Academic literature on the topic 'RG Gynecology and obstetrics : RA Public aspects of medicine'

Altering maternal nutrition affects fetal development and can have long-lasting effects on the offspring, potentially predisposing them to later metabolic disease. These effects can occur without affecting birth weight, although small for date offspring appear to be at increased risk. One mechanism linking changes in the maternal environment to an increased risk of later disease is enhanced exposure to glucocorticoids (GC). Tissue sensitivity to cortisol is regulated, in part, by the GC receptor (GR) and 11-beta-hydroxysteroid dehydrogenase (11βHSD) types 1 and 2. Several studies have shown the effects of maternal nutrient restriction on the programming of GC action in the offspring, however, dietary excess is far more characteristic of the diets consumed by contemporary pregnant women. The aim of this thesis was to provide a novel insight into the effects of moderate changes in the macronutrient ratio, within the maternal diet fed to pigs (whilst maintaining energy content), on offspring growth, development and liver metabolism until adolescence. Fat supplementation (Fat supplemented (FS): 9 %; Control (C): 2.5 %) from day 0 until 110 of gestation, reduced maternal glucose tolerance at term and decreased the survival rate of piglets after birth, possibly due to hypoglycaemia. In addition, supplementing the maternal diet with protein (Protein supplemented (PS): 16.3 %; C: 12.3 %) also increased the incidence of postnatal mortality, with surviving offspring demonstrating an up-regulation of mRNA transcripts involved in GC sensitivity i.e. GC receptor and 11βHSD-1, in the liver. Furthermore, this thesis demonstrated no negative effects of accelerated postnatal growth on low-birth weight piglets as others have suggested. In conclusion, this thesis has demonstrated a detrimental effect of fat and protein supplementation until day 110 of gestation on postnatal mortality. These findings could have profound consequences for the pig industry where reducing piglet mortality is of economic importance. In addition, an increased level of protein in the diet during gestation increases GC sensitivity in the offspring which may be indicative of excess GC exposure in utero. These types of adaptations could have significant implications in determining the programming effects of maternal diet on adult disease risk.

Evidence from human and animal studies has highlighted the sensitivity of the developing fetus to environmental insults, such as maternal undernutrition, during gestation. These nutritional perturbations to the intrauterine milieu may engender a legacy of deleterious health consequences in adulthood. This thesis presents a series of studies which test the `mis-match‘ fetal programming theory; that is, whether a nutritionally poor diet prenatally interacts with a nutritionally excessive diet postnatally to overtly increase risk factors for adult disease. The effect of a maternal global energy restriction is contrasted against a maternal specific protein restriction, each fed during either early or late gestation. Adult offspring were subsequently exposed to an obesogenic environment (elevated feed with increased lipid content whilst restricting physical activity). Offspring metabolic flexibility and competence were assessed through routine blood samples throughout postnatal life and at 7, 18 and 24 months of age by glucose (GTT) and insulin (ITT) tolerance tests and body composition by dual energy x-ray absorptiometry. In general males appeared more susceptible to developmental programming than females at a number of timepoints. Furthermore, an increased first-phase or incremental area-under-the-insulin-response curve was observed in 1) offspring following maternal protein restriction in early gestation at 7 and 24 months of age, despite maternal protein restriction in late gestation significantly reducing birthweight and 2) in offspring exposed to maternal energy restriction during late gestation at 24 months of age in response to a GTT. Since, in both groups, the response of all offspring to an ITT (from a euglycemic baseline) was similar, infers that developmental programming in sheep followed by nutritional excess is first revealed as affecting either the pancreas (~insulin hypersecretion) or the liver (hepatic insulin resistance, reduced first-pass insulin metabolism). The studies illustrate the importance of habitual consumption of an `optimal’ balanced diet through gestation on postnatal health, especially in light of the current obesity epidemic.

This thesis is a contribution to the literature and debate on health inequalities and in particular on health care delivery to ethnic minority women and children. Its argument is that when discussing the causes of health inequalities of ethnic minorities, a perspective which focuses solely on the gender, ethnicity, or class of the ethnic minority is inadequate. It is argued that health outcomes, service delivery and experience of patients is shaped by the way gender,ethnicity and class intermesh. The specific context of the research is the organisation, delivery and experience of formal and informal health care to Negev Bedouin Arab mothers and their infants during and after childbirth in hospital and during the first two months post partum. Methodologically a combination of qualtitative and quantitative data have been collected over a period of four years. The quantitative data are from an epidemiological infant feeding study which was carried out from 1981-83 and which the researcher coordinated. A subsample of 412 women and their infants in this study were interviewed after delivery, during their stay in hospital and subsequently at home between 40-50 days after birth. The qualitative data was gathered in 1984 by observation and unstructured interviewing with Bedouin Arab women both in the hospital setting and in two sub tribes, one of which was living in a neighbourhood of a planned urban settlement and the other was living in an encampment. The mothers and grandmothers interviewed during the fieldwork were women known to the researcher from fieldwork undertaken 12 years previously in the Negev. This thesis explores the way in which the quantitative and qualitative data complement each other. In Part One there are three introductory chapters. Chapter 1 explores the literature on gender, ethnicity and class relations both in general and in relation to health inequalities. Chapter 2 sets out the gender, ethnicity and class relations of Negev Bedouin Arab society and Israeli society in general and in the delivery of health care. Chapter 3 sets out the methodology both theoretically and empirically. Part Two is comprised of Chapters 4 and 5 which deal with hospital care to mothers and infants at childbirth and post partum. Part Three focuses on the informal health care setting of the home. Chapter 6 deals with the care given to mothers in the home during the first 40 days. Chapters 7 and 8 explore the health of the infants in terms of their growth and development and how this is related to mother's infant feeding options and their socio economic environment. The way in which gender, ethnicity and class relations intermesh in Israeli and Bedouin Arab society influences both the living conditions and the health outcomes of the infants. Chapter 9 sets out the conclusions which are subdivided in to those which are pertinent to the theoretical debate on gender, ethnicity and class relations and health inequalities, those which are methodological, and those which are pertinent to enhancing health service delivery in this setting.

Hysterectomy is commonly performed but there is scant evidence concerning appropriate follow-up by vaginal vault cytology testing. This observational, retrospective cohort study, using routinely collected data, linked women’s entire cervical screening histories with their operation details and subsequent vault cytology test results, to establish: Which women are having hysterectomies? What was the indication? Which were followed-up? How did they differ from those who were not? 6,141 women underwent hysterectomy; an incidence of 23/10,000 women/pa. 11.61% had malignancy, 3% had CIN and 82.9% had benign disease. Median age was 48years, women were of greater deprivation and different ethnicity from the background population. Post-operatively 1,016 (16.5%) had vault cytology testing. Those having CIN at total hysterectomy should have vault cytology but only 63% had any, of these less than 10% had it according to protocol. Many factors were associated with having vault cytology (younger, less deprived, non-benign diagnosis and abnormal index cytology) but few clinically meaningful. Only 2.9% of vault cytology tests were abnormal. Efforts to identify and eradicate inappropriate use of vault tests should swiftly lead to savings. Although national guidelines are targeting the right women, it is recommended that all vaginal vault cytology should be undertaken in secondary care hereafter.

Waterbirths have been available in the United Kingdom as a method of pain relief for childbirth for over two decades but the neonatal safety of birth in water remains unevaluated. Opponents of a waterbirth randomised controlled trial state randomisation would undermine women’s childbirth experience. In addition, little is known about midwives’ attitudes to waterbirths. This thesis addresses some of the lack of evidence by reporting the findings of two studies which had three aims: to investigate the feasibility of a waterbirth RCT to assess the effects of a waterbirth on the neonate, to explore women’s thoughts about participation and whether randomisation affects women’s satisfaction with their childbirth experience and to assess midwives’ attitudes to waterbirths. The first study involved a RCT with a ‘preference arm’. Eighty women were recruited: 60 in the RCT and 20 in the ‘preference arm’. Women were asked to complete questionnaires to assess their expectations for, and satisfaction with, their childbirth experience: at recruitment, after the birth and 6 weeks after the birth. Women in the randomised arm indicated willingness to partake but questioned midwives’ commitment to offering waterbirths. A Q Methodology study was undertaken to identify factors which influence midwives’ (n=31) attitudes towards waterbirths. Four factors were identified: Motivation, Risk Assessment, Confidence, Safety. Conclusion: It is feasible to organise a larger RCT to assess neonatal safety and women would be supportive. Strategies would be required to ensure midwives are confident and supportive of the waterbirth service.

Background: With increasing numbers of people with a learning disability (LD) choosing to become parents (Booth and Booth, 1994) it is important the right support is provided to enable them to parent effectively (Macintyre and Stewart, 2011). Materials and Methods: This study used semi-structured interviews with four women with a LD who received doula support prenatally, during labour and postnatally. The women were interviewed during prenatal and postnatal support periods. The doulas were interviewed about their experience of supporting a woman with a LD towards the end of the postnatal support period. Results: Interview transcripts were analysed using Interpretive Phenomenological Analysis (IPA). Themes were identified from each of the ten interviews, before analysis of themes for the same support phase were analysed together for mothers and doulas, allowing discussion of similarities and differences. Conclusions: The findings show that prenatally the women considered the doula to be a reliable source of information about pregnancy and birth. Each mother perceived doula support as a means of keeping her child in her care. Postnatally, mothers described a trusting relationship with their doula, which enabled them to make informed choices. Doulas described the need to adapt their work to meet the needs of parents with LD. The experience of working alongside statutory agencies was perceived as potentially challenging, and an important area for supervision.

Background: Breastfeeding has the potential to significantly improve public health. As part of UK government policy peer support interventions have been recommended to increase breastfeeding rates but the evidence base for this is of low quality. Methods: The aim of this thesis was to investigate the effect of breastfeeding peer support on initiation though a systematic review; on continuation through an RCT and a systematic review; and to explore women’s experiences through a qualitative study. Results: Universal peer support to improve breastfeeding initiation was ineffective. Peer support for breastfeeding continuation in both the RCT and review findings appears to be effective in low/middle income countries; when provided in an intensive schedule of contacts (>5 contacts); and given in the postnatal period. Women’s experience of peer support is generally positive and those interviewed gave several suggestions to how current local services may be modified. Conclusions: Peer support per se, in any format in the UK-setting, has not been supported. Targeted and intensive peer support may improve breastfeeding rates in the UK but this must be evaluated using high-quality methodologies. Peer support appears to be effective in the developing world, were it is intensive and targeted to those already considering breastfeeding.

Background: The scope of postpartum pelvic dysfunction and perineal trauma is under-researched. Instrumental vaginal delivery or 3rd/4th degree tears were recognised risk factors for pelvic/perineal dysfunction; caesarean delivery was not implicated. Aims: • To analyse obstetrical/biological factors associated with pelvic dysfunction after caesarean or non-instrumental vaginal delivery • To compare these associations between groups after determining frequencies • To evaluate severity of pelvic/perineal dysfunction, including quantifying maternal perception of the psychosocial impact Participants and Methods: 284 primiparae (184 caesarean, 100 vaginally delivered) had domiciliary, in-depth medical interviews using structured and open questioning. Results: Caesarean (elective, emergency) vs. vaginally delivered were compared: Stress incontinence manifested in 60/184 (33%, 33%) vs. 54/100 (54%), anal incontinence in 94/184 (53%, 50%) vs. 44/100 (44%), dyspareunia in 50/184 (28%, 27%) vs. 46/100 (46%), haemorrhoids in 3/184 (2%) vs. 5/100 (5%) and double incontinence with dyspareunia in 33/284 (14%, 10% vs. 12%). Sixty sustained perineal trauma. Delivery mode and non-labour factors were predictors. Severity was evaluated by devising a psychosocial measure tailored to maternal functioning. New faecal incontinence necessitated continuous perineal protection in two pre-labour caesarean and one vaginally delivered mother. Severe dysphoria was associated with incontinence (p=0.038, OR 2.334, CI 1.049, 5.192), dyspareunia (p=0.005, OR 2.231, CI 1.272, 3.914) and post-caesarean wound problems (p=0.022, OR 3.620, CI 1.203, 10.896). Incontinence impaired leisure activities (p=0.036, OR 2.165, CI 1.051, 4.463) and employment (p=0.023, OR 1.912, CI 1.093, 3.345); caesarean mode affected social-networking (p=0.018, OR 2.438, CI 1.166, 5.099) and employment (p=0.031, OR 1.967, CI 1.064, 3.636). Conclusions: Pelvic/perineal dysfunction was: ▪ Predicted by caesarean or non-instrumental vaginal delivery, with anal incontinence being more prevalent post-caesarean ▪ Comparable following elective or emergency caesarean ▪ Associated with severe and quantifiable biopsychosocial maternal morbidity.

Epidemiological studies indicate that the prevalence of obesity and overweight is increasing rapidly in both developed and developing countries. Against this background it is important to determine the effects of obesity upon health and well-being. Defining the impact of obesity upon behaviour lies within the scope of such studies. It is known that variation in the maternal diet during early sensitive periods of development can programme risk of obesity and metabolic dysfunction in offspring. Although the effect of maternal obesity and/ or obesogenic diet throughout pregnancy and lactation on a wide range of physiological systems in rats is well documented, the effect of such manipulations on behaviour is yet to be elucidated in detail. The initial aim of the present thesis was to use a rat model to investigate the relative contribution of maternal obesity induced by a hyperenergetic cafeteria diet (CD) prior to pregnancy and/or maternal exposure to the CD during pregnancy and lactation, on anxiety and exploratory behaviour in adult offspring. Despite all of the maternal feeding periods having some contribution to offspring behaviour, the lactation period appeared to be the most important, with maternal CD having an anxiolytic effect in offspring exposed to the elevated plus maze and open field paradigm. It was hypothesized that maternal exposure to CD during lactation would also impact upon appetite related behaviour and performance on behavioural measures of learning and memory in adult offspring. Maternal CD during the lactation period altered feeding behaviour as measured by the behavioural satiety sequence in adult offspring of both sexes. The structural integrity of feeding behaviour was grossly perturbed in female offspring, with a significant delay in the onset of satiety. Maternal CD during lactation enhanced memory performance on a novel object discrimination paradigm in male offspring, but reduced performance of females. CD feeding during lactation increased both 5-hydroxytryptamine (5-HT) and dopamine (DA) concentration and reduced 5-HT turnover in the hypothalamus, but not the hippocampus or the frontal cortex, in both male and female offspring. The findings outlined in the present thesis demonstrate for the first time that maternal exposure to an obesogenic diet during early sensitive periods of development can programme a range of behaviours in adult offspring of both sexes.

The modern Western diet is typically high in salt and fructose. Variations in maternal diet can have delayed developmental effects on the adult offspring’s cardiovascular function leading to acute or chronic hypertension. The aim of the work in this thesis was to determine the effect of moderate dietary salt and/or fructose intake on maternal and fetal growth, metabolic status and cardiovascular health of the adult offspring. Sprague Dawley rats were fed either 1) control diet (chow) with tap water, 2) salt diet, 4% NaCl, 3) fructose diet, purified chow plus 10% fructose in tap water or 4) fructose and salt diet for 28 days prior to conception, through gestation and lactation. Data were collected on the non-pregnant and pregnant dam, the fetus and neonate and the adult offspring. Cardiovascular data in adult offspring were recorded between the ages of 10-15 weeks by implanted radiotelemetry probes. Dams fed fructose prior to and during gestation increased caloric intake (P<0.001) from fructose water with a consequential decrease in total energy intake (P<0.001) from food. Increases in plasma glucose (P=0.04) (without an effect on insulin), triglyceride (P<0.014), non-esterified fatty acids (P<=0.05), cholesterol (P<0.001) and uric acid (P<0.004) were all increased by the consumption of fructose in pre-gestational females. Dams consuming salt prior to and during gestation elicited an increase in cardiac (P<0.001) and kidney tissue mass (P<0.001). Fructose-fed dams also displayed a significant redistribution of regional fat depots i.e. visceral fat increased (P<0.001) whilst gonadal fat decreased (P<0.008). Fructose also increased liver weight (P<0.001) and intra-hepatic triglyceride concentration was also observed to be increased (P<0.007). However, few effects on the fetus but subtle effects on fetal and neonatal growth were observed at this stage. Fructose and salt combined reduced litter size (7 vs. 14 pups) (P<0.001) without an effect on birth weight. Maternal fructose diet skewed the sex ratio in favour of males (60:40) (P<0.001) and maternal salt influenced placental architecture (decreased labyrinthine (P<0.007), increased trophoblast layer (P=0.03)) and had marked effects on maternal osmolality (P<0.001). Male (P=0.07) and female (P<0.02) offspring from fructose-fed mothers had relatively heavier livers. In the adult offspring male and female offspring plasma osmolality was significantly increased in offspring fed prenatal salt (P<0.001). In the offspring, maternal salt diet significantly increased (~15mmHg) basal mean arterial pressure (MAP) in the adult male offspring (P<0.001), but significantly decreased basal MAP (~8mmHg) in the adult female offspring. Both fructose and salt diet had effects on the circadian variation in blood pressure and heart rate. Subsequent cardiovascular challenges revealed little beyond an altered cardiovascular set-point in these offspring. The study emphasizes the importance of quality rather than quantity when assessing maternal diet, particularly in terms of its mineral and simple sugar content. In conclusion, data within this thesis demonstrates for the first time a moderate maternal dietary intake of salt and fructose can affect offspring osmolality profile and blood pressure in a sex-specific manner and produce a pattern of symptoms resembling NAFLD which, in part, are passed vertically to the offspring.