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1
Sherr, Lorraine. "Psychological aspects of communication, anxiety and satisfaction in obstetrics." Thesis, University of Warwick, 1989. http://wrap.warwick.ac.uk/73323/.
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Communication, anxiety and satisfaction during pregnancy was examined. Ley (1977) presents a cognitive model to explain satisfaction and its links with understanding. Janis (1958, 1971) notes a curvilinear relationship between anxiety and post-operative coping and postulates that information, anxiety and cognitive preparation are the variables accounting for this. Kumar and Robson note that obstetric anxiety is related to concerns for maternal and infant well being rather than irrational anxiety. This study examined the experience of women, stressors, communication satisfaction, knowledge and information and looked at the extent to which these three theories could interrelate to provide a fuller explanation of the psychological experience of women. Five studies were undertaken. Initially a pilot study revealed many negative statements about communication when transcripts were analysed. Communication factors and anxiety laden instances were correlated. The next study was set up to examine knowledge levels as Ley predicts that these, together with misunderstandings could contribute to dissatisfaction. Desire for knowledge was high. Knowledge varied according to social class but not parity. Doctors felt parity would be a factor. Women had difficulty approaching their doctor for information yet still desired doctors as their primary information source. Doctors delegated much information imparting to classes. Study three examined anxiety, communications and satisfaction in labour with pain management (a noted stressor in study 1). Patients receiving Pethidine were dissatisfied. Their pain experience did not differ markedly,but their psychological preparation did. In study 4 anxiety and outcome was monitored, together with information gathering strategies. Linear, rather than curvilinear relationships were found (unlike those predicted by Janis). The course of anxiety was a useful measure and the impact of anxiety on caregivers in the cycle of communications and recovery were explored. The final study looked at the impact of intervention on anxiety and satisfaction in ante-natal care. Women were randomly allocated to groups receiving no intervention, information and information plus feedback. The latter group had significantly lower post-consultation anxiety and higher satisfaction than the other two. The role of knowledge and accuracy in relation to satisfaction was explored. Kumar and Robsons propositions about anxiety were supported in these studies. Ley's cognitive model contributed much to the understanding but limitations in this model are explored, especially in relation to process and interaction factors and the routes to understanding. Janis' curvilinear relationship was not upheld, but his theoretical explanations involving the use of information and worry needs further testing.
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Stelmach, Aleksandra. "Field-making and sense-making : foetal programming, risk and human reproduction." Thesis, University of Nottingham, 2018. http://eprints.nottingham.ac.uk/52697/.
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Sembi, Sukhdev. "Mums4Mums : structured telephone peer-support for women experiencing postnatal depression : a pilot RCT to test its clinical effectiveness." Thesis, University of Warwick, 2018. http://wrap.warwick.ac.uk/114368/.
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Background: Postnatal Depression (PND) is experienced by around 13% of women, who suffer a range of disabling symptoms that can have a negative effect on the mother and infant relationship, with significant consequences in terms of the child's later mental health. Research has shown that providing support to mothers experiencing PND can help reduce their depressive symptoms and improve their coping strategies. This study aimed to evaluate the impact of telephone peer-support for women experiencing PND. Methods/Design: A pilot RCT was conducted in which women who screened positive for postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS > =10) were randomised to receive telephone-based support from peers who had recovered from PND, or standard care. Primary outcome measures included depressive symptomatology measured post-intervention and at six-months using the EPDS, and parent-infant interaction using the CARE-Index. Secondary outcome measures included anxiety and depression, dyadic adjustment, parenting stress, and self-efficacy. Maternal perceptions of the telephone peer-support were being assessed using semi-structured interviews. Quantitative and qualitative data was also collected from the peer-supporters to assess the impact on them of delivering the intervention. Results: Participants: twenty-eight participants were recruited to the study, and there was a fifty-percent dropout rate (intervention group n=6, control group n=8). While there were no differences in EPDS scores between the two groups at post-intervention, the intervention group continued to improve at six-month follow-up, whereas the control group showed signs of relapse. The intervention had no impact on mother-infant interaction. In-depth interview data show that women valued the support that was provided. Peer-Supporters: nineteen peer-supporters were recruited, of whom five left before supporting a participant, and eight left after supporting only one participant. The quantitative results showed a significant non-clinical increase in anxiety at post intervention. The qualitative results indicated that the peer-supporters found the majority of calls challenging, and that delivering the intervention had had a deleterious impact on some peer-supporters. Conclusion: While these findings suggest a positive impact of telephone-based peer-support, further research into ways of improving mother-infant interaction are urgently required. Research is also required into providing effective support for the peer supporters.
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Eapen, Abey. "Recombinant human granulocyte colony stimulating factor for unexplained recurrent miscarriage : a randomised placebo controlled multi-centre study." Thesis, University of Birmingham, 2018. http://etheses.bham.ac.uk//id/eprint/8297/.
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Immune mediated mechanisms are thought to contribute to recurrent pregnancy losses. A number of treatment options with limited evidence are being used in clinical practice to treat women with recurrent miscarriages. The objectives of this thesis was a. To summarise the available evidence for granulocyte colony stimulating factor (G-CSF) in reproductive medicine. b. To perform a randomised controlled study (RCT) to evaluate the efficacy and safety of recombinant human granulocyte colony stimulating factor (rhG-CSF) in women with unexplained recurrent miscarriages. The main conclusions from this thesis are: a. The systematic narrative review found that available evidence is of poor quality, but suggestive of benefit with granulocyte colony stimulating factor in women with recurrent miscarriages. b. The RCT concluded that administration of rhG-CSF does not improve pregnancy outcomes among women with a history of unexplained recurrent miscarriages. RhG-CSF appears to be safe for both mothers and their offspring/s.
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Shehmar, Manjeet. "An evaluation of recovery after hysterectomy." Thesis, University of Birmingham, 2018. http://etheses.bham.ac.uk//id/eprint/8259/.
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Differences in recovery from types of hysterectomy may be due to different advice, rather than different incisions alone. Aims: What are the beliefs and experiences of women who have a hysterectomy and the practices and beliefs of health care professionals? Explore the evidence for psychological preparation for surgery. Methods: .Retrospective structured questionnaires .Semi-structured interviews and validated quality of life questionnaires .Systematic review Results: No significant difference in return to work for type of employment and incapacity pay. Variation between the advice given for recovery by UK gynaecologists and nurses. Regardless of route of surgery, the expectations and fears of women are similar and rely on health care advice, with conflicting advice and varied recovery experiences. Women who had a vaginal hysterectomy had concerns around sitting, laparoscopic route had a lower length of stay and abdominal hysterectomy had higher anxiety scores (P 0.003). Mean quality of life scores by EQ5 were not different based on route of surgery (pre-surgery P 0.4446, 1 week P 0.447, 4 weeks P 0.876,12 weeks P 0.850). There was a reduced length of stay [P 0.03, 5.65 (-10 82 to -0.48)] and reduced trait anxiety intervention [P < 0.00001, mean difference 7.78 (7.19, 10.61)] for psychological interventions.
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Walker, S. "Competence and expertise in physiological breech birth." Thesis, City, University of London, 2017. http://openaccess.city.ac.uk/20269/.
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This doctoral thesis by prospective publication aims to provide pragmatic, evidence-based guidance for the development and evaluation of physiological breech skills and services within the context of contemporary maternity care. The research uses multiple methods to explore development of professional competence and expertise. While skill and experience are acknowledged in multiple national guidelines as important safety factors in vaginal breech birth, prior to this research no guidance existed about how skill and experience should be defined, developed and evaluated. The thesis begins with an integrative review of the efficacy of current breech training methods, highlighting a lack of evidence associating any training methods with improved outcomes for breech births. Following this are two papers reporting the results of a Delphi consensus technique study involving a panel of breech experienced obstetricians, midwives and service user representatives. The first outlines standards of competence, training components and volume of experience recommended to achieve competence and maintain proficiency in upright breech birth. The second outlines principles of practice for physiological breech birth, rooted in relationship and response, and divergent from medicalised practices based on prediction and control. Following this is a grounded theory paper exploring the deliberate acquisition of breech competence among midwives and obstetricians with moderate upright breech experience. The paper reports a theoretical model that can inform development of breech teams and training programmes. The final paper reports a mixed methods analysis of data from the Delphi and grounded theory studies concerning breech expertise. The results present a model of generative expertise, underpinned by affinity, flexibility and relationship, which may function to increase the availability and safety of vaginal breech birth. Each paper is followed by critical analysis and reflection. The thesis ends with a discussion of the implications for practice and research in light of the overall body of work.
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Brown, Catriona Elizabeth. "Assessment of cardiovascular risk in women with a history of pre-eclampsia." Thesis, University of Glasgow, 2018. http://theses.gla.ac.uk/9129/.
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Pre-eclampsia is an important and serious condition affecting 2-8% of pregnancies worldwide and carries with it significant associated risk of morbidity and mortality for both mother and child. It is characterised by new onset hypertension after the 20th week of gestation with accompanying proteinuria. Resolution of symptoms should occur following delivery. Several pathophysiological mechanisms are common to both pre-eclampsia and cardiovascular disease, and the link between pre-eclampsia and cardiovascular disease later in life has been established. While the underlying pathophysiological mechanisms of pre-eclampsia are complex, endothelial dysfunction is a key component. Increased arterial stiffness and hypertension have also been documented. Endothelial dysfunction has been shown to extend beyond childbirth, into the postpartum period. Studies evaluating endothelial dysfunction at even longer time-points following an affected pregnancy have produced conflicting results. Results from biomarker studies have supported the concept of endothelial dysfunction throughout pregnancy and the postpartum period, but as more time elapses between index pregnancy and biomarker sampling, these results also vary. Cardiac imaging and electrocardiographic studies have also contributed to knowledge about the normal physiology of pregnancy and changes which are associated with hypertensive disorders of pregnancy during pregnancy, the postpartum period and beyond. The main focus of this thesis was to investigate the possible mechanisms behind the link between pre-eclampsia and future cardiovascular disease. The aim was to investigate women who were free from cardiovascular disease for any evidence of subclinical vascular damage long-term following a pre-eclamptic pregnancy. Overall women recruited to this study would be older than women who participated in the majority of previously published studies on this theme. Before embarking on the investigation of subclinical vascular damage in women with a history of pre-eclampsia, a link was confirmed between a history of pre-eclampsia and cardiovascular disease up to 30 years from time of index pregnancy. This was accomplished using record-linkage in a large Scottish cohort; the Generation Scotland Family Health Study (GS:SFHS). Following on from this, ECGs available in women with and without a remote history of pre-eclampsia in the GS:SFHS cohort were assessed for any obvious differences. There was a more leftward shift in the QRS-axis in these women and a trend towards a longer corrected QT interval (QTc) which approached statistical significance, but after adjusting for other co-variates, pre-eclampsia did not independently predict QTc. Investigations for subclinical vascular damage were carried out by means of non-invasive vascular function studies in women recruited from three different cohorts (blood pressure clinics, GS:SFHS and the previous Proteomics in Pre-eclampsia (PIP) study of women during pregnancy). Time since index pregnancy varied between 1-30 years. Flow-mediated dilatation (FMD) was performed to assess for endothelial dysfunction, pulse wave analysis (PWA) and pulse wave velocity (PWV) assessed arterial stiffness, and carotid ultrasound was performed to establish whether there was any evidence of atherosclerosis. After adjusting for other co-variates, I was able to demonstrate the presence of endothelial dysfunction many years after pregnancy in women with a history of pre-eclampsia in comparison with those who experienced a normotensive pregnancy. There was also a significantly higher presence of carotid plaque in women with a history of pre-eclampsia. To investigate whether the findings from the vascular study translated to findings in biomarker studies of women with a history of pre-eclampsia in comparison with controls, samples from the vascular studies cohort and from the wider GS:SFHS cohort were used. Markers of inflammation, angiogenesis, cardiac damage and collagen turnover were studied. A significantly higher vascular endothelial growth factor (VEGF) was detected in women with a history of pre-eclampsia. Pre-eclampsia is associated with an increased risk of cardiovascular disease, and endothelial dysfunction is evident later on in life. Larger studies are required to further investigate the vascular and biomarker results, and studies including more thorough cardiac assessment (such as echocardiography) in this population should also be considered. The studies described found no evidence of one single component to explain the relationship between pre-eclampsia and cardiovascular disease later in life. This is not unexpected as pre-eclampsia is a complex condition with multiple contributing factors and it is likely that the increased cardiovascular risk later in life is likewise multifactorial in origin.
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Webb, Sara Samantha. "An investigation of subsequent birth after obstetric anal sphincter injury." Thesis, University of Birmingham, 2017. http://etheses.bham.ac.uk//id/eprint/7807/.
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Obstetric anal sphincter injuries (OASIS) are serious complications of vaginal birth with a reported average worldwide incidence of 4%-6%. They are a recognised major risk factor for anal incontinence resulting in concern amongst women who sustain such injuries when considering the most suitable mode of birth in a subsequent pregnancy. This thesis contains three studies; a systematic review and meta-analysis of the published literature exploring the impact of a subsequent birth and it’s mode on bowel function and/or QoL for women with previous OASIS, a follow-up study on the long-term effects of OASIS on bowel function and QoL and finally a prospective cohort study of women with previous OASIS to assess the impact of subsequent birth and its mode on change in bowel function. The work in this thesis demonstrated an increase in incidence of bowel symptoms in women with previous OASIS over time and that short-term bowel symptoms were significantly associated with bowel symptoms and QoL. This thesis also showed that the mode of subsequent birth was not significantly associated with bowel symptoms or QoL and for women with previous OASIS who have normal bowel function and no anal sphincter disruption a subsequent vaginal birth is a suitable option.
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Deboutte, Danielle J. E. "Cost-effectiveness analysis of emergency obstetric services in a crisis environment." Thesis, University of Liverpool, 2011. http://livrepository.liverpool.ac.uk/4453/.
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The study investigated the cost-effectiveness of caesarean section (CS) as the major component of Emergency Obstetric Care (EMOC) in a humanitarian context. Research was conducted from December 2007 until June 2008 in Bunia, in the north-east of the Democratic Republic of Congo. Methods A case-control study explored the factors determining whether a woman had a CS or a vaginal delivery. Cases (n=178) were randomly selected from women who had delivered by CS. Controls (n=180) were women who had delivered vaginally within two weeks of a case and were matched by place of residency. Face-to face interviews in the local language used a structured questionnaire about obstetric and socio-economic factors. Obstetric care was assessed during repeat visits to health structures using checklists. Provider cost of CS was calculated for four hospitals, of which one provided free emergency healthcare. Information about cost allocation to CS was collected from hospital managers, maternity staff, and administrators. Costs were verified with local entrepreneurs, international organisations and UN agencies. The social cost of maternal death was discussed in focus groups, which also obtained user cost information additional to the data from the case-control study. Results CS constituted 9.7% of expected deliveries in the Bunia Health Zone. During the study period, the humanitarian hospital performed 75% of all CS. There were no elective CSs in the study sample. The study found no evidence of obstetric surgery for non-medical reasons. Previous CS and prolonged labour during this delivery were the strongest predictive factors for CS. The risk increased with age of the mother and decreased with the number of children alive. Fifteen obstetric deaths were reported to the research team, three among them were women who had a CS. After adjusting the observed number for missed pregnancy-related and late post-partum deaths, the estimated number of maternal deaths avoided by humanitarian EMOC, compared to expected mortality without additional services, ranged from 20 to 228. Compared to recent estimates for the DRC, perinatal deaths avoided ranged from 237 to 453. Cost-effectiveness was expressed as cost per year of healthy life expectancy (HALE) gained. The estimated cost of adding one year of HALE by providing CSs in a humanitarian context ranged from 3.77 USD to 9.17 USD. Comparison of the cost of EMOC and the social cost of maternal death was complicated by the existence of local customs such as “sororate”. The user capacity to pay for health insurance was found to be low. Conclusion Caesarean sections as part of humanitarian assistance were cost-effective. To keep EMOC accessible during and following the transition from emergency relief to development, a change in the national financing policy for health services is advisable.
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Lavender, Tina. "Managing prolonged labour using different partogram action lines : obstetric outcome and maternal satisfaction." Thesis, Liverpool John Moores University, 2000. http://researchonline.ljmu.ac.uk/5057/.
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Abhishek, Abhishek. "Chondrocalcinosis : risk factors and radiographic phenotype." Thesis, University of Nottingham, 2012. http://eprints.nottingham.ac.uk/12926/.
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Objectives: The objectives of this study were to a) examine the distribution of chondrocalcinosis (CC), b) determine the risk factors of CC, and c) examine the radiographic phenotype of osteoarthritis (OA) associated with CC. Methods: Data from the Genetics of Osteoarthritis and Lifestyle (GOAL) study were used to describe the radiographic distribution of CC, and to conduct a case-control study in which cases with CC were compared with controls without CC. All participants had already completed a detailed questionnaire, been examined by a research metrologist, had radiographs of knees, hands, and pelvis, and had given urine and blood samples. All radiographs had been scored for structural radiographic changes of OA, and for the presence of CC. Frontal plane knee alignment was measured on all knee radiographs. The prevalence (95% confidence interval (CI)) of CC was calculated. The odds ratio (OR) and 95% CI were calculated for risk factors of CC, and for structural changes associated with CC in joints with OA. This was adjusted for age, gender, body mass index (BMI), and OA as appropriate, using logistic regression. Results: 3170 participants were included in this study. There were 431 cases with CC. The overall prevalence (95%CI) of CC in the GOAL population was 13.7% (12.5% - 14.9%). In the GOAL population, knee was the commonest site of CC. However, 42% of participants with CC did not have any knee involvement. There was evidence for a generalized predisposition to CC. For example, CC at one joint associated with CC at distant joints. Joints with CC clustered together more than would be expected by chance alone. At knees, wrists and hips, bilateral CC was more likely to associate with CC at distant joints than unilateral CC – also supporting the existence of a systemic predisposition to CC. After adjusting for confounding factors, there was an association between CC and increasing age, lower current BMI, and OA. The association between OA at one joint and CC at the same joint was present for all joints except for the hip. There was no association between CC and gender, diuretic intake, and selected single nucleotide polymorphisms in enzymes involved in pyrophosphate (PPi) metabolism. CC associated with peri-articular calcification, vascular calcification, low cortical bone mineral density (BMD) but not with low cancellous BMD. Self-reported arthroscopy, meniscectomy, knee injury, occupational knee joint loading and knee mal-alignment in the 3rd decade of life associated with knee CC. However, after adjusting for confounding factors including OA, there was no association between either self-reported or radiographically assessed current knee mal-alignment and knee CC. In joints with OA, the additional presence of CC at the same joint associated with a different radiographic phenotype of structural arthropathy. For example, in knees with OA, knee CC associated with attrition. In hips with OA, hip CC associated negatively with osteophytes, joint space narrowing, and sclerosis at the right hip but not at the left. Similarly, in wrists with OA, wrist CC associated with sclerosis in the right but not in the left wrist; in scapho-trapezioid joints (STJs) with OA wrist CC associated with sclerosis on both sides; in metacarpophalangeal joints with OA, wrist CC associated with cysts in the right but not in the left hand; and in 1st carpometacarpal joint with OA, wrist CC associated with cysts in the left but not in the right hand. In knees with OA, the additional presence of CC at distant joints associated with knee attrition. Those with knee CC + OA were excluded from this analysis to remove any local effects of CC. CC at distant joints did not associate with a distinct structural OA phenotype in other joints examined. Conclusion: These findings suggest that CC results form a systemic predisposition, and that it commonly occurs at other joints in the absence of knee involvement. Established risk factors of CC such as age, OA, and previous arthroscopy and/or meniscectomy were validated in this study. Several novel risk factors of CC e.g. low current BMI, low cortical BMD, and vascular calcification were identified. Several novel associations of knee CC i.e. early life knee malalignment, self-reported knee injury, and occupational knee loading were also recognised. There was convincing evidence to suggest that in joints with OA, the additional presence of CC modifies the OA phenotype, and that this varies from joint to joint.
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Cadagan, David. "The molecular mechanism of insulin action in human theca and adipocyte cells in polycycstic ovarian syndrome." Thesis, University of Nottingham, 2013. http://eprints.nottingham.ac.uk/28112/.
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PCOS is one of the leading causes of infertility worldwide affecting 1 in 10 women of a reproductive age. One of the fundamental abnormalities in women with PCOS can be seen within hormonal irregularities, which may include hyperandrogenemia hyperinsulinemia and hyper secretion of luteinising hormone (LH); and it is hypothesised that a defect in steroid secreting ovarian theca cells is involved due to their contribution in non-PCOS hormonal synthesis. Hyperinsulinemia has been associated with hyper-androgenemia through in vitro studies of cultured PCOS theca, where it has been suggested that insulin increases progesterone and androstenedione secretion when compared to normal theca cells. Furthermore the augmented effects of LH and insulin have been seen to increase ovarian androgen synthesis in non-PCOS theca cultures whilst also increasing the expression of steroidogenic enzymes specific to the PI3-K pathway. Many theories exist toward the etiology of hyper androgenemia within PCOS. Very few approaches however, consider dysfunction in multiple tissue types that may contribute to hormonal imbalances. It is well established that an association between obesity and PCOS exists and it is often the first therapeutic target for re-establishing reproductive function in obese PCOS patients. Furthermore PCOS patients tend to show distinct gynoid body fat distribution, which is reported to aggravate PCOS symptoms. It was therefore valid to examine the involvement in adipocyte function and its contribution to androgen levels within peos. This is further supported through the link between metabolic disorders such as insulin resistance and hyperinsulinemia, and their associations to obesity. Our study employed isolated preadipocyte and thecal cultures with close regulation of the influential factors LH and insulin. In doing so, we analysed androgen synthesis through activation and expression of steroidogenic enzymes CYP17 within both normal and polycystic ovaries. This allowed us to examine whether protein/hormonal concentrations vary across non-PCOS and peos cultures. This also allowed us to examine the possibility of a novel pathway leading to localised adipocyte synthesis as well as pinpointing whether dysfunction existed within the insulin-signalling pathway of thecal androgen steroidogenesis. The work in this thesis shows that adipocytes derived from non-PCOS and PCOS women, maintained in vitro differ on the basis of their morphology, rates of differentiation and proliferation. Furthermore, they reacted differently under conditions designed to mimic PCOS in vitro (increased insulin and LH), with reduced non-PCOS proliferation, and increased non-PCOS androgen secretion on insulin treatment. We also found increased steroidogenic CYP 17 expression in PCOS cultures under insulin stimulation. However PCOS adipocytes androstenedione secretion remained unaffected by insulin stimulation and secreted constant levels of androstenedione similar to that seen by insulin stimulated non-PCOS adipocytes. Our examination of non-PCOS and PCOS primary thecal cultures showed CYP17 expression is increased in pcas theca under basal conditions and that increases in insulin and LH leads to increases in in vitro theca proliferation. These conditions were also seen to lead to significant increases in androstenedione secretion over non-PCOS thecal cultures, and the results suggest it to be acting through the PI3-K pathway. These results therefore point to a specific area of dysfunction that should be further targeted for examination. Furthermore, they suggest that an adipocyte dysfunction exists within PCOS patients that may significantly contribute to hyperandrogenemia through localized synthesis of androgens.
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Butler, Michelle. "Definitions of midwifery competence : implications for professional learning." Thesis, University of Nottingham, 2001. http://eprints.nottingham.ac.uk/11243/.
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This study explores the nature of competence required to fulfil the role of the midwife, learning to become competent, and professional learning beyond registration. The research was undertaken through a qualitative, case study approach, exploring competence as a phenomenon, as experienced by thirty-nine student midwives as they went through the final stages of pre-registration midwifery education programmes, were assessed to be competent, and took on the role of the midwife. The views of the thirty-nine participants of competence and of their own capability, development and learning, were compared with the views of teachers, assessors, other midwives, and supervisors of midwives, working with participants. Also explored are the characteristics of the expert and the characteristics of good and bad midwives. The case is made early on in the thesis that a definition of competence is required for midwifery to develop as a profession, to protect the public, and to facilitate midwife development pre and post registration. Towards achieving this, the research begins to construct a model of midwifery competence as an integrated, holistic concept. The research explores the relationship between the various components and dimensions in the integrated model and the factors involved in being competent across contexts and from situation to situation. Factors involved in the maintenance of competence over time and in learning beyond registration are identified by exploring the nature of learning beyond registration and the characteristics of good and bad midwives.
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Tyers, Theresa Lorraine. "The rebirth of fertility : the Trotula and her travelling companions c. 1200-1450." Thesis, University of Nottingham, 2012. http://eprints.nottingham.ac.uk/14017/.
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This thesis examines to what extent women were involved in their own healthcare and that of others, in the late medieval period. It starts from the observation that modem text editing practices often exclude from discussion other widely disseminated texts that formed the 'travelling companions' of a manuscript - in this case particularly the ensemble known as the Trotula. By focusing on one specific text within the manuscript compilations, the diverse and widespread dissemination of women's knowledge of healthcare and the use of vernacular texts have been marginalised. The thesis argues that the consideration of these 'travelling companions' can offer an alternative view of women's involvement in healthcare, despite the seeming female exclusion from the culture of book-learning and the development of professional licensing in the later Middle Ages. The corpus of manuscripts examined is taken from a range of vernacular compilations produced in England, Flanders and Italy, with some discussion of ownership and transmission of these into the Early Modem period. A number of transcriptions and close readings of the contents are used to identify the discrete characteristics of each copy and to track changes that took place during the transmission process. Detailed comparisons demonstrate that conscious, active choices were made in both the adaptation and interpretation of the material being copied. Analysis of these manipulations reveals that the production of vernacular texts enabled easier consultation and use. The manuscripts point to women's continuing engagement with both the texts and the practice of self-care and that, despite the increase in the number of professional male practitioners over the period, women continued to offer advice to others well into the sixteenth century.
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Crittenden, Mark E. "Real-time intrapartum fetal electrocardiogram analysis." Thesis, University of Nottingham, 1997. http://eprints.nottingham.ac.uk/27969/.
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The research within this thesis concerns the monitoring of the fetus during labour, using the fetal electrocardiogram (FECG). A versatile FECG analysis system was developed for the Microsoft Windows environment, to allow various FECG parameters to be extracted. Algorithms, currently used in other FECG analysis systems, were implemented using Object Oriented Programming, thus allowing new algorithms to be easily added at a later stage. Although these current algorithms have been demonstrated by several authors, it was felt that they had been used with only partial investigation of their limitations, and with failure to fully determine their accuracy in controlled conditions. These factors are fully addressed within this thesis. By developing a FECG simulator, in which heart-rate, morphology, and noise levels could be varied, the ability of the analysis algorithms to extract the parameters, and the accuracy of these parameters under different noise conditions, were thoroughly checked. Both ability and accuracy were shown to be very good in ideal noiseless conditions; but, with the addition of noise, there exists a compromise between parameter accuracy when the morphology is static, and parameter accuracy when the morphology is changing. The accuracies of the most common indices in this field (the Conduction Index, and the T/QRS ratio) were determined for different levels of simulated noise, and their values demonstrated for data previously recorded from the fetal scalp. Errors as large as 0.3 in the CI and 0.05 in the T/QRS suggested that in the clinical environment, an indication of the accuracy of each index ought to be displayed, and this may be estimated from the measured level of noise. Furthermore, this analysis system allows the direct comparison of both indices. Finally, in order to design a more effective front-end filter, it is important to be aware of the frequency content of the underlying FECG. The Integral Pulse Frequency Modulation (IPFM) model, combined with Pulse Amplitude Modulation (PAM), was used to estimate realistic frequency components within the FECG signal. The effects of filtering could then easily be modelled to show the distortion of both the FECG and any parameters taken from it. For a FECG frontend filter, distortion was found to be insignificant provided that, above 1 Hz, both the gain remained constant and there was no phase-distortion.
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Vadiveloo, Thenmalar. "Sequential testing strategies in prenatal screening for down's syndrome." Thesis, University of Glasgow, 2010. http://theses.gla.ac.uk/1889/.
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It is important therefore that maternal smoking is accurately recorded on screening request forms and in this study, the accuracy of self reported smoking status was assessed by analysis of cotinine in serum. Results showed that the percentage of self-reported smokers (24.1%) at booking was significantly lower than the cotinine-validated estimate of 30.1%. Also, smoking was associated with low birth weight, delivery prior to 39 weeks, increased AFP level (3.1%) and reduced hCG level (28.7%) in the second trimester. An increasing AFP level (but not hCG level) was associated with lower birth weight and delivery prior to 39 weeks in both smokers and non smokers but the effect was most marked in smokers. The difference in birth weight between the highest and the lowest AFP category for non-smokers was 448.3g and for smokers was 619.2g, suggesting that smoking exacerbates the effect of an elevated AFP on birth weight. Overall the difference in birth weight between the lowest AFP category in non smokers and the highest AFP category in smokers was 931.6g. Summary In summary, this study has shown that a cross-trimester contingent screening protocol with repeat measures has the potential to meet the UK NSC aspirational standard of 90% detection of Down’s syndrome pregnancies with a screen positive rate of less than 2%. Around 90% of women would complete screening in the first trimester without the need for a second stage sequential test. Correcting for factors such as maternal smoking habits, ethnicity and ART would further improve screening performance. Also it has been shown that where ultrasound resources are scarce, within-trimester and across-trimester protocols can reduce the need for NT measurement in all women and still deliver excellent screening performance although this falls short of the higher performance standard. The potential of these new screening protocols now need to be tested in prospective multicentre trials to confirm their performance in prospective practice.
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Huda, Shahzya Shahnaz. "Metabolic pathways in normal and pre-eclamptic pregnancies." Thesis, University of Glasgow, 2011. http://theses.gla.ac.uk/2537/.
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Maternal metabolism undergoes dramatic changes in pregnancy in order to sustain and nourish the developing fetus. During healthy pregnancy the mother goes from an anabolic state in early pregnancy to a state of catabolism in late pregnancy with increased lipolysis together with a significant reduction in insulin sensitivity. Pre-eclampsia (PE) characterised by hypertension and proteinuria is a major cause of maternal and perinatal morbidity. There is acute ‘atherosis’ in PE placenta, and lipid accumulation within glomerular cells and liver. PE women have an early, excessive triglyceride and free fatty acid (FFA) rise and greater cardiovascular disease (CVD) risk in later life. The cause of these lipid abnormalities in PE is unknown but disordered adipocyte function including exaggerated lipolysis and aberrant release of adipokines (such as IL-6 and TNF alpha) is a major candidate pathway. Elevations in FFAs, and pro-inflammatory adipokines could underpin the oxidative stress, endothelial dysfunction, inflammation, and insulin resistance - characteristic features of PE. The aims of this thesis were to acquire a better understanding of lipid metabolism and function in normal pregnancy, to determine if adipocyte function was altered in PE and, if so, to establish mechanisms. In addition I planned to corroborate epidemiological evidence of increased future CVD risk and to establish which risk factors accounted for this increased risk. I collected subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) biopsies in non-labouring pregnant healthy (n=31) and PE (n=14) women who underwent caesarean section. Maternal blood was collected prior to delivery and phenotyping of the mother was performed including plasma assay for cholesterol, triglyceride, HDL-cholesterol, IL-6, TNF-α, leptin, adiponectin, high sensitivity CRP, glucose and insulin concentrations. Maternal BMI at booking, standardised blood pressure measurements and birth weight centile were also recorded. I determined ex vivo lipolytic activity (basal, isoprotenerol stimulated and insulin suppression of lipolysis) and adipokine production in response to lipopolysaccharide (LPS) stimulation from these biopsies. The gene expression of relevant target genes and macrophage densities in each adipose depot by immunocytochemistry (ICC) was also performed. In addition I performed carotid ultrasound assessment of women with a previous history of PE (n=31) and matched controls (n=29). Ethical approval was obtained from Glasgow Royal Infirmary LREC and all patients gave their informed consent. I found that in normal pregnancy, adipocyte lipolytic function is independent of maternal BMI. Adipocyte lipolytic function of SAT and VAT are also independent of each other. Adipose tissue is very metabolically flexible and the rate of whole body lipolysis is still insulin sensitive in late gestation. VAT is more closely related to markers of maternal insulin resistance (IR) and is more sensitive to catecholamine stimulation and less sensitive to insulin suppression of lipolysis than SAT, the basis of the “portal paradigm”. Increasing BMI is associated with an increase in VAT cell size, with increased lipolysis and an increase in pro-inflammatory adipokines, a potential mechanism through which increasing obesity could predispose to metabolic complications of pregnancy. In contrast SAT cell size is not closely related to BMI and this may reflect the adaptation of this depot to increasing fat mass through both hypertrophy and hyperplasia, a metabolically advantageous response. TNF alpha is an important correlate of basal lipolysis in SAT. In PE there is decreased insulin sensitivity of both SAT and VAT compared to controls as calculated by the fat cell insulin sensitivity index (or responsiveness to insulin once the tissue is stimulated by isoproterenol). This would potentially make a significant impact on total circulating FFA as almost 60% of circulating FFA are from these adipose depots. The rise in FFA in PE occurs early in pregnancy and contributes significantly to IR. Therefore the IR of adipose tissue could lead to a vicious cycle of increased lipolysis, increased FFA and further exacerbation of IR. In contrast to controls, SAT cell size is intimately related to BMI suggesting that adaptation to increasing fat mass is mainly through adipocyte hypertrophy which could lead to increased endoplasmic reticulum stress, increased IR and increased release of inflammatory adipokines. I have shown that SAT cell size does relate to adipokine release in PE, with increased release of leptin, CRP and PAI-1 and paradoxical increase in the anti-inflammatory IL-10. I had hypothesised that in addition to an inherent defect in adipocyte function there was an additional factor present in maternal serum of women with PE released from the placenta which excessively stimulated lipolysis. I failed to demonstrate any effect of maternal serum on adipocyte lipolysis in either controls or PE. I also found that after stimulation with LPS, there was increased release of TNF alpha and IL-6 in VAT in PE but not in controls, with higher gene expression of these adipokines. TNF alpha release also correlated negatively with the fat cell insulin sensitivity index (FCISI) of VAT implicating a paracrine effect in this tissue. I also demonstrated an increase in gene expression of cfms (activated macrophages) relative to control gene, and increased density of cfms+ macrophages/adipocytes in the VAT of PE women implicating activated adipose tissue macrophages as a potential source of the increased release of inflammatory adipokines. Lastly I attempted to corroborate epidemiological evidence for the increase future risk of CVD women with a history of PE by assessing two surrogate markers for atherosclerosis - carotid IMT and carotid plaque scores. Both were found to be increased, with plaque scores significantly so. Classic risk factors such as age, lipids, BP and smoking did not attenuate this effect and BMI only marginally attenuated it, therefore only partially explaining this increased risk. In summary the data presented in this thesis provides further evidence that PE is a “metabolic syndrome of pregnancy” with disordered adipocyte function and metabolism, with an increased future risk of CVD in later life. Further studies on adipose accumulation, function and composition in normal and complicated human pregnancy are warranted.
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Carty, David Martin. "Pre-eclampsia : early prediction and long-term consequences." Thesis, University of Glasgow, 2012. http://theses.gla.ac.uk/3124/.
Full textAbstract:
Approximately one in ten pregnant women will have their blood pressure recorded above normal at some point during their pregnancy. Pre-eclampsia, the most common hypertensive disorder of pregnancy, affects around 5% of all first time mothers, and is an important cause of foetal and maternal morbidity and mortality worldwide. Efforts to diagnose the condition have been hampered by inability to predict which women are likely to be affected. Multiple pathways are known to be involved in its pathogenesis, and several screening tests have been suggested for its early prediction. None, however, have been sensitive or specific enough to have come into routine medical practice. The work contained in this thesis describes a study which was designed to detect biochemical and clinical markers that could improve ability to predict pre-eclampsia. Over 3900 women were recruited in early pregnancy at four maternity clinics across the West of Scotland; baseline characteristics and information on past medical and obstetric history were obtained. Women were followed up throughout their pregnancy, and information on deliveries obtained from hospital databases. One-hundred and eighty of these women, who had multiple risk factors for pre-eclampsia, attended for further sampling and vascular assessment at gestational weeks 16 and 28. The primary aim of the overall study was to examine whether a proteomic strategy could be used to identify patterns of peptides in urine that detect pre-eclampsia in the first and second trimesters. Using samples from healthy pregnant and non-pregnant women I was able to describe the normal human urinary proteome in pregnancy. By comparing these pregnancy-associated peptides between women who went on to develop pre-eclampsia and matched controls, I was able to identify a pattern of peptides, characterised by collagen fragments, fibrinogen and uromodulin that accurately predicted pre-eclampsia at week 28. No such markers were identified in the first trimester samples. A further aim of the overall study was to identify early pregnancy plasma markers that could help to identify women destined to develop pre-eclampsia. By examining samples from early pregnancy I was able to demonstrate that the angiogenic markers soluble endoglin and placental growth factor are already altered at week 12-16 in women who go on to develop pre-eclampsia. Using a multi-marker approach, I also showed that E-Selectin, an adhesion molecule expressed on endothelial cells which controls interaction between circulating leukocytes and the endothelium, is higher at week 12-16 in women who go on to develop pre-eclampsia. Experiments using samples from later pregnancy, alternative analysis techniques and samples from an independent study population all helped to confirm these novel findings. Endothelial dysfunction is known to play a key role in the development of pre-eclampsia, contributing to the hypertension, proteinuria and oedema seen in affected women. In the risk factor cohort I used vascular function studies to examine whether they supplied additional information to aid in risk stratification. Peripheral arterial tonometry, a novel non-invasive tool for the assessment of microcirculatory endothelial function, was examined in 180 women at gestational weeks 16 and 28. Reactive hyperaemia index (RHI), a measure of endothelial dysfunction calculated from vascular response to arm blood-flow occlusion, did not correlate with maternal factors such as age, BMI and blood pressure. Further, RHI did not help to identify which women would go on to develop pre-eclampsia, when examined at either week 16 or 28. I found that PAT score was negatively correlated with baseline digital pulse amplitude, suggesting that in later pregnancy, when women are more vasodilated, PAT and other techniques which rely on flow-mediated dilatation are less likely to be reliable. I used pulse wave analysis, a well-established method for measuring arterial stiffness and central pressures, to determine whether it supplied additional information about pre-eclampsia risk. This technique has been previously reported to predict pre-eclampsia in early pregnancy. In this cohort of high risk women, no difference was seen at either week 16 or 28 between those who would go on to develop pre-eclampsia and those who would have normotensive pregnancies. Although blood pressure and proteinuria return to normal after pre-eclampsia, evidence has emerged the condition has long-lasting implications; women with a history of pre-eclampsia have an increased risk of cardiovascular disease later in life, suffering stroke or myocardial infarction more frequently than women who had a healthy pregnancy. Conventional risk factors are thought to contribute, but do not fully explain this increased risk. I carried out further vascular function studies in women after pre-eclamptic pregnancy, to examine whether they had ongoing detectable endothelial dysfunction and arterial stiffness. At 6-9 months post-natally, affected women had lower baseline digital pulse amplitude but no other evidence of persistent vascular dysfunction. Taken together, these data provide information about a number of markers that may improve understanding of the pathophysiological mechanisms underlying pre-eclampsia. As well as potentially improving the early prediction of disease, this work represents a highly topical area for further studies. While vascular function analysis does not appear to provide additional information on top of risk factors, these studies also provide useful information on vascular physiology in high-risk pregnancies.
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Anderson, Laurie. "The myometrial effects of progesterone." Thesis, University of Glasgow, 2010. http://theses.gla.ac.uk/2203/.
Full textAbstract:
Introduction: Preterm birth is the leading cause of perinatal morbidity and mortality and rates are rising. The UK now has the highest rate of premature birth in Europe with 5.3% of overall births in Scotland occurring spontaneously before 37 weeks gestation (1, 2) .Preterm babies have higher rates of perinatal mortality and morbidity and those that survive are at risk of multiple conditions including respiratory distress syndrome, central nervous system abnormalities, necrotising enterocolitis and sepsis. The mechanisms of preterm birth are poorly understood. Preterm birth can be spontaneous or induced and spontaneous preterm labour has multiple aetiologies. Current evidence suggests that prolonged treatment with progesterone and 17 α-hydroxyprogesterone caproate (17OHPC) may reduce the incidence of premature delivery in high risk patients with a history of spontaneous preterm birth (3) or with a short cervix. However, progesterone is not uniformly effective in preventing preterm labour and at present its principal mode of action on myometrium is unknown. I aimed to determine some of the specific mechanisms of action of progesterone. Aims: I hypothesised that progesterone has a direct inhibitory effect on spontaneous myometrial contractility, induces increased sensitivity to tocolytic agents and decreases sensitivity to contractile agonists such as oxytocin. I also hypothesised that progesterone has inhibitory effects on endogenous uterine stimulants, stimulatory effects on endogenous uterine relaxants, induces upregulation of endogenous receptors that inhibit uterine contractions and inhibits contraction associated proteins both in vitro and in vivo. Methods: I recruited women already enrolled in the STOPPIT (a double blind randomised placebo controlled study of progesterone for the prevention of preterm birth in twins) who were given vaginal progesterone, or placebo and who were scheduled for caesarean section. I also recruited women with healthy twin or singleton pregnancies undergoing elective caesarean section. Myometrial biopsies were obtained from the upper border of the lower uterine segment incision during caesarean section. Samples were divided and used for contractility measurements, or subsequent mRNA, protein and immunohistochemical analysis. Myometrial strips were cut and suspended under resting tension within organ baths. Concentration-response curves were carried out in response to oxytocin, levcromakalim, nifedipine and ritodrine to ascertain any reduction in effect by progesterone on oxytocics or enhancement of tocolytic effects. I also carried out concentration-response curves to progesterone alone and in the presence of potassium channel blocking agents. I then assessed ex vivo, the inherent contractility of the placebo versus progesterone groups from myometrium sampled from the STOPPIT cohort of patients. I carried out cell culture experiments on myometrium from healthy singleton women who were not in labour at the time of sampling. Myometrial explants were placed in cell culture medium, cultured for 1, 4 and 24 hours, and the supernatants were then analysed using Bio-Plex array technology to ascertain cytokine release. I selected time points and concentrations conditions to incubate myometrial tissue using progesterone and 17OHPC and was able to assess cytokine release. The myometrial explants were used for subsequent molecular studies. I performed real time-polymerase chain reaction (RT-PCR) (Abi,Taqman) to quantitate endogenous inhibitors of uterine contractility (cGRPR, EP2,NOS), cytokines (interleukins- IL6, IL8, IL1β), uterine stimulants COX-2 and gap junction components ( connexin 26 and connexin 43) expressed relative to housekeeping gene 18s. Lastly, I analysed the STOPPIT cohort of myometrial samples for to determine the in vivo effect of progesterone. We carried out RT-PCR (Abi,Taqman) to quantitate endogenous inhibitors of uterine contractility (cGRPR, EP2,NOS, PGDH), cytokines (IL6, IL8, IL1β) and gap junction components (connexin 26 and 43).I performed immunohistochemistry, staining for localisation of pro-inflammatory cytokines. I then carried out protein expression analysis using Western blot for contraction associate protein, connexin 43. The project was approved by North Glasgow University Hospitals Research Ethics Committee ref no. 05/S0705/18. All patients gave written informed consent to participate. Results: I found that progesterone, exerted consistent, rapid and sustained inhibition of the amplitude of spontaneous myometrial contractions in vitro at high concentrations however, this affect was not achieved through the principal potassium channels. Levcromakalim, a KATP channel opener, produced a concentration-dependent inhibition of the amplitude and frequency of spontaneous contractions. These effects were antagonised by the KATP channel blocker, glibenclamide. In contrast, glibenclamide had no effect on the progesterone-induced inhibition of myometrial contractility. Charybdotoxin 10 nM (which blocks IKCa, BKCa and Kv channels), iberiotoxin 100 nM (which blocks BKCa channels) and apamin 100 nM (which blocks SKCa channels) failed to affect the ability of progesterone to inhibit myometrial contractility. In contrast, 17OHPC did not exert any inhibitory effect on myometrial activity in vitro. Results indicated, at the selected pharmacological doses used in vitro that progesterone did not increase sensitivity to tocolytic agents tested. There was no decrease in sensitivity to the uterotonin oxytocin. Lastly, from our STOPPIT patient cohort I demonstrated no difference between the progesterone and placebo groups in either spontaneous contractility, response to tocolytics as above or response to oxytocin. One main conclusion of this arm of the study is that in vivo progesterone therapy to prevent pre-term labour does not appear to modify contractility ex vivo. I demonstrated that administration of progesterone but not 17OHPC for up to 24 hours in vitro does not appear to modify mRNA expression of uterine stimulants such as cytokines, COX-2 or endogenous uterine relaxants such as NOS and PGDH. Progesterone but not 17OHPC inhibited production of gap junction component connexin 43. This modification of contraction associated protein is in agreement with other literature presented on human myometrial data in vitro (4) . I used STOPPIT patients as a potential example of the myometrial effects of progesterone in vivo with a placebo treated control group. Prolonged maternal administration of progesterone appeared to inhibit expression of gap junction components connexin 26 and 43 in myometrium. Connexin 43 importantly, was also modified in vitro within the progesterone treated arm. However, ex-vivo assessment of the functional impact on human myometrium does not demonstrate a long-term inhibitory impact on myometrial function with down regulation of endogenous contractile inhibitors such as eNOS and EP2. The connexins play an essential role in regulating synchronous myometrial contractions. If progesterone has been of benefit in those at risk of preterm labour with a history of spontaneous preterm birth, it is possible therefore that this is by reducing connexin expression, which prevents the development of these synchronous contractions whilst on progesterone therapy. In summary, I have demonstrated putative mechanisms by which progesterone (and its analogue 17OHPC) might prevent preterm birth. Further studies characterising these pathways might inform the design of other agents which could provide additional efficacy in preventing preterm delivery.
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Rayment, Juliet. "Midwives’ emotion and body work in two hospital settings : personal strategies and professional projects." Thesis, University of Warwick, 2011. http://wrap.warwick.ac.uk/36856/.
Full textAbstract:
Much has been written in recent years of a ‘crisis’ in the recruitment and retention of midwives in the NHS. The crisis has been attributed variously to burnout, a lack of professional autonomy, a bullying culture, and an ideological conflict between the way in which midwives wish to practise and the way they are required to practise within large bureaucratic institutions, such as NHS Trusts. Negotiating these experiences requires a significant amount of emotional labour by midwives, which they may find intolerable. This thesis explores the strategies NHS midwives deploy in order to continue working in NHS maternity services when many of their colleagues are leaving. It examines the extent to which working in a midwife-led service rather than a consultant-led service helps or hinders midwives’ capacity to manage the emotional and ideological demands of their practice. Ethnographic fieldwork was carried out in a consultant unit and an Alongside Midwife-led Unit (AMU) in two NHS Trusts in England. The findings from negotiated interactive observation and in-depth unstructured interviews with eighteen midwives were analysed using inductive ethnographic principles. In order to ameliorate the emotional distress they experienced, the midwives used coping strategies to organise the people and spaces around them. These strategies of organisation and control were part of a personal and professional project which they found almost impossible to articulate because it ran contrary to the ideals of the midwifery discourse. Midwives explained these coping strategies as firstly, necessary in order to deal with institutional constraints and regulations; secondly, out of their control and thirdly, destructive and bad for midwifery. In practice it appeared that the midwives played a role in sustaining these strategies because they formed part of a wider professional project to promote their personal and professional autonomy. These coping strategies were very similar in the Consultant Unit and the Midwifery Unit. A midwife-led service provided the midwives with a space within which to nurture their philosophy of practice. This provided some significant benefits for their emotional wellbeing, but it also polarised them against the neighbouring Delivery Suite. The resulting poor relationships profoundly affected their capacity to provide a service congruent with their professional ideals. This suggests that whilst Alongside Midwife-led Units may attempt to promote a midwifery model of care and a good working environment for midwives, their proximity to consultant-led services compounds the ideological conflict the midwives experience. The strength of their philosophy may have the unintended consequence of silencing open discussion about the negative influence on women of the strategies the midwives use to compensate for ideological conflict and a lack of institutional and professional support.
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Stewart, Frances Maria. "The impact of maternal obesity on vascular and metabolic function throughout pregnancy." Thesis, University of Glasgow, 2008. http://theses.gla.ac.uk/426/.
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Maternal obesity increases the risk of numerous maternal and fetal complications of pregnancy. Women were recruited at booking for antenatal care. Each subject was examined in the first, Second and third trimester of pregnancy as well as twelve weeks post partum. Using non invasive techniques microvasular function was measured at each visit. Fasting bloods were taken. This assessment allowed us to observe microvascular function, inflammatory response, dislipidaemia and changes in fatty acid composition with advancing gestation and the degree of recovery in the post partum. By recruitment of women with varying body mass index (BMI) values we were able to examine the influence of maternal BMI on these responses to pregnancy.
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Breslin, Eamonn. "Pre-eclampsia : predicting onset and poor outcome." Thesis, University of Warwick, 2013. http://wrap.warwick.ac.uk/65257/.
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Pre-eclampsia is a pregnancy-specific, multi-system disorder of placental origin. Affecting between 2-8% of women, it is one of the leading causes of both maternal and fetal morbidity and mortality in the United Kingdom. Although the disorder presents after 20 weeks gestation with the classic symptoms of hypertension and proteinuria, the pathological process(es) leading to this syndrome initiate early in the first trimester. In current clinical practice, prediction of those who will get the disease and those who will have a poor outcome once it develops is poor. This thesis focuses on novel ways to enhance the prediction of the development of pre-eclampsia and poor outcome once the syndrome manifests. Firstly, the current risk factors for pre-eclampsia were challenged. Racial variation in these risk factors has demonstrated the importance of considering maternal ethnicity when assessing the likelihood of developing the disease. Obese Black women were more likely to develop pre-eclampsia than obese white women (aOR 2.06 (95%CI 1.34-3.23) p=0.002). In the normal BMI group Black women were less likely to develop pre-eclampsia than White women (aOR 0.421 (95%CI 0.24-0.73) p<0.001). Younger (<20 years of age) Black women were less likely to develop pre-eclampsia than younger white women (aOR 0.628 (95%CI 0.49-0.83) p<0.001). Conversely, older (>35 years of age) Black women were more likely to develop pre-eclampsia than older White women (aOR 1.67 (95%CI 1.39-1.99) p<0.001). Secondly, first trimester maternal plasma studies have identified a cohort of potential disease (and pathophysiological) markers that may allow for the development of an early screening test for pre-eclampsia. The ratio of angiotensinogen to Kallikrein is raised in the first trimester of pregnancies that later develop pre-eclampsia (p<0.001). The receiver operator curve (ROC) for the ratio of angiotensinogen to kallikrein had an area under the curve (AUC) of 0.81 (SE=0.05). A cut-off value of >0.27 has a sensitivity of 0.9 (95% CI = 0.74 – 0.97), a specificity of 0.5 (95% CI = 0.24-0.65), positive predictive value (PPV) 0.63 (95%CI = 0.47-0.75) and negative predictive value (NPV) of 0.87 (95% CI = 0.53-0.96) in predicting the onset of preeclampsia. Common haematological and biochemical tests are presented as markers for both the development of the disease and poor outcome when it occurs. The ratio of Neutrophil to Lymphocyte (NLR) is raised in the first trimester of pregnancies that develop pre-eclampsia (p<0.001). The ROC of the ratio to Neutrophil to Lymphocyte has an AUC of 0.84 (95% CI = 0.85-0.95). A cut off value of 2.53 has a sensitivity of 0.92 (95%CI = 0.85-0.95), specificity of 0.6 (95%CI = 0.51-0.67), PPV 0.68 (95%CI = 0.6-0.74) NPV 0.87 (95%CI = 0.8-0.93) for predicting the onset of pre-eclampsia. At the time of diagnosis of pre-eclampsia, a raised NLR predicts poor maternal outcome and the need for a caesarean section due to fetal distress (p<0.05). In addition, a reduced level of bilirubin predicts both poor fetal and maternal outcome and the need for a caesarean section (p<0.05).
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Moss-Luffrum, Beverley Jane. "Paradigmatic resonance and dysjunction in the development of the human sciences : accountability and expertism in the history of parturial practices." Thesis, University of Warwick, 1993. http://wrap.warwick.ac.uk/36195/.
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This thesis examines the function of discursive paradigms in the process of subjectivisation and the formulation of objects in the development of the human sciences. The history of childbirth practices exemplifies the operations of paradox and paradigm, and of epistemic changes and continuities, in relation to medical, ethical, and pedagogic discourses. The recent past has brought rapid change in the practices and outcomes of parturition with regard to technologisation, and the improvement in mortality rates. The achievement of technological childbirth has a complex and paradoxical history, and should be understood other than as an inevitable and progressive phenomenon of scientific endeavour, or as a conspiracy of patriarchy which victimises and subjugates women as a matter of intentionality. The histories of the parturient and of the midwife are only partially linked. An examination of childbirth history reveals some of the implications of phallogocentricity for the history of women and for the constitution of gender and gender relations. Midwifery has its own unique but unmistakeable place in the historical discourse of pathologisation and professionalisation - and cannot be regarded simply as an arena of masculine appropriation. The mechanisms for change in parturial practices have been developing to facilitate the modifications of recent history since around 1800, but there are discursive resonances which are linked also to changes in pedagogic organisation which began in the Middle Ages. Further, in order to analyse and evaluate the history of parturition over the past two hundred years, it is necessary to examine the paradigmatic structures based upon dialectical reasoning which have dominated the development of the human sciences since antiquity. Childbirth provides examples of many historical exigencies which informed a panoply of disparate effects, but it is also in many respects unique and anomalous. An exploration of the operations of power, knowledge and influence in this sphere, reveals as much in terms of its resistances as its susceptibilities, to medical appropriation. The history of childbirth is unusual insofar as the technologies and innovations that developed in relation to it, were in fact, slow to be implemented. Evidence of such paradigmatic dysjunction is provided by the examples of the use of forceps, asepsis and anaesthesia in the nineteenth century. This thesis addresses aspects and effects of professionalisation, and the increasingly disciplinary implications of expert discourses for the pregnant and parturient woman in the twentieth century.
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Purkis, Judith Christine. "Beyond qualification : learning to be midwives." Thesis, University of Warwick, 2006. http://wrap.warwick.ac.uk/4079/.
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"I know that every day I am gaining experience ... learning more" (Int. 6(a)) This thesis examines the social practices and associated learning that shape the meaning of midwifery for new members of the profession. In doing so it explores the extent to which the implications of practice either liberate or circumscribe midwives' identity formation. The thesis further suggests how this identity formation may impact upon commitment to a long term career in midwifery. The theoretical framework for this thesis acknowledges that continuing professional development and evidence of recognised learning activity is, for all midwives, a professional requirement. However, less attention has historically been paid to the unstructured, unintended and relatively informal learning that occurs within and throughout midwives' involvement in everyday practice. It is through these forms of learning, and drawing upon data elicited through surveys, interviews and diaries, that this thesis seeks to make a contribution. Using a social model of learning, particularly through Wenger's (1998) work on communities of practice, the development of identity is presented as a negotiated process mediated to a greater or lesser degree by workplace relationships. Whilst relationships with pregnant women form an important element of this process, the thesis argues that collegial relationships generally assume greater importance and impact on the development of identity and meaning for newly qualified midwives. By situating the everyday experiences of newly qualified midwives within a broader theoretical debate about social learning, identity and the making of meaning, this thesis suggests that the contemporary 'doing' of hospital based midwifery remains within what are fairly narrowly prescribed, contested, yet firm boundaries. The development, existence and negotiation of these boundaries is central to the space which pregnant women, midwifery and midwives can occupy. These boundaries are simultaneously hierarchical, intra professional and personal. Furthermore, in practice, these boundaries are frequently unclear and rapidly changing. Whilst this contributes to a potentially dynamic opportunity for identity formation, the thesis demonstrates how this also transpires to contribute to an unstable, frustrating and frequently challenging context particularly for newly qualified members of the profession. Overall, this thesis contributes to an understanding of the development, or lack of development, of midwifery practice at theoretical, conceptual and practical levels. Viewing practice as social learning offers a new perspective on the opportunities and challenges inherent in the current model of care. Simultaneously it suggests a new perspective on the recruitment crisis faced by the profession and accordingly the opportunity for new potential solutions.
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Bailham, Dawn Bernadette Ruth. "Psychological trauma following childbirth." Thesis, University of Warwick, 2001. http://wrap.warwick.ac.uk/4506/.
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The aim of this study was to assess risk factors to PTSD following childbirth incorporating a longitudinal design. Since the introduction of DSM-IV (APA, 1994) there has been an awareness in the literature that women can develop PTSD following childbirth. The first study in this thesis provides a comprehensive review of the literature in this area and the clinical implications of the disorder. The aim of the second study was to investigate the factor structure of a questionnaire measure (PLDQ) that has been used in past studies to assess women's perceptions of labour and delivery. The findings from this study indicate that the PLDQ consists of three internally reliable factors that can assess a woman's perception of pain, staff support/care and fear during labour and delivery. The scale can differentiate among women on these factors according to type of delivery. The aim of the third paper was to assess risk. factors to PTSD across time in the antenatal period, appraisal factors during delivery with the PLDQ, and maintenance factors in the postnatal period. There is an absence of studies in the literature that assess risk factors to PTSD over time. The results of this study indicate that postnatal depression (PND) and a negative appraisal of staff support and care during labour and delivery can predispose women to PTSD at 5-8 weeks following delivery. At 10 -14 weeks the relationship between PTSD and PND was still consistent. The clinical implications of the research are discussed for screening women at risk of PTSD following childbirth, assessment of a woman's appraisal of a difficult labour and delivery and the provision of support in the postnatal period.
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Briscoe, Lesley. "Vulnerability within maternity care." Thesis, Edge Hill University, 2018. http://repository.edgehill.ac.uk/10083/.
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Background: Vulnerability is universally present but experienced biopsychosocially on an individual level. Stigma develops when populations are labelled vulnerable. Individual vulnerability can be lessened by resources accessed to assist in developing resilience. A deeper analysis of vulnerability and resilience is required to inform policy, ethics, law and social life. Design: Qualitative, quantitative and mixed method approaches were used. Sample: Five papers represented the perspectives of 102 women, 21 clinicians and 13 student midwives. A further paper presented a concept analysis which included the perspectives of 10,067 women and 325 clinicians (total sample size women n=10,169; clinicians n=346; student midwives n=13). Methods: Gadamer’s ontological perspective of time, place and culture and was seen through Engel’s biopsychosocial lens. Epistemologically, truth originated from multiple realities. Methodologically, women’s experiences were captured via mixed methods. 7 Analysis: Thematic analysis and descriptive statistics were synthesised via framework analysis. Findings: A coherent theme of vulnerability in maternity care was apparent. Women’s concerns were trivialised. The professional’s style of communication determined the women’s experience of maternity care. Clinician control of care provision undermined women’s ability to choose. Women developed resilience in adverse circumstances via: accessing other supportive members of society, identifying their need for information, talking to others and developing accommodative coping strategies. Conclusion: The new conceptual model, in this thesis, should be evaluated via mixed methods. A biopsychosocial approach should underpin informed choice. Clinicians need raised awareness about how interaction can lower women’s self-esteem and build resilience in others. Higher education needs to challenge preconceived biases in safe environments via reflective processes. Research should explore women’s influential circle in decision making during maternity care. Women should be involved in the design of research to inform how best to capture their complex lived experience. Funders of research and ethics committees should request information about how implementation of evidence may be influenced by the current clinical environment. Impact should be measured post implementation. Social policy should be informed by a deeper, conceptual analysis of vulnerability and resilience.
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Lacey, Lauren. "Prediction of inappropriate myometrial function." Thesis, University of Warwick, 2016. http://wrap.warwick.ac.uk/91479/.
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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.
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Doherty, Nicola. "Disclosure of genetic origins : parental experiences and attitudes in the UK and Brazil." Thesis, University of Warwick, 2018. http://wrap.warwick.ac.uk/100889/.
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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.
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Al-Musharaf, Sara. "Prevalence of vitamin D deficiency in pregnant women and its association with gestational diabetes mellitus." Thesis, University of Warwick, 2017. http://wrap.warwick.ac.uk/94005/.
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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.
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Weli, Homayemem Kinikanwo. "Changes in advanced glycation content, structural and mechanical properties of vaginal tissue during pregnancy and in prolapse." Thesis, Keele University, 2018. http://eprints.keele.ac.uk/5104/.
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Introduction: Pelvic organ prolapse is present in up to 50% of women. It is commoner in older women, often above 50 years of age and associated with hormonal e.g. oestrogen decline, and stiffer vaginal tissue. Pregnancy, on the contrary is a physiologic condition with higher oestrogen level and exhibits reversible structural and mechanical changes in pelvic tissues. Advanced glycation products, the ageing markers, stiffen connective tissues. There has been no previous systematic study on the relationship and action mechanisms of oestrogen, glycation level and mechanical property of vaginal tissues. Aim: The aim of this project was to study the ultrastructural and mechanical properties of vaginal tissues, and understand the relationship and possible mechanisms of accumulation of glycation (pentosidine), vaginal wall mechanics and oestrogen receptor (ER-a) expression in the vaginal tissues in both pregnancy and prolapse. It was hypothesised that prolapse is a disease of accelerated ageing and that mechanical and ultrastructural changes in prolapsed tissues and oestrogen decline are related to the elevation of glycation content in the tissues. Methods: Following ethical approval, vaginal tissues from 49 women with prolapse and 16 controls were obtained and proformas containing information on known and suspected prolapse associations were completed for each participant. Female Sprague Dawley rats‘ vaginal tissues were used for the pregnancy study. Nano-scale, micro-scale and tissue level mechanical characterizations of the tissues were performed using ball indentation technique, scanning electron microscopy, peakforce nanomechanical property mapping atomic force microscopy, and optical coherence elastography, which was applied for the first time to the study of vaginal tissues. The glycation contents of vaginal tissues in pregnancy and prolapse were quantified by high performance liquid chromatography and values obtained were analysed in comparison to medical comorbidities. Tissues were qualified by histological and immunological staining for structure (haematoxylin &eosin, trichrome and picrosirus red stainings), glyoxalase I, ER-a, elastin and neural stain. A sulphated glycosaminoglycan (sGAG)-collagen model was used to study the role of sGAG in collagen fibrillogenesis. Results: Rat vaginal tissues in pregnancy contained significantly lower amounts of pentosidine, higher oestrogen receptor-a and glyoxalase I (antioxidant enzyme) expression with larger creep, lower elastic modulus, larger fibril diameter and higher sGAG content than their non-pregnant counterparts. Observed morphological changes of the collagen fibrils in pregnancy were attributed to sGAG, which was noted to influence collagen fibril aggregation and bundling. Skin pentosidine content was reflective of vaginal tissue pentosidine in the same subjects. Pentosidine was significantly higher in prolapsed tissues and increased with age; with more age-dependent increase observed in the prolapse population and also significantly different between the 6th and 7th decades. Glyoxalase I and ER-a were poorly expressed in the prolapsed tissues in comparison to controls. Prolapsed tissues had notably disorganized ultrastructure and higher collagen fibril modulus. At all levels of tissue organization, prolapsed tissues were stiffer than controls, with increased stiffening at the more superficial layers of the tissue. Hypertension and smoking were associated with higher glycation and prolapse. In both pregnancy and prolapse, higher expression of glyoxalase I and ER-a were associated with lower glycation content of the vaginal tissues and lower modulus. These observations have led to the suggestions that oestrogen plays an important role in increase or reduction of glycation through an oestrogen-gluthathione-glyoxalase (antioxdant) pathway, which directly affects vaginal tissues‘ mechanics. Future implications: These findings have implications to the current understanding of how prolapse may occur and can inspire future translational research on improved treatment of women with prolapse. Oestrogen may significantly influence the temporary and permanent mechanics of pelvic tissues such as the vaginal wall through its modulation of glycation accumulation within the tissues. Oestrogen thus shows promise of a potential future medical treatment for early stages of prolapse. The knowledge of new prolapse comorbidities can aid the early detection and possible prevention of prolapse through a high index of suspicion.
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Badger, Frances Jane. "Delivering maternity care : midwives and midwifery in Birmingham and its environs, 1794-1881." Thesis, University of Birmingham, 2014. http://etheses.bham.ac.uk//id/eprint/5318/.
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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.
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Gehrig, Jochen. "Function of core promoters in differential gene regulation during embryogenesis." Thesis, University of Birmingham, 2010. http://etheses.bham.ac.uk//id/eprint/971/.
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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.
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Bakour, Shagaf Haj. "Evaluation of ambulatory diagnosis of abnormal uterine bleeding." Thesis, University of Birmingham, 2003. http://etheses.bham.ac.uk//id/eprint/42/.
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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.
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Connolly, Thomas James. "Calcium signalling during human sperm interaction with cells of the female reproductive tract." Thesis, University of Birmingham, 2012. http://etheses.bham.ac.uk//id/eprint/3411/.
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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.
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To, Wilson King Lim. "A role of ATP in modulating vasomotion during hypoxia in umbilical cord blood vessels." Thesis, University of Birmingham, 2012. http://etheses.bham.ac.uk//id/eprint/3313/.
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Previous studies have associated intracellular calcium ([Ca2+]i) oscillations in vascular smooth muscle cells (SMC) with vasomotion in multiple species. In normal and pre-eclamptic pregnancies, there is strong evidence to suggest that the intrauterine environment is hypoxic. The aim of this study was to investigate whether ATP and [Ca2+]i oscillations play a role in modulating vasomotion during hypoxia in human umbilical blood vessels. The results obtained from in vitro studies using firefly luciferase assay and quinacrine staining indicated that human umbilical artery and vein endothelial cell (HUAEC, HUVEC respectively) constitutively released ATP and, in HUVEC at least, the release was accentuated by hypoxia (7.6 mmHg O2, 30 min). This release is dependent on the PI3K/ROCK pathway, and on normal vesicular transport. Further, application of ATP to human umbilical artery SMC induced dose-dependent [Ca2+]i oscillations, which was mediated by P2Y4 receptor. Moreover, ex vivo data from freshly isolated umbilical artery rings showed that acute hypoxia increased the frequency of vasomotion. It is therefore proposed that the findings of the present study is important in the understanding of the behaviour of human umbilical vessels in normal pregnancy, but may also have implications in the pathophysiology of complicated pregnancy such as pre-eclampsia.
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Smith, Paul Philip. "The practice of office hysteroscopy." Thesis, University of Birmingham, 2015. http://etheses.bham.ac.uk//id/eprint/6061/.
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Advances in technology have led to the miniaturisation of hysteroscopes without compromising optical performance. This development has facilitated the routine use of diagnostic hysteroscopy in an outpatient setting without the need for general anaesthesia. Further developments have expanded hysteroscopy from a simply diagnostic intervention to an operative one with a plethora of hysteroscopic surgical procedures. The work in this thesis has adopted a mixed methodological approach to rigorously evaluate patient selection, feasibility and efficacy of office hysteroscopy. Based on the results of this thesis we recommend: 1) Women with recurrent PMB should be investigated with either hysteroscopy or saline infusion sonography. 2) Vaginoscopy should probably be used in preference to other techniques to introduce the hysteroscope into the uterine cavity. 3) Women who have a uterine cavity >9cm or dysmenorrhoea should be warned they are more likely to require further intervention after endometrial ablation. 4) There appears to be no difference between the effectiveness of bipolar radiofrequency ablation and thermal balloon ablation at five years of follow up. 5) Women who present with abnormal uterine bleeding and an endometrial polyp should have it removed. 6) The hysteroscopic morcellator should be used in preference to bipolar resection for endometrial polyp removal.
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Wilne, Sophie Helen. "The Pathways Project : developing guidelines to facilitate the diagnosis of childhood brain tumours." Thesis, University of Birmingham, 2011. http://etheses.bham.ac.uk//id/eprint/2881/.
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The Pathways project was undertaken to devise guidelines to facilitate rapid diagnosis of paediatric brain tumours. Methods: A systematic review and meta-analysis of published data on paediatric brain tumour presentation and analysis of the presentation of children newly diagnosed with a brain tumour at four oncology centres was undertaken. The results informed a professional consensus process. Results: 74 papers met the inclusion criteria for the meta-analysis. 56 symptoms and signs at diagnosis were identified. The most frequent symptoms and signs at diagnosis were: headache (33%), nausea and vomiting (32%), abnormalities of gait and coordination (27%), and papilloedema (13%). 139 patients were recruited to a multi-centre cohort study. Symptoms and signs at disease onset and at diagnosis and factors associated with a long and short symptom interval were determined. A shorter symptom interval was associated with nausea and vomiting and motor system abnormalities. A longer symptom interval was associated with head tilt, cranial nerve palsies, endocrine and growth abnormalities and reduced visual acuity. A multi-disciplinary workshop and Delphi consensus voting were used to translate the evidence into a clinical guideline comprising 76 statements advising on the identification and assessment of children who may have a brain tumour.
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Aḥmad, ʿĀʾishah. "The association between fetal position at the onset of labour and birth outcomes." Thesis, University of Birmingham, 2012. http://etheses.bham.ac.uk//id/eprint/3723/.
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Fetal position throughout labour exerts considerable influence on labour and delivery, with a mal-positioned fetus during active labour known to contribute towards fetal and maternal morbidity. In response there is a move towards promoting the Left Occipito-Anterior (LOA) position at labour onset as optimal. It is thought that the LOA position encourages anterior rotation thus reducing the likelihood of mal-rotation. A systematic review was undertaken which highlighted an absence of scientific evidence. A prospective cohort study was therefore conducted with 1250 nulliparous women who were scanned to accurately determine fetal position, specifically the LOA position at the onset of labour and the association with delivery mode and other birth outcomes was examined. The LOA position at the onset of labour was not associated with mode of delivery, nor were any of the other positions (p=0.39). Pain relief, labour duration, augmentation, and Apgar scores did not show any association with the LOA or other positions. The only association found was that women with a fetus in the posterior position were more likely to use pethidine (p=0.008). This study has shown that the LOA fetal position at labour onset was not associated with improved outcomes and therefore should not be promoted as optimum.
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Wilson, Amie. "Interventions to reduce maternal mortality in developing countries : a systematic synthesis of evidence." Thesis, University of Birmingham, 2014. http://etheses.bham.ac.uk//id/eprint/5147/.
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Background: Every year 287,000 women die from pregnancy related complications. Methods: Systematic reviews of interventions to reduce maternal mortality in developing countries with meta-analysis or meta-synthesis where appropriate. Results: Participatory learning and actions cycles with women’s groups significantly reduce maternal and neonatal mortality, training and supporting TBAs also reduces perinatal mortality. Clinical officers performing caesareans section do not seem to cause any more maternal or perinatal mortalities than doctors. Prophylactic antibiotics reduce infectious morbidity in surgical abortion, yet the effect on miscarriage surgery is unclear. Cell salvage in ectopic pregnancy and caesarean section appear to be a safe and effective alternative in the absence of homologous transfusion. Motivational interviews may have potential to improve contraceptive use short term. Symphysiotomy may be a safe alternative to caesarean section. The anti-shock garment may improve outcomes when used in addition to standard obstetric haemorrhage management. Potential solutions to emergency transport for pregnant women include motorcycle ambulance programmes, collaboration with local minibus taxis services, and community education and insurance schemes. Conclusion: Several interventions reviewed in this thesis can be utilised to aid reduction in maternal mortality, however the level of evidence available within each review varies, some allowing firm inferences with others more tentative.
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Pritchett, Ruth Victoria. "The treatment of postnatal depression with exercise : a randomised controlled trial, qualitative study and systematic review." Thesis, University of Birmingham, 2016. http://etheses.bham.ac.uk//id/eprint/6492/.
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This thesis investigated the effectiveness of exercise in the treatment of postnatal depression (PND). PND is highly prevalent, affecting mothers, families and child development. Exercise is currently recommended to mothers with PND, potentially offering fewer side effects than antidepressants and wider accessibility than psychological treatments. This thesis reported three studies. A randomised controlled trial (RCT) investigated the effectiveness of an exercise counselling intervention, in addition to usual care, in treating PND. This intervention provided a moderate, non-significant decrease in depression compared to usual care alone. A qualitative study found that exercise was viewed as acceptable and often preferable to antidepressants in the treatment of PND. A range of mechanisms via which exercise produced psychosocial benefits were proposed, including improving self-confidence and supporting personal identity after childbirth. A systematic review with meta-analysis of RCTs of exercise interventions for PND concluded that exercise can be effective in reducing depression in general and depressed postnatal populations. Preliminary findings suggested the importance of social support within such interventions. Exercise is likely to be effective in the treatment of PND and should therefore be recommended to mothers. However, further research investigating the relative effectiveness of different intervention designs would be valuable.
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Cooper, Natalie Ann MacKinnon. "Ambulatory gynaecology : guidelines and economic analysis." Thesis, University of Birmingham, 2013. http://etheses.bham.ac.uk//id/eprint/4421/.
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The aim of this thesis was to investigate the role of outpatient hysteroscopy in modern gynaecological care by conducting a series of systematic reviews and meta-analyses to examine how the procedure can be optimised to reduce pain and by performing a cost effectiveness analysis. The systematic reviews concluded that women undergoing outpatient hysteroscopy should take simple analgesia beforehand and that the hysteroscopist should adopt a vaginoscopic approach using a small diameter, rigid hysteroscope and normal saline as the distension medium. If dilatation of the cervix is required this should be done under a paracervical block. These findings were incorporated into a clinical guideline and the quality of the evidence that the reviews provided was assessed using the SIGN and GRADE methods. A comparison of the assessments found that they gave varying estimates of the quality of evidence and that neither offered a perfect solution to the assessment of evidence quality when writing clinical guidance. The economic analysis found that initial testing with outpatient hysteroscopy was the most cost-effective testing strategy for investigation of heavy menstrual bleeding when compared to other diagnostic tests, regardless of a woman’s wish for future fertility or prior treatment with a levonorgestrel intrauterine system.
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Kilby, Mark David. "The role of thyroid hormones in placental and fetal central nervous system development." Thesis, University of Birmingham, 2011. http://etheses.bham.ac.uk//id/eprint/2911/.
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Thyroid hormones are critical to growth and development of the human fetus. In particular, the fetal central nervous system is extremely sensitive to the actions of the active ligand, tri-iodothyronine (T3). The placenta is the organ during pregnancy that allows transport between the mother and her baby by close interaction of the maternal and fetal circulations. Endogenous fetal thyroid hormone production does not occur until the beginning of the second trimester. However, there appears to be transplacental transport of thyroid hormones to the fetus earlier in gestation and organs, such as the central nervous system, appear to be exquisitely sensitive to their actions. The content of this Thesis describes my work, published in peer reviewed papers over the last fifteen years. It outlines the molecular mechanisms controlling the delivery and actions of thyroid hormones to the fetus.
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Correia, Joao Natalino. "Novel modulators of human sperm motility and migration." Thesis, University of Birmingham, 2012. http://etheses.bham.ac.uk//id/eprint/3450/.
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Overall, signaling events in human sperm, together with the identity of many of the molecules stimulating them, remain very poorly characterised. A two-pronged approach involving characterisation of sperm receptors in a model-cell system, followed by single cell [Ca2+]i imaging of large numbers of capacitated human spermatozoa, was employed to start to unravel some of these possibilities. Data were compared to responsiveness of the best-characterised physiological ligand of sperm – the steroid hormone progesterone. Proteomic data strongly indicates the presence of OR2AE1, an olfactory receptor, in mature human sperm. OR2AE1 was cloned into the mammalian expression vector pcDNA3 and expressed in HEK293 cells. Functional expression of OR2AE1 (5.6±1.1% of cells showing correct localisation of FLAG-tagged recombinant receptor at the plasma membrane level) was demonstrated. Despite this relatively low level of functional expression, this system still allowed identification of a potent volatile agonist for OR2AE1 – omega () – via an elimination-panel system used alongside [Ca2+]i imaging. Around 3% of cells in the heterologous system generated a response to the agonist, indicating correct functional expression. When sperm were exposed to 50 μM , [Ca2+]i imaging revealed a transient response which occurred in 30-40% of capacitated cells. 10 μM NNC 55-0396, an antagonist of the CatSper channels, inhibited around 80% of these responses. Similar inhibition levels were demonstrated by inhibitors of the cAMP pathway (100 μM SQ22536 and 25 μM cAMPS-Rp), but no substantial effect was observed by inhibition of PLC by 5 μM U73122. Chemotactic assays indicated that 50 μM had an optimal chemoattractive effect, with 500 μM significantly stimulating acrosome reaction. An unrelated family of chemicals, the boronic acids, were also examined for their ability to affect sperm motility, migration and [Ca2+]i dynamics. A significant effect on the number of sperm which migrated from semen when exposed to these chemicals was observed, with pathway inhibition distinctly indicating a bifurcating signal propagating mainly via IP3 but also involving the cAMP pathway. Manipulation of the signalling events described, with inherent modulation of sperm motility may underlie the ability to develop future novel therapy, including contraceptive and diagnostic treatment regimes for the human male.
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Hamad, Asma M. "Molecular and physical interactions of human sperm with female tract secretions." Thesis, University of Birmingham, 2017. http://etheses.bham.ac.uk//id/eprint/7477/.
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To achieve fertilisation, human sperm have to navigate and interact with the female reproductive tract (FRT) on molecular and mechanical levels. The current knowledge of some aspects of both types of interactions are limited and they were examined in this research. Proteomic analysis of crude and depleted human follicular fluid (hFF) by three proteomic approaches identified 479 hFF-proteins of which 22% were novel. A table of hFF-proteins, compiled from twenty-four hFF proteomic studies, resulted in 1586 hFF proteins; a resource for folliculogenesis and discovery of hFF biomarkers. A comparative proteomic study of media-capacitated human sperm versus capacitated sperm in the presence of hFF revealed certain hFF proteins were acquired by sperm during capacitation. Comparative metabolomics revealed some elevated metabolites in the sperm capacitation-media following 6-hour incubation compared to 1-hour swim-up, which may have relevance to sperm energy metabolism and potentially to sperm signalling mechanisms in the FRT causing remodelling for fertilisation and preparation for implantation. Sperm micro-particle image-velocimetry revealed an average fluid velocity around the motile sperm of ≤ 25- 45 μm/s and ≤ 20-35 μm/s in low and high viscosity media respectively. The averaged fluid vorticity manifested a trail of spatially confined mixing of the fluid surroundings motile sperm. To the best of our knowledge, this work is the first to conduct a comparative proteomic analysis of human sperm versus sperm-hFF interaction and to perform metabolomics analysis of human sperm capacitation media at two time points. The novel perspective of mechanical aspects of sperm motility by studying fluid velocity and vorticity around motile sperm adds a new approach to the study of sperm motility and chemotaxis. In conclusion, sperm-FRT interactions involve complex molecular and physical interactions and regulatory events. Further research of these interactions may enhance our understanding of potential applications for improved assisted reproductive techniques’ outcome and possible diagnostic approaches of infertility.
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Harb, Hoda Maaly. "Early pregnancy challenges : study of caesarean scar pregnancy through a novel national surveillance platform and systematic reviews of priority questions in miscarriage management." Thesis, University of Birmingham, 2015. http://etheses.bham.ac.uk//id/eprint/6421/.
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Uncommon disorders are difficult to study because routine information sources are unreliable, and comprehensive studies would require a large collaboration to identify relatively few cases. This PhD developed a national network and research platform for the study of serious and uncommon disorders in early pregnancy: The UK Early Pregnancy Surveillance Service (UKEPSS). A national collaboration can enable high quality research to improve our knowledge and help us provide better care for women with rare early pregnancy conditions. Using the UKEPSS platform, with an early pregnancy network of 86 UK hospitals and Early Pregnancy Units (EPUs), nation-wide prospective cohort and case control studies of caesarean scar pregnancy were performed. The second section of this thesis comprises of systematic reviews in priority questions in miscarriage management, exploring the effectiveness of progesterone to reduce miscarriage in women presenting with early pregnancy bleeding; the effect of ethnicity on miscarriage; and the effect of hydrosalpinx and its management on miscarriage risk.
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Halliday-Bell, Jacqueline A. "Pregnancy outcomes for women employed as hairdressers, cosmetologists and laboratory workers : systematic review of the literature and data-analysis of Finnish medical birth registry." Thesis, University of Birmingham, 2015. http://etheses.bham.ac.uk//id/eprint/6132/.
Full textAbstract:
This thesis included a systematic literature review, yielding studies on three employment categories: hairdressers, cosmetologists and laboratory workers. The original research examined pregnancy outcomes for Finnish singleton births between 1990 and 2010. The parameters were increased male gender, low birth-weight, high birth-weight, pre-term delivery, post-term delivery, small for gestational age, large for gestational age, stillbirth and early neonatal death. Finnish Birth Registry data included 507,659 prima gravida women who delivered singletons with at least 22 weeks’ gestation 1990- 2010. There were 12,854 hairdressers, 1841 cosmetologists and 3587 laboratory workers. Control populations: 40,405 teachers, 1968 musicians and 447,004 women-general population. When hairdressers were compared to the general public, there were three marginally statistically significant results for new-borns: SGA, (OR 1.01, 95% CI 1.00 - 1.02), LGA, (OR 1.02, 95% CI 1.00 - 1.03) and post-term delivery (OR 1.06, 95% CI 1.02 -1.11). Marginal increased statistically significant results for pooled effect size (ES) from the meta-analysis were found for LBW among hairdressers ES 1.083 (95% CI, 1.017-1.153) and SGA infants among hairdressers ES 1.077 (95% CI, 1.006-1.153). Hairdressers may be at a marginally increased risk of low birth weight and small size for gestational age. This may be due to occupational exposure.
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Latthe, Pallavi. "Chronic pelvic pain : prevalence, risk factors and laparoscopic uterosacral nerve ablation." Thesis, University of Birmingham, 2006. http://etheses.bham.ac.uk//id/eprint/40/.
Full textAbstract:
This thesis sheds light on chronic pelvic pain in following areas: 1. Summarising prevalence of chronic pelvic pain 2. Exploring the risk factors in chronic pelvic pain, 3. Exploring beliefs on laparoscopic uterosacral nerve ablation and 4. Developing a protocol for a Multicentre randomised controlled trial of laparoscopic uterosacral nerve ablation.
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Israfil-Bayli, Fidan. "Cerclage outcome by the type of suture material (COTS) study : randomised pilot/feasibility study comparing monofilament (intervention) sutures versus multifilament (comparison) for cervical cerclage." Thesis, University of Birmingham, 2018. http://etheses.bham.ac.uk//id/eprint/8565/.
Full textAbstract:
COTS provided the necessary information for planning a definitive trial investigating the clinical effectiveness of monofilament non-braided suture materials in reducing pregnancy loss rate following cervical cerclage compared to the traditional multifilament braided sutures. COTS study was a stepwise process, which initially involved retrospective data analysis and later was supported by the evidence from national survey and systematic review. Evidence from retrospective analysis and systematic review confirmed that the research question about the suitability of multifilament/braided sutures in cervical cerclage; and that they may be associated with poor obstetric outcome. The Systematic review confirmed that at the time of writing there were no RCTs addressing this issue. Our national survey proved that this scientific question is of significant interest to the Obstetrical community and that the practice with cerclage varies across the country. Based on the findings of COTS trial, funding was sought from the NIHR HTA programme, and we were successful in being awarded £1.2 million (co-applicant) to conduct a multi-centre randomised controlled trial (RCT): The C-STICH trial Cerclage Suture Type for an Insufficient Cervix and its effect on Health outcomes Trial.
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Yap, Jason Ker Wei. "Improving the outcome of patients with premalignant and malignant disorders of the vulva." Thesis, University of Birmingham, 2016. http://etheses.bham.ac.uk//id/eprint/6533/.
Full textAbstract:
Research presented in this thesis was driven by the need to identify risk factors that predict local recurrence (LVR) in patients with vulval cancer (VSCC), and the need for more effective treatments for women with vulvar intraepithelial neoplasia (VIN). To identify the risk factors that predispose women to LVR, a multivariate analysis was performed on a well-characterized cohort of women treated for VSCC. This analysis revealed that the only independent predictor of LVR was the presence of Lichen Sclerosis (LS). These women were five times more likely to recur than those without LS. VIN is a recognised precursor lesion of HPV-positive VSCC. Topical application of Epigallocatechin-3-gallate (EGCG), a green tea polyphenol, has been shown to be an effective treatment for genital warts; a condition caused by HPV. Although the mechanism(s) by which EGCG influences the growth of HPV-associated proliferative disorders are unknown, I demonstrate that EGCG inhibits cell proliferation and promotes apoptosis, an effect that was accompanied by down-regulation of the E6 and E7 proteins and the induction of p53, p21 and pRb. Biochemical analysis revealed that EGCG did not stimulate E6 degradation by enhancing poly-ubiquitination and proteasome-mediated degradation, suggesting that EGCG-mediated E6 proteolysis occurred through other mechanisms.
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Baxter, J. "Listening to women after birth : their perceptions of postnatal support and the potential value of having a postnatal debriefing session with a midwife." Thesis, City, University of London, 2017. http://openaccess.city.ac.uk/17911/.
Full textAbstract:
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.