Primordial follicles are long-lived structures in the ovary and some ofthem last until the woman reaches menopause. However, the intra-oocyte signaling pathways thatactivate primordial follicles and early follicular development are largely unknown. In this thesis, the functional roles that the phosphatidylinositol 3-kinase (PI3K) signaling pathwayplays in follicular development were investigated. In vivo approaches using genetically modifiedmouse models were used to determine the functions of several members of the PI3K signalingpathway in oocytes and in follicles. The function of Foxo3a, a substrate of Akt, was investigatedby expressing Foxo3a constitutively in oocytes of primary follicles. We found that continuouslyactive Foxo3a in mouse oocytes caused retardation of oocyte growth, resulting in arrest offollicular development. The functions of p27kip1 (p27) were studied using p27-deficient (p27-/-)mice. It was found that p27 suppresses follicle endowment/formation and activation, and that itinduces follicle atresia. The functions of PI3K signaling in oocytes during follicular activationwere also investigated using conditional mutant mice, by disrupting the Pten in oocytes ofprimordial follicles. We found that, all primordial follicles were prematurely activated due toovergrowth of oocytes and these follicles were depleted in young adulthood, causing prematureovarian failure (POF). At the same time, disruption of the Pten from oocytes of primary follicleshad no effect on activation of primordial follicles, and the follicles developed and maturednormally. The results clearly show that the PI3K pathway in the mammalian oocyte plays a keyrole in follicular activation through control of initiation of oocyte growth and folliculardevelopment. / Ovary development

Introduction. Allopregnanolone and pregnanolone (neuroactive metabolites of progesterone) act as positive modulators of the GABAA receptor system which is the major inhibitory system in CNS. Contradictory results on the effect of GABAA receptor modulators are reported. Beneficial properties such as anaesthesia, sedation, and anxiolysis are reported as well as adverse, anxiogenic and aggressive effects. It has been suggested that GABAA receptor agonists have bimodal effects. Low concentrations increase an adverse, anxiogenic effect, whereas higher concentrations show beneficial, calming properties. Aims. To investigate if progesterone treatment induces adverse mood in postmenopausal women and if the severity in mood symptoms is related to progesterone, allopregnanolone or pregnanolone serum concentrations. To evaluate differences in steroid concentrations induced by different doses and routes of administration of progesterone. Methods. Two randomised, placebo-controlled, double-blind crossover studies of postmenopausal women were performed. Subjects were treated with estradiol continuously. Different doses of progesterone, given vaginally or orally, were added sequentially during the last 14 days of each treatment cycle. Daily symptom ratings were kept using a validated rating scale. Blood samples for progesterone, allopregnanolone and pregnanolone analyses were collected during each treatment cycle. A study regarding the pharmacokinetics after ingestion of low-dose oral progesterone was conducted with postmenopausal women. Blood samples for the analyses of progesterone, allopregnanolone and pregnanolone were collected and pharmacokinetic parameters were calculated. Results. Certain postmenopausal women on sequential HT with vaginal and oral progesterone experience mood deterioration during the progesterone phase while on a low dose of progesterone but not on higher doses or the placebo. Negative mood symptoms occurred when the serum concentration of allopregnanolone was similar to endogenous luteal phase levels, whereas lower and higher concentrations had no effect on mood. Pharmacokinetic analyses show that low-dose oral progesterone can be used as a prodrug to allopregnanolone when the aim is to achieve physiological concentrations of allopregnanolone. Conclusions. A bimodal association between allopregnanolone concentration and adverse mood is observed in postmenopausal women treated with progesterone. The addition of low-dose progesterone to estradiol induces adverse mood in postmenopausal women, whereas higher doses and placebo have no mood-deteriorating effect.