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Introduction: Pregnancy is a time of both transformation and adaptation within the human body. Entering pregnancy with a body mass index (BMI) above the healthy range of 18.5-24.9kg/m2 increases a range of health risks for both the mother and baby and so is a targeted area for weight management. This thesis aims to evaluate a weight management programme (Bumps and Beyond) developed for pregnant women with a high BMI and delivered in two geographic areas in the UK. Methods: Service evaluation was based on audit sheets completed by staff at the two locations. Data from anonymised records were statistically analysed to see if the intervention reduced gestational weight gain, and complications in pregnancy and labour. Intervention fidelity was reviewed via transcripts of staff delivering the intervention in Lincolnshire. Hermeneutic phenomenological analysis (HPA) was undertaken on transcripts of staff delivering the sessions within the intervention at one site. The HPA used the novel approach of utilising the Roles of 'Sarah the Mother', 'Sarah the Dietitian', and 'Sarah the Researcher' to find the essence within the texts of the transcripts. Results: Intervention fidelity was good, and staff were responsive to participants' needs. Full attendance at Lincolnshire Bumps and Beyond showed a positive impact on gestational weight gain, total pregnancy complications, pre-eclampsia, preterm birth, low birth weight and breastfeeding initiation. Full attendance at Nottinghamshire Bumps and Beyond did not show the same benefits and was associated with greater risk of instrumental delivery and lower breastfeeding initiation. HPA of transcripts brought out several essences for each role that indicated possible pathways for development of the programme in the future. Discussion: The contrasting efficacy of Bumps and Beyond at the two locations gives a clear indication that just transferring a programme from one setting to another is not enough to ensure it will be successful. Despite being geographically close, the two locations had different populations which may in part explain the lack of success in Nottinghamshire. In addition to this, the type of staff may have had some effect in how the programme was delivered in each location. Use of the HPA output allowed insight into possible areas that could be further developed or adapted for the population the intervention is to serve. The Bumps and Beyond programme is similar to other small-scale midwife-led interventions that report positive outcomes in one local area. Larger trials have been less successful overall. Conclusion: Small local interventions to control gestational weight gain in women living with obesity can be effective when adapted to suit the needs of the population.

High density lipoprotein (HDL) is well-known for its ability to protect vascular function. It is hypothesised that HDL could be a protective factor for vascular function in healthy pregnancy that fails in preeclampsia resulting in endothelial dysfunction. The aims of this thesis were to determine HDL composition and function throughout healthy pregnancy and in preeclampsia. HDL protein and sphingolipid compositions were determined using proteomic and lipid analysis approaches in healthy pregnancy from pre-pregnancy to postpartum. There were 16 proteins changed in HDL throughout gestation. Higher HDL α-1-antitrypsin content was observed in the first trimester (median LFQ intensity 5.8x108 at 8.4 weeks and 4.2 x10 pre-pregnancy, p=0.044) and may protect the reverse cholesterol transport (RCT) function of HDL. HDL content of sphingosine-1- phosphate (S1P) and ceramides increased in the third trimester (S1P 101.1±9.8, 108.0±19.8 and 128.8±15.6 ng/mL, C18:0 12.0±2.6, 16.9±6.8 and 20.2±6.2 ng/mL, C20:0 30.6±10.6, 40.32±13.0 and 52.6±17.5 ng/mL, C22:0 196.0±101.8, 266.9±119.6 and 362.7±164.2 ng/mL, C24:1 137.2±48.4, 151.8±54.8 and 201.4±60.4 ng/mL for 16, 25 and 35 weeks, respectively), suggesting improved anti-inflammatory, vasodilatory and RCT function of HDL. In preeclampsia, the third trimester HDL protein composition, both late and early onset, was compared to HDL from gestation-matched healthy pregnancy. ApoA-IV was lower in early-onset preeclampsia (median LFQ intensity 3.0x109 and 3.9x109 for early-onset preeclampsia and control, p=0.018), suggesting that HDL may be less efficient at inhibiting excessive inflammation in early-onset preeclampsia. The LFQ intensities of antithrombin-III (9.3x107 and 1.4x108 for late-onset preeclampsia and control, p=0.045) and β-2-glycoprotein 1 (5.9x108and 9.0x108 for late-onset preeclampsia and control, p=0.030) were lower in late-onset preeclampsia which might suggest both activating and inhibiting effects on the coagulation cascade. Next, assays to assess HDL function, including HDL effects on vascular reactivity using wire myography and the anti-clotting potential of HDL, were developed. The wire myography protocol was able to assess HDL effect on vasoconstriction responses of human pregnant visceral adipose tissue arteries, but not vasodilatory responses because vessels contracted to the maximum dose of noradrenaline did not maintain a stable contraction. An antithrombotic functional assay of HDL was developed by adapting an existing thrombin generation assay protocol used for plasma. NaBr carried over from HDL isolation process inhibited thrombin production in the assay, leading to difficulty in standardizing thrombin generation activity measured in HDL samples. Finally, an isolation protocol for HDL was developed where potential extracellular vesicle (EV) contamination in HDL samples was removed using a combination of size-exclusion chromatography and sequential ultracentrifugation. ApoA-I recovery in HDL isolated by this protocol was 39.8%. Comparison of protein composition of EV and HDL (EV-free HDL) isolated by this protocol and HDL isolated by the gold standard method, sequential ultracentrifugation, suggested that the EV proteins that were removed from HDL by this isolation protocol were mostly immunoglobulins and complement proteins. Several essential HDL proteins were partially removed from the HDL particles during the isolation of EV-free HDL, for example, apoC-IV, apoA-IV and paroxonase-1. In conclusion, this thesis provided evidence of pregnancy and preeclampsia-associated changes of HDL protein, S1P and ceramide in a manner that may improve or decrease HDL function. HDL functional assays are needed to validate the relevance of these HDL composition findings.

The current working hypothesis in recurrent pregnancy loss (RPL) suggests an immune dysregulation in women with this condition, with most studies highlighting an increase in natural killer (NK) cell numbers and cytotoxicity and a shift towards T helper (TH) cell pro-inflammatory cytokine secretion, termed "Type-1/Type-2 hypothesis". Experimental findings however remain contentious, hindering the introduction of immunological testing into clinical practice, despite the increasing pressure from clinicians and couples affected. Through a nationwide survey, a strong variation in clinical practice was observed, with different definitions of RPL used and multiple tests employed for the identification of potential risk factors. Immunological testing was offered in 3 (9.38%) clinics included, while several therapies, including immunomodulatory agents, were utilised for the management of idiopathic RPL, underlining the need for further research into the role of the immune system in this condition. Using peripheral blood samples from non-pregnant women with RPL and healthy controls, a broad immunophenotypic analysis was performed, confirming the NK cell increase and revealing a reduction in T cell prevalence in women with RPL. Further examination by mass cytometry displayed a decrease in regulatory-like T and B cell subsets and an increase in a plasma cell-like subpopulation, although validation of these findings utilising additional markers is required. The elevated NK cell cytotoxicity, often referenced in RPL, was undetectable in the present study, although an increased degranulation capacity of these cells was seen. Cytolytic molecule release by peripheral blood mononuclear cells (PBMCs) appeared reduced in women with RPL, possibly counterbalancing the enhanced degranulation. A unique mass cytometry panel was employed for the detailed investigation of activating and inhibitory receptor expression on NK cells. Increased prevalence of mature cytotoxic CD57+ NK cells was detected in the RPL population, accompanied by an increase in subsets lacking the expression of multiple inhibitory receptors, indicating an enhanced responsiveness of the NK cell population to activating signalling. Furthermore, elevated pro-/anti-inflammatory cytokine-producing TH cell ratios were detected in women with RPL, accompanied however by decreased pro-/anti-inflammatory cytokine expression intensity on these cells. NK cell cytokine production appeared deficient in women with this condition. Interestingly, the shift towards pro-inflammatory molecules was evident when the levels of cytokine secretion by PBMCs were assessed, in agreement to the Type-1/Type-2 hypothesis. Pro- and anti-inflammatory cytokine secretion by PBMCs also appeared elevated in women with RPL and a following miscarriage, compared to those that were either in the 3rd trimester of their subsequent pregnancy or had a live birth, highlighting a potential prognostic capacity of these markers. The findings of the present study highlight a dysregulation in peripheral immunity of women with RPL, which cannot however be appropriately described using a pro-/anti-inflammatory dichotomy. Although certain immune parameters, such as elevated NK cell levels, could provide potential diagnostic biomarkers, with plausible prognostic markers also proposed, further research on both peripheral and uterine samples is required to fully elucidate the role of the immune system in RPL, allowing the introduction of immunological testing into clinical practice.

Cefuroxime and cefazolin are used intravenously pre-caesarean section (CS) to prophylactically prevent or decrease post-surgical infections. Cefazolin pharmacokinetics (PK) has been evaluated in obese-pregnant women; while cefuroxime posology, appropriateness of doses, has not been assessed in this population. The aim of the current project was to investigate the appropriateness of cefuroxime dose given to obese-pregnant women at time of CS. Available cefazolin PK data in an obese-pregnant population was utilised to guide investigation of cefuroxime PK in an obese-pregnant population. This project comprised of four work packages: (1) Systematic review to identify information regarding cefazolin PK and rate of infection when cefazolin was given pre-CS in obese-pregnant women, and a systematic review to identify information on cefuroxime PK and rate of infection when cefuroxime is administrated to lean- or obese-pregnant at CS; (2) A research study was developed to clinically measure cefuroxime concentrations in plasma and adipose tissue in lean- and obese-pregnant (this study was approved by ethical authorities, and currently is suspended due to COVID-19 pandemic); (3) A partial validation of an analytical method to measure cefuroxime concentrations in plasma and adipose tissue samples using High Performance Liquid Chromatography; and (4) A physiologically based pharmacokinetic (PBPK) obese-pregnant model was utilised to predict cefazolin and cefuroxime disposition in such population. At around 1-1.5 hours post cefuroxime 1500 mg dose, reported clinical cefuroxime plasma concentrations ranged within 8.7-57 mg/L in lean-pregnant women (4 articles, n=108 women); while a dose of 750 mg attained a mean plasma concentration of 14.9 mg/L at around 1 hour. There is no publicly available information of cefuroxime adipose tissue concentration in a lean-pregnant population. To the best of our knowledge, there is no clinical information regarding cefuroxime plasma or adipose concentrations in obese-pregnant women. Information from both cefuroxime PK systematic review in lean-pregnant and PBPK modelling proposed the following: (1) A dose of 1500 mg cefuroxime appears therapeutically more appropriate than 750 mg dose for obese-pregnant women undergoing CS, if a minimum inhibitory concentration of 8 mg/L is required for up to 2 hours post dose; and (2) giving cefuroxime 15-30 minutes before skin incision is superior to current guidelines (15-60 minutes before skin incision). A clinical study is required to measure cefuroxime concentrations in plasma and site of incision to assess the appropriateness of cefuroxime dose in obese-pregnant population and to use these data to optimise the obese-pregnant PBPK model.

Epithelial ovarian cancer is an aggressive disease with a five-year survival rate of just 45% in the UK. The understanding of steroid hormone metabolism in epithelial ovarian cancer remains elusive. Steroid metabolites have not been fully characterised using mass spectrometry for benign and malignant ovarian masses. I interrogated existing ovarian cancer genomic data to find changes in gene expression for steroidogenic enzymes and receptors and developed a biological study, using mass spectrometry for steroid analysis. I characterised steroid metabolism in epithelial ovarian cancer cell lines and fresh human ovarian tumours (benign, borderline and malignant). I demonstrated a time-course for androgen metabolism in Type 1 and 2 epithelial ovarian cancers cells and replicated this in ex vivo human ovarian tumours, observing several metabolic fluctuations in the newly synthesised steroid products. Unexpectedly, both the cell lines and tumours consistently showed downstream metabolism towards weaker androgens. I then conducted a multi-centre prospective study investigating urinary steroid profiles in healthy women and women with benign and malignant ovarian tumours. In patients with Type 1 ovarian cancers, I identified five urinary steroid metabolites that differentiate them from Type 2 ovarian cancers, benign ovarian tumours, and healthy ovary. Surprisingly, these metabolites are derived in early classical steroidogenesis. Of interest, there were incremental increases in these five steroid metabolites with advancement from healthy ovary to benign mucinous tumour, to borderline mucinous ovarian tumour and to mucinous ovarian cancer. In summary, I show that urinary steroid profiling can be utilised as a diagnostic tool for Type 1 ovarian cancers and provide evidence that steroid metabolism may be involved in the aetiology of mucinous ovarian cancer.

This thesis was completed as part of the Clinical Psychology Doctorate programme and includes three chapters. Chapter one is a meta-analysis examining the current literature on the prevalence rates for perinatal post-traumatic stress disorder following childbirth. Chapter two is an empirical paper exploring Black women's experiences of pregnancy and birth from a qualitative stance. Chapter three comprises of a press release for both papers, conveying findings in an accessible manner.

This research was conducted to interrogate the myeloid compartment of the immune response within the tumour microenvironment of ovarian cancer and its metastatic sites. Despite the advances in the surgical approach of managing ovarian cancer, the prognosis remains dismal, highlighting the urgent need to develop immunotherapeutic agents to control disease progression and prevent relapse. Little is currently known about the myeloid compartment in ovarian cancer, and as such this thesis focuses upon these cells to fully phenotype and characterise the cells present in the primary site of ovarian cancer but also its secondary metastatic sites. This work demonstrated the presence of myeloid-derived suppressor cells (MDSC) in both benign and malignant neoplasms, a finding that has not been demonstrated previously. It was also shown that the ratio of granulocytic to monocytic MDSC was more predictive of underlying pathology, with high-grade serous ovarian cancer having a much greater ratio compared to healthy donors. Further functional characterisation of these MDSC was then performed in order to demonstrate their immunosuppressive function, where it was demonstrated that there were potential flaws within the laboratory technique of suppression assays. It was shown that MDSC have a great phagocytic capability, which led to phagocytosis of the Dynabeads thus affecting their ability to cause T cell proliferation and demonstrating an inaccurate immunosuppressive effect. Further suppression analyses demonstrated a lack of consistent immunosuppression and as such their phenotypic characterisation was sought through their gene expression using single cell RNA sequencing. The myeloid cells were identified through their unique genetic signatures and a cluster of MDSC-like cells were identified and were found to be in greatest number in the ovarian cancer specimens compared to the metastatic adenocarcinoma and normal samples. They were shown to have an upregulation in arginine and S100A8, both known to have a role in immunosuppression, which may suggest that these MDSC may serve a function in causing immunosuppression despite being unable to demonstrate this experimentally. This may suggest MDSC as a potential therapeutic target within ovarian cancer, however further functional work needs to be done in order to validate these findings.

Recurrent pregnancy loss is a common condition carrying stark physical and psychological morbidity. Chronic endometritis (CE) is a purported cause with an emerging body of literature demonstrating an association. Despite this the pathophysiology of this association is poorly understood. This thesis aims to understand further the pathophysiology of CE through understanding the biological significance of the diagnostic methodology of CE and profiling the effect of CE on the characteristics of the endometrium. A three-fold approach to this is taken. Firstly, through systematic review and meta-analysis, current CE diagnostic methodology was reviewed. This demonstrated a wide heterogeneity in methodology with under-reporting of key steps. A wide range in reported CE prevalence was seen. Diagnostic methodology was shown to affect the ability to predict clinical outcome. Secondly, given the variance in prevalence, the primary diagnostic methodology utilising the plasma cell marker CD138 was explored. Evaluation of the constitutive endometrial expression of CD138 was undertaken. Immunohistochemical and transcriptional profiling demonstrated proliferative phase constitutive stromal expression of CD138 which dissipated on transition into the secretory phase. This finding suggested that CD138+ CE may be related to disordered progression of the endometrium across the menstrual cycle. Two-distinct sub types of CE based on immunohistochemical staining pattern were identified. Thirdly, using both histological and molecular timing, this timing relationship was examined in a prospective clinical study. CD138+ endometrium was shown to be associated with impaired endometrial timing. This was also associated with alterations in the balance between decidualised and senescent endometrial cells. Nevertheless, a causal relationship with the endometrial microbiota was not seen. These findings are the first to demonstrate a relationship between impaired endometrial timing and CE further elucidating the likely pathophysiological mechanisms by which CE predisposes to miscarriage. Furthermore, two distinct sub-types of CE may provide a clinical triage platform for differing treatment approaches.

Background Maternal sepsis is a major global cause of maternal death, and bacterial infections in pregnancy are responsible for a huge proportion of maternal and neonatal adverse outcomes. A lot of time and resources are dedicated to investigating suspected infection in pregnancy and around the time of delivery, and blood tests are ubiquitously used in UK obstetric practice to objectively investigate the likelihood and severity of disease. However, it is poorly understood how infection/inflammatory markers behave in preg- nancy, and how (or whether) they should be interpreted to inform clinical decisions. Methods Over the course of three years, I have authored a series of peer-reviewed articles, letters and conference abstracts, as part of an active working group. We have defined 95% reference intervals (RIs) for the major infection markers used in current clinical practice: C-reactive protein (CRP), white blood cells (WBC) and its subtypes, procalcitonin (PCT) and lac- tate. In several cases we have evaluated these new reference limits in other cohorts to investigate their added value for improving diagnostic accuracy in pregnancy. Results The 95% RI for CRP is substantially and consistently elevated from the first trimester of pregnancy, and using this upper reference limit (19 mg/L) rather than that which is currently recommended (7 mg/L) confers a sig- nificant improvement in the overall diagnostic accuracy for chorioamnionitis. WBC are also elevated from early in pregnancy (5.7-15.0 x109/L), with subtype-specific changes in the differential counts. Both CRP and WBC are so dramatically and unpredictably elevated in labour and the postnatal period that they cannot reliably be interpreted to investigate in- fection and, while lactate in pregnancy is similar to non-pregnant women (< 2 mmol/L), a much higher limit should be used to investigate the severity of sepsis in labour (4 mmol/L). In contrast, levels of PCT are stable throughout pregnancy, and the existing upper limit (0.25 ng/mL) is valid throughout labour and the puerperium. Discussion These publications constitute a substantial body of novel evidence in the field of obstetrics. Some of this may be applied directly to influence policy and clinical practice, while other findings may form the basis of important future research. By drawing reference to these publications and associated works, I present this thesis as an investigation of how we must re-evaluate our clinical practices to improve diagnostic accuracy and prevent morbid- ity and mortality from infections in pregnancy.

Introduction: The prevention of maternal infection and sepsis are essential to reduce maternal mortality and morbidity worldwide. Internationally, childbirth in healthcare facilities is actively encouraged to reduce maternal mortality; however, it can increase the risk of healthcare associated infections if infection prevention and control standards are not met. By adhering to World Health Organization (WHO) guidelines for health facilities, incidence of maternal infection can be reduced. The relevant WHO guidelines include those on: 'water, sanitation and hygiene'; 'hand hygiene'; and 'recommendations for the prevention and treatment of maternal peripartum infection'. This PhD research investigated the feasibility of implementing these in maternity care, focussing on low resource settings. Methods: Three separate studies were undertaken as part of this PhD research. (1) The UK hospital inpatient cases (n = 455) of maternal infection and sepsis during the GLOSS 1-week inception cohort study were reviewed. The aetiology, causative organisms and risk factors for severe infection were explored using descriptive statistical analysis. (2) An explanatory sequential mixed methods feasibility study entitled 'Preventing Maternal Sepsis in Low Resource Settings' was designed and conducted in three low resource maternity settings in Malawi. Aligned with Proctor's implementation framework, this study investigated the feasibility of introducing the WHO guidelines using ward infrastructure surveys at 4 time points, observed hand hygiene opportunities (n=7472), patient record reviews (n=858), qualitative semi-structured interviews (n=33) and six member validation events with healthcare professionals. (3) The WHO 'hand hygiene reminders for the work place' were examined using a convergent mixed methods approach, investigating their acceptability in maternity settings using a survey (n=342) qualitative semi-structured interviews (n=12) and a focus group. Data collection and analysis aligned with Sekhon's acceptability framework. Results: Study 1: the incidence of maternal infection in inpatients in the UK was 32 cases per 1000 live births; lower than the global incidence. Most cases were endometritis or chorioamnionitis where the source was identified, in keeping with the global findings. Study 2: all sites lacked reliable access to running water. The biggest improvement to hand hygiene adherence was seen with the introduction of alcohol-based handrub; to 81%, from 8% at baseline. A significant improvement in antibiotic prophylaxis (75% at baseline to 94% after intervention (P < 0.001)) and vaginal cleansing at caesarean section (0% at baseline to 58% after intervention (P<0.001)) was seen. However, long courses of antibiotic prophylaxis continued to be given against WHO guidance. Two themes (a) study context and (b) characteristics of the intervention were interpreted from the qualitative data to understand these findings and draw recommendations for randomised controlled study (RCT) scale up. Study 3: WHO hand hygiene reminders for the workplace were found to have high acceptability for use in maternity settings but did require some adaptions. Participants from high income settings reported overfamiliarity with the reminders, whereas following the guidance was an issue in low and middle income countries due to resource availability. Conclusion: This PhD research demonstrated that it is feasible to improve the prevention of maternal infection in low resource settings. Adapting guidance and implementation strategies to the local context improved acceptability and uptake. The results are being used in an RCT assessing clinical outcomes. Additionally, the research findings have influenced development of new WHO posters and training materials, aiming to reduce global maternal mortality and morbidity from infection.

High levels of unmet need for contraception in low- and middle-income countries (LMICs) are alarming and contribute significantly to maternal and child morbidity and mortality. This thesis describes the implementation of a six-country initiative aimed at setting up services providing postpartum family planning (PPFP) counselling and postpartum intrauterine device (PPIUD) insertion for those consenting across 48 referral hospitals. The countries involved included Nepal, Sri Lanka, India, Bangladesh, Kenya, and Tanzania. Six published works are included. The first study analysed complications rates from PPIUD across all countries at the six-week postnatal follow up visit. Complications such as infection and perforation were minimal and expulsion rates were similar to when the intrauterine device (IUD) is inserted as an interval method in non-pregnant women (3%). Task shifting to nurses and midwives was safe, with no increase in complications reported. In the second study, analysis of four out of the six countries looked at which factors influenced women's decision to accept the method through quantitative analysis of exit interviews. Repeated counselling in the antenatal period was the only factor that increased uptake across all countries with each country having particular associated factors pertaining to their context. Uptake of PPIUD was initially very low in Nepal. A third study was designed using qualitative methodology to understand how women made their decisions regarding consenting for PPIUD and which factors influence that choice. Subjective norms were found to have a strong influence. It was suggested that community agents known as Female Community Health Volunteers (FCHVs) could help modify this. Strategies were altered to allow for greater involvement of FCHVs. The fourth study used mixed methods to find that formal training increased FCHV's knowledge, their counselling of women and consequently PPIUD uptake. The fifth study looked at sustainability of this strategy. Using a mixed method approach the study found that after one year FCHVs were able to retain their knowledge and were active in counselling on PPFP/PPIUD albeit to a lesser extent than immediately post intervention. Following implementation of the initiative through donor funds, the issue of sustainability of services through local governments became increasingly important. Information on costeffectiveness of PPIUD in LMICs was lacking. The sixth study therefore looked at the costeffectiveness of services in Bangladesh and Tanzania as well as cost savings to the health system were these services to be expanded nationally. In both countries, services were highly cost-effective with national rollout saving more funds through aversion of associated morbidity and mortality related to unplanned pregnancies than it would cost to roll out. In conclusion, the six studies form a cohesive group of research that expands the knowledge on PPFP/PPIUD in LMICs. They demonstrate that implementation of PPFP/PPIUD services was successful, cost-effective and highlighted the importance of: considering contextual realities when devising counselling strategies, using task shifting to increase access and the value of involving community agents. The sustainability of initiatives such as this one and the move to upscaling however remain a challenge.

Premenstrual syndrome (PMS) is a distressing psychological and somatic disorder of unidentified aetiology occurring during the luteal phase of the menstrual cycle. This thesis includes systematic reviews of the published literature on the therapeutic effect of surgical and hormonal suppression of ovulation in the management of premenstrual disorders. Both approaches use the principle that elimination of ovulation removes premenstrual symptomatology along with its consequences. Oestrogen treatment eliminates ovulation, but the necessity for progestogen to prevent endometrial hyperplasia may limit its use. Whilst there are several published trials of the use of oestrogen to treat PMS, this is the first systematic review aiming to evaluate the effectiveness and safety of non-contraceptive oestrogen-containing preparations (oral, patch, implant and gel) in managing PMS. The use of oral contraceptives to treat PMS lies outside the scope of this review. Gonadotropin-releasing hormone (GnRH) agonists also suppress ovarian function and have been found to reduce premenstrual symptoms in virtually all studies. Hypo-oestrogenic side effects may limit their use in clinical practice. Ours is the first Cochrane systematic review of the therapeutic effectiveness of GnRH analogues (agonists and antagonists) in the management of PMS. The only existing systematic review on the topic can be considered outdated. Surgical approaches that eliminate menstruation or ovulation have been reported to treat PMS symptoms. Surgery is an important option for the management of patients with severe premenstrual disorders who have failed to respond to other treatments. However, it is uncertain whether these invasive procedures are justified by the symptomatic relief obtained. Ours is the first systematic review aiming to assess the outcomes and safety of surgical interventions in the management of PMS. To help future clinical trial design, an online survey was conducted collecting the experiences and preferences of women suffering from PMS regarding treatment options and their expectations about the need for and taking part in research studies.

Introduction: Most maternal deaths which occur in the world are recorded in Low and Middle-Income Countries (LMICs). Home visits offer opportunities to educate pregnant women on care practices and safer delivery options. Objective: To review and synthesise the evidence on the effects of home visits to pregnant women, and to investigate CHW/CHN partnerships for home visits, for improved skilled attendant at birth and other health outcomes for mother and baby. Methods: First a systematic review and meta-analysis was conducted. Medline, Embase, Cochrane databases were searched for published data on trials, which assessed the effects of home visits. Then a clusterrandomised controlled trial was conducted where, after an intensive community mobilization, CHWs provided three follow-up visits to pregnant women enrolled in ten intervention zones. Women in control zones had usual care. Independent assessors collected data on health outcomes after delivery, for the intention to treat analysis. Results: The systematic review did not find a study where CHWs partnered with other cadres to conduct home visits. The results showed that home visits to pregnant women led to improvement in SAB (OR1.5 (95% CI: 1.2, 2.0) and other care practices. However, the pooled data in a meta-analysis did not show a statistically significant difference in overall neonatal mortality among intervention and control arms (Pooled RR: 1.002 (95% CI 0.922, 1.089). The field trial had widespread acceptance among community members with 952 women participating. CHW-CHN partnerships led to high Skilled Attendant at Birth among intervention arm, 98 percent, and controls, 89 percent. There was a statistically significant difference on the effect of home visits on SAB among intervention arm, compared to the controls (Odds Ratio, OR: 5.24, 95% Confidence Interval, CI: 2.70 to 10.17), and with a statistically significant p-value of < 0.001. Regarding neonatal indicators, breastfeeding initiation was significantly affected by the home visits (OR 2.89 (95% CI 1.21, 6.90), p=0.001) as well as BCG vaccination statuses at month 1; OR 3.10 (95% CI 1.73, 5.56), P=0.001. Conclusion: CHW/CHN home visits to pregnant women led to improvements in some care practices for mothers and babies. Innovative approaches where trained health staff and clinically oriented cadres such as CHNs partner with CHWs during home visits, could lead to better health outcomes in LMICs. Community mobilization was identified as an essential contributor to the successful field work. Further research on cost effectiveness of these partnerships is needed.

Hydrogen sulfide (H2S) has recently attracted substantial interest as an endogenous gaseous signalling molecule. Like nitric oxide (NO) and carbon monoxide (CO), it promotes vasodilation and exhibits cytoprotective and anti-inflammatory properties. It is involved in diverse physiological and pathophysiological processes such as neurogenesis, regulation of blood pressure, atherosclerosis and inflammation. Endogenous H2S is synthesised predominantly by three enzymes: cystathionine β-synthase (CBS), cystathionine γ-lyase (CSE) and 3-mercaptopyruvate sulfurtransferase (3-MST). Recently, the endogenous production of H2S in human myometrium and placental tissues and its role in pathophysiology of complicated pregnancies with pre-eclampsia (PE) and fetal growth restriction (FGR) has been studied. In PE, inadequate remodelling of spiral arteries by trophoblasts causes ischemia-reperfusion insult of the placenta which is one source for oxidative stress, and it causes reductions in utero-placental blood flow, often resulting in FGR. The limited research undertaken to study expression of H2S synthesising enzymes in anormal and abnormal placental tissues is characterised by contradictory findings in mRNA and protein expressions of these enzymes. All studies used a random placental sampling method which could mask spatial variation in gene expression. Therefore, this study aimed to examine expression of these enzymes using a systematic sampling method in which placental samples were taken from different identified zones of each placenta. The expression of these enzymes was studied at both mRNA and protein levels using quantitative polymerase chain reaction (qPCR) and western blotting techniques. Extensive testing of several anti-CBS and CSE antibodies for western blotting revealed persistent non-specific binding of these antibodies to multiple unidentified proteins in all sample types. Antibodies tested included all those used in the previous studies in western blotting and in situ methods. These all showed highly images of CBS and CSE bands and lacked any supplementary data about testing antibodies specificity raising concerns about the previous research findings and identifying another potential source of the lack of consistency in conclusions they reached. CRISPR knockout clones of each protein were generated using two different cell lines to test specificity of these antibodies which confirmed the antibodies did detect proteins of the expected size. This enabled identification the correct CBS and CSE bands to study the expression at protein level in the comparative groups. Additionally, these clones identified isoforms not predicted by gene databases, allowed retrospective specificity testing of in situ procedures used and revealed an intriguing regulation of CBS, CSE by 3-MST which may be of relevance to placenta. CBS, CSE and 3-MST spatial expressions were examined in normal placentas obtained from women who delivered by caesarean section (CS) and were not in labour, in placentas from women who delivered spontaneously and in placentas from women with complicated pregnancies with PE, FGR and high body mass index (BMI). The study showed that there were significant spatial differences in expression of CSE and 3-MST, with an up-regulation in labour when compared to non-labour group at a particular placental site. Also, the study showed a significant increase in 3-MST mRNA and protein abundances in FGR group compared to control healthy group at the outer placental site. Only CBS and CSE mRNA abundances were significantly increased in PE compared to healthy controls at inner and middle placental sites, respectively. The spatial difference in gene expression in labour or complicated pregnancies at precise zones suggests that there is a controlled spatial change in expression or susceptibility to change which may be due to the vascular biology of the placenta. The physiological and pathological significances of these differences remain to be elucidated but oxidative stress and inflammatory pathway are the common links. Also, the reduction in CBS and CSE protein abundances in absence of 3-MST may suggest that there is a complex of regulatory mechanisms on these enzymes. Taken together, these results suggest that H2S involves in labour and pathophysiology of PE and FGR. However, further investigations with highly specific antibodies are required especially the data in this study showed significant differences in expression between controls and the targeted groups. To conclude, the present study highlights the possibility that ordinary placental sampling methods may mask the altered expression of some genes, and therefore, this study represent a further step toward developing a systematic way for sampling in placental research. In addition to this, the present study illustrates how using simple CRISPR knockout technology could help testing specificity of primary antibodies, and presents a real example of how incomplete reporting of antibodies research antibodies compromise the reducibility of research results. Furthermore, it emphasises on full documentation of the experimental procedure describing the data supporting the specificity of antibodies validation to help researchers to collaborate and build on each other's work.

The incidence of breast cancer is increasing at an alarming rate across Asia, by up to 6% annually, compared to near stable incidence rates in many Western countries. While selective oestrogen receptor modulators and aromatase inhibitors are actively being studied as chemoprevention among high-risk Caucasian women, the risks may outweigh the benefits among Asian women with lower population risk of breast cancer. Modifiable lifestyle targets for primary prevention have long been identified, such as post-menopausal obesity, alcohol intake, and hormone replacement therapy use, but these risk factors are less prevalent among women in Asian countries. There remains an urgent need to find primary prevention strategies that are low risk, acceptable, and effective for Asian women. Epidemiological evidence in Asian women suggests that high soy intake is associated with lower risk of breast cancer, but these findings were not observed in epidemiological studies of Caucasian women nor in clinical trials of soy isoflavone supplements. To date, there are no clinical trials that examine the effect of soy isoflavone intake from diet nor supplement on breast cancer risk among Asian women. In this thesis, I present the research studies undertaken to investigate if soy isoflavone intake is causally and inversely associated with post-menopausal breast cancer risk among Asian women. The objective of the first research study was to identify mammographic density measures that are suitable biomarkers of breast cancer risk in the target population (Chapter 3). In this study, volume-based mammographic density measures and breast cancer risk factors were compared between 1,501 Malaysian women and 4,501 age- and BMI-matched Swedish women with no personal history of cancer. The analysis demonstrated that absolute dense volume, rather than percent density, may be a better biomarker of breast cancer risk among post-menopausal Asian women. Based on the above findings, the second research study sought to determine if mammographic density mediates the association between soy intake and breast cancer risk in the target population (Chapter 4). A cross-sectional analysis of 3,277 healthy Malaysian women showed that mammographic density was lower among women with frequent soy intake compared to non-consumers, by up to 2.5cm3 dense volume or 2.0cm2 dense area, but this was not statistically significant. Intriguingly, regular soy intake was associated with lower mammographic density among overweight or obese women, but for leaner women, regular soy intake was associated with higher mammographic density. This interaction was statistically significant among pre-menopausal women (pinteraction = 0.029). Prior to designing a robust clinical trial to test the causal association between soy intake and mammographic density as a biomarker of breast cancer risk, the feasibility of a dietary soy intervention was assessed in a small sample of the target population (n=10, Chapter 5). Overall, women in the study were able to maintain a diet of 70-90mg/day of soy isoflavones for 2 months, but the target of 100mg/day was not feasible and may have led to some adverse events. Thematic analysis of semi-structured interviews revealed that women participated in the study for altruistic reasons and due to emotional attachments to the cause, and that adherence was largely influenced by the practicability of the new diet or routine. Building from the results of the previous three chapters, the primary objective of the last research study was to test the effect of daily soy isoflavone intake for 1 year on breast cancer risk among Asian women, using mammographic density as a biomarker of risk (Chapter 6). In this clinical trial, 57 healthy post-menopausal Malaysian women were randomized into the Supplement arm (100mg/day isoflavones, with >90% daidzein), the Dietary Soy arm (50mg/day isoflavones), or the Control arm. After 1 year of intervention, women in the Supplement arm experienced 4.1cm2 lower dense area and 2.4% lower area-based percent density compared to women in the Control arm, but these associations were not statistically significant. The associations were weaker for women in the Dietary Soy arm and for volume-based mammographic density measures. Interestingly, stronger associations were observed when the analysis was limited to women with high BMI or low dietary fat intake, but the sample size was too small for robust analyses. In conclusion, the data presented in this thesis suggest a causal association between soy isoflavone intake and lower post-menopausal breast cancer risk among Asian women. However, due to the small sample size, the analysis was underpowered to show statistically significant effects and will require confirmation in a larger trial. Nonetheless, the research undertaken here adds to existing evidence that the soy isoflavone daidzein may be responsible for the protective effect of soy. Furthermore, it proposes new hypotheses in understanding the association between soy intake and breast cancer risk across populations, including possible effect modification by BMI or dietary fat intake.

Miscarriage and pregnancy loss is unfortunately, an all-too-common early pregnancy complication for women and couples around the world. However, there are a great deal of unanswered questions about its causes and best practice surrounding its management. This thesis aims to improve the care of women and couples who have suffered from a miscarriage or have recurrent miscarriage. Using a systematic review and meta-analysis, a prospective cohort study, a systematic review and network meta-analysis and a narrative systematic overview review, the following has been found: 1. Hydrosalpinx is associated with higher pregnancy loss rates, particularly biochemical pregnancy loss in IVF pregnancies. Treatment of a hydrosalpinx may improve pregnancy outcomes, particularly using salpingectomy and tubal-conservational surgery. 2. Blocked fallopian tubes are common in the recurrent miscarriage population. Women with blocked fallopian tubes are at higher risk of pregnancy loss, have lower pregnancy rates and a lower chance of live births than women with patent tubes. 3. Suction curettage with cervical preparation is the best method for completing a miscarriage and expectant management is the worst method. Expectant management has the highest risk of serious complications and needing emergency surgery, medical methods have the highest risk of vomiting, diarrhoea and pyrexia. 4. Very few interventions have evidence of benefit for reducing miscarriage in both women who are symptomatic and asymptomatic of symptoms of miscarriage. 5. The majority of evidence for interventions being of benefit or where no difference was shown, is very-low to moderate-quality and based on small numbers of trials and participants.

First, I present the background and need that led to this work. While the assessment of fetal growth is an essential part of clinical care, there were substantial limitations in traditional models' growth charts in clinical practice; namely, their 'one size fits all' approach, with no allowance for individual variation. I next describe the innovative concepts applied to address this problem, and outline the principles that led to the 'gestation-related optimal weight' (GROW) standard: adjustment for individual variation, optimisation to exclude pathological influences, and the application of a fetal rather than a birthweight standard to delineate normal growth. Using these principles, GROW can produce personal antenatal charts, centred on each baby's individual growth potential. I then selected eight publications to illustrate the validation and application of these principles, highlighting for each: objective, my contribution, key findings and impact. The first three studies dealt with validation of the GROW principle through comparison with various population based standards, and show that the customised approach performs better at confirming normal growth and identifying growth-restriction-related pregnancy outcomes. The next five studies present various applications of this standard to enhance our understanding of risk factors for fetal growth restriction, stillbirth, perinatal morbidity and cerebral palsy. A key finding (publication 7) was that risk can be reduced by improved antenatal recognition of fetal growth problems, helping to stimulate and focus health service initiatives on prevention. The series culminates in a study describing the results of implementation of a surveillance programme including GROW charts across three English health service regions, leading to a significant reduction in stillbirth rates. I believe my contribution to these studies and others over more than 25 years has supported the development and international recognition of the GROW standard.

This thesis presents a feasibility study to assess the effect of local oestrogen in postmenopausal women undergoing pelvic organ prolapse (POP) surgery (LOTUS study). It stemmed from a Cochrane systematic review by Ismail et al (2010) which identified the dearth of a well organised randomised controlled trial with adequate sample size, validated outcome measures and long term follow up to assess the value of oestrogen in the prevention as well as management of pelvic organ prolapse. This thesis aimed to answer this question. Firstly, a systematic review was performed to ascertain the global prevalence of POP in women in order to understand the burden of disease using epimaps. The review found that the prevalence of symptomatic POP increased with age up to 65-75 years (mean of 35%); thereafter it plateaued. Secondly, another systematic review utilising the COSMIN checklist was carried out in order to determine which validated questionnaire or patient reported outcome measure best captured the subjective outcomes from women with POP. Strong evidence supported internal consistency and construct validity for Pelvic floor distress inventory short form 20 (PFDI sf 20), Pelvic organ prolapse symptom score (POP-SS) and electronic Personal Assessment Questionnaire pelvic floor (ePAQ-PF). Subsequently a feasibility study to assess the effect of local oestrogen in postmenopausal women undergoing pelvic organ prolapse (POP) surgery (LOTUS study) was set up as the first step in a phased approach to performing a large-scale study. The feasibility study concluded that a large multicentre RCT was feasible. In addition, a qualitative study was conducted to understand the factors that motivate these women for, and barriers to recruitment in clinical trials. From the findings of the two systematic reviews, the qualitative study and the feasibility study, a proposal for a robust multi-centric randomised controlled definitive study was designed.

Approximately one in four pregnancies result in pregnancy loss, with 1 % of couples suffering from recurrent miscarriage. Genetic investigations are recommended after three consecutive miscarriages and require pregnancy tissue. This thesis investigates the use of cell-free fetal DNA from maternal blood to identify chromosomal abnormalities in recurrent miscarriage. 123 cell-free DNA samples were collected from first trimester miscarriages (5+1 to 11+6 weeks) and 62 % of samples had a corresponding routine cytogenetic result. 54 % of genetic aberrations were correctly identified using single end sequencing on a HiSeq2500 and the WISECONDOR pipeline, and 68 % of genetic aberrations were correctly identified using paired end sequencing on a NextSeq and the Illumina pipeline. This thesis also investigates other genetic causes of miscarriage in euploid pregnancies and includes a published systematic review and whole exome sequencing in seven euploid miscarriage trios. The systematic review identified 50 studies which included variants thought to be causative of miscarriage, and the whole exome sequencing cohort demonstrated the difficulty in interpreting variants without human phenotype ontology or genes without a reported disease-association. However, identification of genes/ variants that are causative of or predisposing to miscarriage will be of significant individual patient impact with respect to counselling and treatment.

The myometrial smooth muscle of the uterus is responsible for force generation during labour, leading to successful delivery and expulsion of the foetus. This contraction occurs as a result of electrical signalling, and the firing of the myometrial action potential. Development of a more detailed understanding the mechanisms that regulate electrical excitability in the myometrium may allow for the identification of new strategies to manage preterm birth and prolonged labour clinically. The calcium activated chloride channel (CaCC) anoctamin 1 (ANO1) has been suggested to play an important role in promoting myometrial contractility, though its potential mechanism is unclear. In this work, a novel model of uterine excitability has been developed to allow investigation of these processes in silico. Simulations run using this model suggest that ANO1 may play a role in initiating the myometrial action potential and coupling the electrical signalling to chemical signalling via oxytocin. ANO1 may also play a role in stabilising and prolonging the action potential. These hypotheses are investigated experimentally using multiple model systems. Cultured immortalised uterine myocytes and intact human tissue were investigated using specific pharmacological inhibition of ANO1 with the novel, potent pharmacological agent Ani9. Experiments using the Cre-Lox system to achieve inducible smooth muscle specific deletion of ANO1 were also carried out. These experiments observed no evidence of ANO1 promoting uterine contractility, suggesting that previously reported findings were the result of non-specific actions of inhibitors. Transcriptional analysis of cultured myocytes and myometrial tissue suggests ANO6 as a potential alternative candidate for forming a CaCC in the myometrium. Simulations also suggest potential roles for the canonical transient receptor protein channel (TRPC6) in initiating the action potential in response to diacyl glycerol generation, and potassium channels such as TWIK-related Potassium Channel 1 (TREK1) in mechano-sensing and regulation of the duration of the myometrial action potential. Plasticity of the myometrial conductome is also considered as a mechanism that underlies the heterogeneity in electrical behaviours between cells, and may dynamically modulate the electrical properties of the cell over physiologically relevant timescales to regulate the action potential. These potential electrophysiological mechanisms are suggested as potential avenues for further investigation.

Recurrent pregnancy loss, defined as multiple miscarriages, is a distressing condition associated with significant physical trauma and psychological morbidity. Miscarriage often causes bleeding in early gestation, reflecting the breakdown of the emerging maternal-fetal interface. However, bleeding is not a prominent feature in missed miscarriage, which typically involves very early-onset fetal growth restriction, fetal bradycardia and ultimately fetal demise. I hypothesised that recurrent missed miscarriage (RMM), defined here as 3 or more 'silent' miscarriages, reflects an endometrial glandular defect that compromises histotrophic nutrition before the onset of placental perfusion around 12 weeks of pregnancy. To test this hypothesis, RNA-sequencing data of laser-captured mid-luteal endometrial glands from RMM patients and control subjects were subjected to metabolic modelling using flux variability and balance analysis. Computational modelling revealed a notable metabolic signature in RMM, characterised by heightened oxidative phosphorylation and fatty acid oxidation and decreased glycolysis, which was not attributable to glandular asynchrony. To explore the drivers of this endometrial defect in RMM, I optimised a robust organoid protocol to assess glandular differentiation in vitro. RMM organoids not only recapitulated the in vivo metabolic signature but displayed a multitude of defects caused by more naïve progenitor cells, including attenuated Wnt and Notch signalling, and impaired specification of epithelial cells into differentiated and senescent subpopulations upon progesterone-induced cell cycle arrest and differentiation. Importantly, senescent epithelial cells, which are a major source of growth factors and extracellular matrix proteinases, may critically regulate endoglandular trophoblast invasion and access to glandular secretions in early gestation. Quantification of p16INK4 immuno reactivity in 48 biopsies confirmed that RMM is associated with lack of glandular senescence during the peri-implantation window. Collectively, the data indicate that aberrant metabolic programming of endometrial epithelial progenitor cells compromises glandular function, thus revealing a novel therapeutic target for RMM prevention.

In this thesis, I investigate the contribution of human papillomavirus (HPV) induced epigenetic changes to the process of cervical carcinogenesis. I used an in vitro progression model of cervical cancer involving primary human foreskin keratinocytes in conjunction with human cervical intraepithelial neoplasia cell line and different cervical cancer cell lines. The Primary Human Foreskin Keratinocyte from one donor transfected with episomal HPV16 and HPV18. Following propagation of PHFK HPV18 and PHFK HPV 16 cell lines, I have shown HPV-induced cytopathic changes in human keratinocytes using immunocytochemistry. I found that HPV-associated with changes in the expression of key epigenetic regulators that follow the HPV life cycle and the process of cervical carcinogenesis. Using PCR methods I showed that specific regions of HPV16 and HPV18 genome are prone to disruption during HPV integration. Overexpression of HPV E7 oncoprotein precedes the disruption of full length HPV E2 and induces expression and enzymatic activity of DNMT1 and DNMT3B. Using co- immunoprecipitation, I found that the endogenous HPV E7 oncoprotein interacts at physiological level with DNA methyltransferase 3B. I have also shown, using chromatin immunoprecipitation, that HPV associated with pattern of epigenetic switching from histone 3 lysine 27 trimethylation to DNA methylation. Using a genome wide methylation array, I found that HPV18 integration induces changes to the human DNA methylome similar to the changes expected in cervical neoplasia. Finally, I show that methylated tumour suppressor genes following HPV integration are reversibly demethylated with 5-azacitidine.

AIM: To explore how women with polycystic ovary syndrome (PCOS) experience conventional forms of feminine identity. RESEARCH METHODS: A systematic literature review of published literature and grey literature produced between 2000- 2020 was performed, following recommendations from PRISMA and eMERGE guidelines. The studies were retrieved from 10 electronic databases (APA PsycArticles, APA PsycInfo, International Political Science Abstract, Embase, CINAHL, ASSIA, ProQuest Central, Dissertations & Thesis, Open Grey and EThOS). Search terms related to the concepts of PCOS, feminine identity, selfidentity and experiences were incorporated into search algorithms. Inclusion criteria consisted of: participants aged over 13 years; qualitative research designs; focus on the experiences of women with PCOS and identification of themes related to feminine or self-identity. A total of 874 records were identified and 15 articles satisfied the inclusion criteria. Quality assessments were conducted by two reviewers using the Critical Appraisal Skills Programme (CASP) qualitative checklist tool. Meta-ethnography was used to synthesise the included studies. RESULTS: Three main themes and six subthemes were identified: identifying differences (Outside in and inside out), meaning (Threats to womanhood and threats to motherhood) and responses (Controlling and avoiding). CONCLUSION: This review provides support for raising awareness of PCOS in both healthcare settings and in public, a need for suitable psychoeducational materials, policies to encourage exercise participation and the potential for third wave CBT interventions.

Additionally, women with RVVC using hormonal contraceptives were found to have a more similar bacterial profile to healthy women, compared with women using other contraceptives. C. albicans biofilm reduction by Lactobacillus species was observed in an in vitro co-culture model. Further, RNA sequencing revealed an α-amino acid biosynthesis/breakdown pathway by which L. crispatus may out-compete C. albicans during VVC to re-establish vaginal health. Finally, bi-daily addition of L. crispatus was shown to reduce C. albicans composition within a complex biofilm model. This study highlights the potential impact of Candida biofilm formation in RVVC and the importance of the consideration of biofilms for diagnosis and treatment. Additionally, it contributes to our current understanding of the vaginal microbiome during RVVC and antagonistic interactions between Candida and Lactobacillus. This work provides a foundation for future studies to further elucidate triggers for the development and recurrence of VVC/RVVC and the pathogenesis of the microbes involved. This and similar work will hopefully lead to the development of novel, more appropriate prevention and treatment options for persistent, azole resistant VVC. Additionally, women with RVVC using hormonal contraceptives were found to have a more similar bacterial profile to healthy women, compared with women using other contraceptives. C. albicans biofilm reduction by Lactobacillus species was observed in an in vitro co-culture model. Further, RNA sequencing revealed an α-amino acid biosynthesis/breakdown pathway by which L. crispatus may out-compete C. albicans during VVC to re-establish vaginal health. Finally, bi-daily addition of L. crispatus was shown to reduce C. albicans composition within a complex biofilm model. This study highlights the potential impact of Candida biofilm formation in RVVC and the importance of the consideration of biofilms for diagnosis and treatment. Additionally, it contributes to our current understanding of the vaginal microbiome during RVVC and antagonistic interactions between Candida and Lactobacillus. This work provides a foundation for future studies to further elucidate triggers for the development and recurrence of VVC/RVVC and the pathogenesis of the microbes involved. This and similar work will hopefully lead to the development of novel, more appropriate prevention and treatment options for persistent, azole resistant VVC.

Ethanol is an intoxicant widely available within the UK which has implications for the behaviour capabilities of persons who have consumed even modest amounts, as well as significant longer-term health issues. Although the sale and consumption of alcohol is subject to legislative restrictions, consumption remains widespread in the UK. Ethanol is recognised as being teratogenic to the developing fetus; while awareness of the potential adverse consequences of alcohol consumption in pregnancy is increasing, a significant number of pregnant women continue to consume alcohol despite national advice to the contrary. This thesis explores the known effects of in utero alcohol exposure upon the unborn child, examines methods of detecting alcohol consumption in pregnancy and describes the pattern and prevalence of prenatal alcohol consumption in the West of Scotland as measured by ethanol biomarkers in the newborn and by confidential postnatal maternal interview. The thesis also explores the potential use of routinely stored newborn blood spot cards for retrospective ascertainment of prenatal alcohol exposure (PAE). A total of 840 mothers consented to participate in an anonymised study of randomly selected participants, 92.5% of those approached. 827 mothers completed a confidential postnatal health questionnaire, including details of alcohol consumption in pregnancy and were asked to retain their infant's first stool (meconium) for analysis for alcohol biomarkers. Additionally, if mothers agreed and the baby's heel bled sufficiently, an extra blood spot card was obtained on day five, coincident with routine newborn blood spot screening. In total 740 meconium samples and 668 dried blood spot cards were returned, of which 712 meconium samples and 502 dried blood spots cards were analysable. 463 recruited mothers had previously delivered a baby and 17.8% of all participants had smoked in pregnancy. 46.4% of mothers declared some alcohol consumption in pregnancy, the majority of whom did not drink after realising that they were pregnant. 114 (13.8%) mothers declared some alcohol consumption after 20 weeks' gestation; in only three cases did this include five or more units of alcohol. Mothers who declared alcohol consumption in later pregnancy were more likely to be aged > 35 years and to identify as white British (p < 0.05). Fatty acid ethyl esters (FAEEs) were identified in all meconium samples with a concentration ≥600 ng/g in 39.6%. There was no relationship between maternal age, body mass index, socioeconomic status as determined by postcode of residence, parity or ethnicity and the likelihood of the infant's meconium being either negative or positive for FAEEs, as defined by a concentration ≥600 ng/g. Mothers tended to have been less likely to smoke during pregnancy within the group whose infant's meconium was positive for FAEEs (14 vs 20%, p=0.071). Correlation between FAEEs in meconium and self-reported alcohol consumption in pregnancy was poor; of the eight mothers that reported drinking at least three units of alcohol on any one occasion beyond 20 weeks of gestation, only three had an infant whose meconium was positive for FAEEs. Ethylglucuronide (EtG) was detected in 41.1% of meconium samples and the concentration was ≥30 ng/g in 14.5%. There was no relationship between maternal age, body mass index, socioeconomic status as determined by postcode of residence or parity and the likelihood of the infant's meconium being either negative or positive for EtG, as defined by a concentration ≥30 ng/g. Infants whose meconium sample was positive for EtG were less likely to have a mother who identified as white British (71.3 vs 81.8%, p=0.028). When infant meconium was positive for EtG the mother tended to have been less likely to have smoked in pregnancy (13.6 vs 18.5%); this difference was not significant. Maternal self-report of any alcohol consumption in later pregnancy did not predict an infant meconium EtG concentration of >30 ng/g. When meconium samples positive for both FAEEs (≥600 ng/g) and EtG (≥30 ng/g) (n=51) were considered, there was a weakly positive correlation between the two biomarkers (Pearson's coefficient= 0.283, p=0.044). Phosphatidylethanol (PEth) was detectable in 262 (52%) dried blood spot samples, with concentrations ranging from 2.4 to 3991.6 ng/ml. When the infant blood spot card contained ≥8 ng/ml PEth, the mother was more likely to self-identify as white British (86.6 vs 79.1%, p=0.028) and to have smoked during pregnancy (p=0.047). Mothers of infants whose blood spot card contained ≥ 20 ng/ml PEth were younger (p=0.023), and their BMI was greater (p=0.038). They were also more likely to have smoked in pregnancy (p=0.21). There was no correlation between PEth measured in dried blood spot cards and either FAEEs or EtG measured in meconium. Compared to self-report of alcohol consumption in pregnancy, the sensitivity of the individual biomarkers ranged from 11.6% for EtG >30 ng/g to 47.8% for a PEth concentration of >8 ng/ml, and specificities ranged from 57.1% (PEth >8 ng/ml) to 84.8% (EtG >30 ng/g). Using a combination of total FAEEs >600 ng/g and EtG >30 ng/g had a very high specificity for alcohol consumption either ever in pregnancy or only after 20 weeks' gestation, but a very low sensitivity of 6.7 and 5.3% respectively. A combination of FAEEs <600 ng/g and EtG <30 ng/g had a positive predictive value of 87% for no alcohol consumption after 20 weeks of gestation. It is concluded that one in seven mothers delivering in the west of Scotland has consumed alcohol in pregnancy beyond twenty weeks' gestation. Reported amounts of alcohol consumed are likely underestimated. This study indicates that routine use of meconium biomarkers for detection of alcohol consumption in pregnancy is not currently justified. Similarly, retrospective testing of stored dried blood spot samples taken on day five of life cannot be recommended as a measure of assessing PAE. Further work is required to explore relationships between alcohol biomarkers in meconium and longer term neurodevelopmental outcomes, as well as the role of measuring PEth in the newborn.

Diabetes in pregnancy confers increased risk of adverse outcomes in pregnancy. Increased risks of fetal overgrowth with subsequent delivery complications and neonatal hypoglycaemia are consequence of fetal hyperinsulinaemia due to maternal hyperglycaemia. Other complications such as stillbirth and preeclampsia, both of which are increased in diabetic pregnancy are less well understood. Understanding of pathophysiological mechanisms in stillbirth and preeclampsia remain limited, but both have links to vascular dysfunction. Specifically, many cases of stillbirth are associated with features of placental vasculopathy. Preeclampsia also originates from abnormal placental vascular development, resulting in release of pro-inflammatory and angiogenic factors from the placenta into maternal circulation and subsequent endothelial and organ dysfunction. Maternal endothelial dysfunction has also been shown to exist in women prior to the onset of preeclampsia. In diabetes, the exact triggers for preeclampsia and stillbirth development are unclear. Most of our understanding of these conditions comes from studies in the general obstetric population. With preeclampsia there is a proven linear relationship with higher maternal glycaemia and increased risk of developing the condition. The hypothesis for this thesis was that diabetes in pregnancy is associated with maternal and placental vascular dysfunction as a potential mechanism for adverse outcome in pregnancy complicated by diabetes. Furthermore, it was hypothesised that such vascular dysfunction is associated with higher maternal glycaemia. To investigate this hypothesis, I first sought to establish the prevalence of adverse outcomes in pregnancy complicated by diabetes by examining Scottish epidemiological data, and compare these to the rates seen in the population without diabetes. Between the years of 1998-2013, pregnancies complicated by type 1 or type 2 diabetes had 3-6-fold higher rates of adverse outcomes in pregnancy compared to women without diabetes. Specifically, higher rates of large for gestational age birthweight infants (52%, 38% and 10% in type 1, type 2 and no diabetes respectively), operative delivery (68% in type 1, 60% in type 2, 26% in those without diabetes) and preterm delivery (35% type 1, 22% type 2 and 6% in those without diabetes). Stillbirth rates were high at 19.5 and 24.8 per 1,000 births in type 1 and type 2, which was significantly higher than the 4.9 per 1,000 births in the population without diabetes. Worryingly, trend data showed that stillbirth and perinatal mortality data were not improving with time. To better understand why we were failing to improve upon stillbirth statistics, I sought to identify the maternal and neonatal phenotype associated with stillbirth. I explored associations of maternal and neonatal demographics and maternal glycaemic data with stillbirth outcome in the Scottish obstetric population with diabetes. Glycaemia had a significant association with stillbirth in both type 1 and type 2 diabetes. In women with type 1 diabetes, higher HbA1c in later pregnancy had the strongest association (OR 1.06 [95% CI 1.04,1.08]) whilst in type 2 diabetes, prepregnancy HbA1c was associated (OR 1.03 [95%CI 1.00-1.04]). Maternal BMI was also linked with risk in type 2 diabetes (OR 1.07 [95% CI 1.01, 1.15]). Taken together, this suggests metabolic factors, and specifically glycaemia play a key role in stillbirth pathophysiology. Other non-metabolic risk factors identified include extremes of birthweight centiles and advancing gestation towards term both of which are linked with placental vascular insufficiency and failure. I then performed mechanistic studies to determine differences in vascular function in pregnancies complicated by diabetes. I designed and recruited to a prospective cohort study comparing maternal and placental vascular function in women with gestational diabetes and pregnant controls with and without risk factors for GDM. For the maternal study, I was interested to see if maternal endothelial dysfunction was present in women with gestational diabetes (GDM), similar to that seen in women who later go on to develop preeclampsia. I made serial measurements of flow-mediated dilatation (FMD) of the brachial artery (a widely accepted, non-invasive test of endothelial function) from 24 weeks across the third trimester of pregnancy. FMD brachial artery was no different in women with GDM compared to both control groups at study entry (14.3+4.5% in GDM, 16.2+5.2% in risk factor group and 14.4+4.5% in control group). FMD did not change significantly with advancing gestational age, and remained no different between groups. There was no association with biochemical measures of glycaemia or insulin resistance and FMD. This suggests that maternal endothelial function is not significantly disrupted in otherwise uncomplicated GDM pregnancy. From the same cohort, I then went onto perform wire myography studies on chorionic plate arteries (CPAs) taken from the fetal side of placental circulation. I tested vasoreactivity to various agonists: U46619 thromboxane mimetic for contraction, calcitonin gene-related peptide to test endothelium-dependent and endothelium-independent vasodilatation mechanisms and sodium nitroprusside (SNP) to test endothelium-independent vasodilatation. In these studies, CPAs from GDM placentas showed reduced vasodilatory response to SNP with lower Emax (49.5+11.0% in GDM compared to 73.9+11.0% and 74.0+12.0% in risk factor and control). There was no difference in response to the other agonists tested suggesting that cyclic GMP (cGMP) pathways are altered in GDM pregnancy. Furthermore, there was significant inverse correlation with fasting blood glucose (Pearson's r -0.526, p=0.01) and significant effect of higher glucose on lower Emax to SNP (p=0.03). In multivariate modelling, insulin resistance measures were not associated with SNP Emax. In summary, adverse obstetric outcomes are high in the population with diabetes and are significantly so compared to the population without diabetes. Despite best efforts of clinical teams and mothers, serious outcomes such as stillbirth and perinatal mortality are not improving. Glycaemia is an important modifiable risk factor associated with fetal mortality. Placental vascular vasodilatory response is reduced in GDM pregnancy. Specifically, this appears specific to altered cGMP pathways and is negatively associated with higher fasting blood glucose. This could be a possible mechanism for placental vascular dysfunction and adverse outcome in diabetic pregnancy, particularly where glycaemia is uncontrolled. Conversely, maternal endothelial function did not appear significantly altered by GDM suggesting that this is not a major mechanism to the higher rates of adverse outcome in such pregnancies. Further mechanistic work is required to better understand effects of glucose on the fetal side of the placental circulation.

The appalling failings at the Mid-Staffordshire trust highlighted by Francis in 2013, prompted a renewed focus upon compassionate healthcare. Consequently, compassion and delivering compassionate care, although, not a new concept in midwifery, formal study in undergraduate curricula is relatively novel. Therefore, those responsible for undergraduate courses, have needed to consider how students may be educated about and for compassion. As midwifery education involves practice learning, consideration also needs to be given to this aspect. This presented an opportunity to learn from midwifery students who were about to, or already had been formally taught about compassion and who had spent varying lengths of time in their midwifery practice placements. A mixed methods approach was utilised and included: data collection via a free writing exercise prior to new students' studying about compassion. Students in all years of the course were surveyed via a self-completion questionnaire, including questions eliciting both qualitative and quantitative data. Finally, focus groups comprising three semi-structured interviews were facilitated separately and with a sample of volunteer students from all years of the midwifery course. Thematic analysis was used to interpret the qualitative findings. Wenger's (1998) Communities of Practice, Social Learning Theory offered a useful lens to make sense of and analyse the data's findings. The quantitative data show to what extent the students reported that being taught about compassion had increased their understanding. Furthermore, it shows how much or how little being taught about compassion had prepared the students for clinical practice and subsequently to what degree clinical practice had informed their learning about and for compassion. The results show that the majority of students reported formal study about and for compassion had increased their understanding. The midwifery practice placements also supported students' learning about and for compassion. Therefore, the formal teaching about compassion during undergraduate midwifery education is recommended. Three distinct yet interrelated phases emerged and the findings show that students' brought their pre-professional life experiences to the classroom and clinical practice; they continued to learn both formally and informally, depending upon the situations they found themselves in. These findings have significant implications for students, midwifery educators, clinical midwives supporting student learning and Heads of midwifery who have an overall responsibility for students' practice learning in the maternity services.

Childlessness is a life crisis with impaired fertility affecting 1 in 7 couples globally. Since the introduction of in vitro fertilisation in 1978, the treatment of subfertility has evolved substantially to incorporate an advanced set of clinical diagnostic tests and novel stratified care pathways encompassing appropriate and effective treatment strategies. To accompany these technological developments, the continued elucidation of the contribution of the female and male preconceptual phenotype in determining clinical outcomes, and identification and influence of potentially modifiable biological pathways is critical. In this thesis, I outline the development of an original prospective cohort of 400 women and their male partners undertaking in vitro fertilisation. For each participant, I performed extensive pre-treatment phenotyping, collected meticulous clinical and laboratory data, and undertook prolonged follow-up allowing ongoing pregnancies from both fresh and frozen embryo outcomes to be considered as clinical outcomes. In parallel, I collected biological samples enabling the creation of a unique comprehensive biobank encompassing pretreatment serum, plasma, DNA, and vaginal swab samples for each participant. Utilising a high-throughput NMR metabolomics platform, covering a wide range of metabolic pathways including lipoprotein lipids, fatty acids, amino acids, ketone bodies, and glycaemic traits which are highly relevant to cardiometabolic risk and overall health, I assessed the association of 155 metabolites with the ovarian reserve, semen parameters, the correlation between couples and the clinical outcome of treatment as defined by an ongoing pregnancy. I conduct a novel insight into the association of ovarian biomarkers with metabolic profiles conjointly with other recent studies. My results suggest that dyslipidaemia has a limited role in the relationship between ovarian reserve and cardiovascular diseases. Some fatty acids and amino acids may have a role in mediating an effect. My study provides preliminary data on a range of metabolic pathways and their association with semen parameters. I identified several metabolites associated with the odds of total motile sperm count. Higher levels of glycolysis metabolites and ketone bodies were associated with increased odds of low total motile sperm counts. I have also explored within couples correlations of multiple metabolomic traits and found weak to modest positive correlations for the vast majority of traits that are known to be influenced by assortative mating or shared couple behaviours. This correlation suggests assortative mating and might have some potential weak to modest impact on couples having similar metabolic traits. After assessing the association of metabolite concentrations with ongoing pregnancy, I was the first to report a higher likelihood of ongoing pregnancy after IVF among both women and men with higher pre-conceptual histidine concentrations. For all these findings, confirmation with a larger number of participants to evaluate the potential clinical implications more fully is essential. My aspiration is that this unique cohort and accompanying biobank will be an important resource contributing to and enabling future collaborative and contemporary research efforts to provide novel insights and personalised approaches to fertility care.

This study explores women's childbirth preferences, decisions, outcomes, whether they are aligned and the factors that shape this within the context of NHS England's Better Births (2016) maternity care policy. Much like previous maternity care policies, Better Births promises to create safer and more personalised maternity experiences for women, utilising a rhetoric of choice to prioritise women's control. However, complex and dominant social and (bio)medical discourses of risk and uncertainty affect Better Births' implementation. Whilst (bio)medical care for birth became normalised within society during the second half of the twentieth century, emergent discourses of 'good' motherhood have, in contrast, privileged natural birth and minimised the need for medical interventions. In this broader social context, as well as immense resource and financial pressures, pregnant women and maternity care providers find themselves caught between competing ideologies and practices of birth, with various implications for the concept of maternal choice. To investigate these issues, this study takes a mixed methods approach, including an analysis of the Better Births (2016) policy, 49 online questionnaires and 14 follow-up interviews with pregnant women and new mothers in a Better Births early adopter site. The study also includes 13 interviews with a range of different maternity care providers operating inside and outside the NHS. This research found that women's childbirth preferences were not realised in their decisions and outcomes but were incrementally medicalised as they moved through the trajectory of childbirth preferences, decisions and outcomes. Discourses of risk and uncertainty were found to constrain women's choices and limit providers' practices in various ways. This study concludes that women need to be better empowered to navigate risk and uncertainty throughout pregnancy and childbirth, and that providing them with means to do this might be more effective in improving women's experiences of maternity than Better Births' rhetoric of choice.

The aim of this thesis is to investigate the role of the recently discovered post-translational modification, O-GlcNAcylation, in the regulation of human placenta physiology. The rationale for this research work arises from the increasing evidence showing that O-GlcNAc signalling is a key mediator of cellular functions involved in a wide range of chronic diseases. However, there is a paucity of studies investigating its role in human placenta. Abnormal placenta physiology is considered as an underlying cause of poor pregnancy outcomes including miscarriage, preeclampsia and intrauterine growth alterations, the latter associated with increased risk for the development of chronic disorders later in life. Despite its importance, some of the molecular mechanisms controlling placental formation and function are still poorly understood. In this thesis, the BeWo cell line, a validated model to study in vitro mechanisms occurring in human trophoblast, and term placental biopsies, were employed. A transient OGT-depleted BeWo cell line was generated using a small interfering RNA (siRNA) methodology, and was used to identify the role of O-GlcNAc transferase (OGT) and its biochemical mark O-GlcNAcylation during the formation of syncytiotrophoblast, a crucial structure controlling the majority of placental functions. In addition, an antibody-based enrichment method, followed by proteomic analysis, was used to identify O-GlcNAc-modified proteins in BeWo extracts. Term placental biopsies were used to investigate correlations between OGT and feto-maternal parameters. Overall, the results obtained in this research work support a critical role for OGT in the control of syncytiotrophoblast formation via mechanisms involving PKA-MAPKs signalling. Importantly, the proteomic analysis showed that O-GlcNAc-modified proteins belong to a wide range of functional classes, in particular, transcription and chromatin remodelling factors. Finally, maternal body mass index (BMI) and depression target OGT signalling in term placentas with consequences on the activity of regulators of fetal growth and mechanisms of placental response to stress. Taken together, this thesis uncovered novel roles for placental OGT in controlling a wide range of placental mechanisms that are crucial to human reproduction success and identified O-GlcNAc signalling as the molecular link between maternal environment and in utero fetal programming of human diseases.

It is widely acknowledged that maternal obesity and metabolic disorder during pregnancy may trigger long-lasting cardiovascular dysfunction in the mother. In obese pregnancy, there is progressive insulin resistance and a systemic inflammatory end-organ structure and function. Emerging evidence suggests that the offspring may also be subject to these metabolic changes and endure these long-lasting effects. The 'Developmental Origins of Health and Disease' (DOHaD) model suggests that exposure to an abnormal environment in utero, such as in obese or diabetic pregnancy, may set a trajectory of greater offspring adiposity throughout the life-course. This is demonstrated by the fact that exposure to maternal adiposity during pregnancy is associated with higher offspring birthweight and greater adiposity through childhood and into adulthood. Offspring of mothers with diabetes or hypertensive disorders of pregnancy (HDP), such as pre-eclampsia (PE), may also adopt a greater risk of cardiovascular disease in later life. This cycle is then perpetuated when the affected offspring become pregnant and extend this exponential risk profile onto the next generation. Epigenetic modification has been proposed in the pathogenesis of disease but shared familial lifestyle and behaviours may also be causal. With the increasing prevalence of childhood obesity and metabolic disorders, such as non-alcoholic fatty liver disease (NAFLD), there is a greater need to examine these causal relationships and determinants of the fetal origins of disease. Adipokines have both endocrine and paracrine function and are secreted by adipose tissue, as well as the placenta. Leptin is required for the regulation of maternal appetite and despite high levels during pregnancy, pregnancy induces a state of leptin resistance. Leptin is also a valid biomarker of neonatal fat mass and may be used as a proxy for neonatal anthropometry. Adiponectin has an opposing function to leptin during pregnancy and correlates with fasting insulin levels. Low adiponectin amongst obese adults is associated with metabolic dysfunction and systemic insulin resistance. Using data from the large prospective cohort, The Avon Longitudinal Study of Parents and Children (ALSPAC), analysis of 5011 cord blood samples was performed for the purpose of this thesis. Offspring biomarkers and birthweight were examined in relation to obese, diabetic and hypertensive disordered pregnancy. Since biomarkers have shown evidence of tracking in later life, repeat measures at serial time points from birth (referred to as 'like for like' measures), using data available from the offspring at later time points, were also examined. Lastly, cord blood adipokines and birthweight were examined in relation to later obesity or development of NAFLD amongst the offspring to determine the impact of fetal over-nutrition, as demonstrated by higher cord blood leptin for example, on the long-term metabolic function of the offspring. This study has demonstrated that maternal body mass index (BMI), rather than appropriate GWG, was more consistently associated with a wider range of offspring cardio-metabolic markers at birth. Whilst there was limited evidence of GDM influencing cord blood at birth, offspring of mothers with pre-eclampsia displayed higher cord blood leptin and lipids. There was limited evidence of tracking of cord blood measures from birth into adolescence, however. Specifically, gamma-glutamyl transferase (GGT) and adiponectin correlated with repeat measures taken at birth and age 9. Whilst the association with adiponectin was lost in later childhood, this study has shown that GGT may track from birth to age 17. Lastly, this study has demonstrated that cord blood leptin was weakly, and adiponectin strongly related to adiposity in childhood and adolescence respectively. As cord blood leptin may be used as a reflection of fetal fat mass, the positive association with adiposity in later life demonstrates that the offspring may be 'programmed' at birth and set on a trajectory of enhanced adiposity in later life. Neither birthweight, nor adiposity at birth were related to offspring markers of liver structure or function in adolescence, however. This suggested that behavioural and environmental factors may have contributed to the pathogenesis of NAFLD, and similar disorders, rather than exposure to an adverse perinatal environment itself. In conclusion, this study has demonstrated a limited association between disordered metabolism in pregnancy and offspring metabolic markers at birth. Whilst cord blood biomarkers being used as clinical predictors of disease may be the focus of future research, they are already established biomarkers of neonatal anthropometry. Given the direction of the association between cord blood leptin and birthweight with later offspring adiposity, exposure to over-nutrition in pregnancy may therefore have a long-lasting impact on the offspring's phenotype rather than the metabolic function itself.

Obstetric fistulas are a preventable and debilitating childbearing injury unique to lower-income settings and result from inappropriate management of prolonged obstructed labour. While this injury is a problem across sub-Saharan Africa (SSA), little is known regarding the context of Zambia. This thesis aimed to understand contributing factors to the development of obstetric fistulas among Zambian women, using the Three Phase Delay Model as a framework. A systematic review was carried out to identify barriers and facilitators to the prevention of obstetric fistulas within SSA. This provided the context for a qualitative study set in Zambia. Semi-structured interviews were conducted with participants from the following groups: women who had experienced complicated labours, the support system of women with obstetric fistulas, and healthcare providers for labouring women. Interviews aimed to explore factors that led to the development of obstetric fistulas from those perspectives. Our findings indicated that health education, addressing the accessibility of healthcare facilities, and improving transferral services between these facilities are instrumental for women reaching and receiving timely care. They shed light on the multifactorial and interrelated elements that influence the development of obstetric fistulas. There is a need for an interdisciplinary approach to address and implement effective preventive measures.

Postpartum haemorrhage (PPH) is a global problem and the solutions to reducing it are complex. This thesis uses a mixture of research methods to investigate strategies that might improve the burden of blood loss following childbirth. The main findings are: 1. The use of contraception medication prior to pregnancy warrants further research as progesterone only contraception in particular might be associated with an increase in the risk of subsequent PPH; 2. The use of antidepressant medication during late pregnancy does not appear to increase the risk of PPH; 3. Following childbirth, a preventative uterotonic drug may not need to be given immediately; a delay of up to 5 minutes does not appear to increase the risk of bleeding; 4. There is little evidence to recommend the use of oxytocin, carbetocin, or misoprostol over each other for use as a first line drug to treat PPH; 5. Less than half of patients who had a PPH of 500mL received treatment uterotonic medication; 6. There is no appreciable long-term effect of PPH on mental health, but there is an increased risk of developing postnatal depression and post traumatic stress disorder; 7. There is no appreciable effect of PPH on cardiovascular health.

Introduction: Maternal sepsis is the third most common direct cause of maternal mortality worldwide. This thesis describes the development and evaluation of the "FAST-M" intervention, which sought to improve the recognition and management of maternal sepsis in a low-resource setting. Methods: A prospective, multi-centre, controlled study, with a before and after design was conducted using a mixed-methods approach to data collection and analysis. The study sought to determine the feasibility of implementing the FAST-M intervention across fifteen healthcare facilities in Malawi and evaluate subsequent improvements in sepsis care. Results: As a result of the FAST-M intervention, patients received more regular monitoring of their vital signs. Patients with suspected maternal sepsis were treated sooner and were more likely to receive all components of the FAST-M treatment bundle within one hour of sepsis recognition. Overall, the FAST-M intervention was feasible to implement, gaining widespread acceptability amongst staff with high levels of adoption and fidelity. There were no reported negative consequences of implementing the intervention. Conclusions: Implementation of the FAST-M intervention in a low-resource setting was feasible and led to the improved recognition and management of maternal sepsis. Lessons learnt during this feasibility work will inform its future scaling up and formal evaluation.

Pre-eclampsia (PE) complicates around 5% of all pregnancies and over 20% of pregnancies in women with chronic kidney disease (CKD). The cause of PE is unknown, but dysregulation of the maternal immune system and an imbalance in angiogenic factors, characterised by a high ratio of soluble fms-like tyrosine kinase-1 (sFLT-1) to placental growth factor (PIGF), are implicated as important aetiological factors. There are limited data published on disturbances in humoral-mediated immunity in PE and it is not well established how important immunological factors are in the development of superimposed PE in CKD. The work of this thesis comprises of three studies and I report: • An increase in polyclonal free immunoglobulin light chains and a reduction in IgG whole immunoglobulin, specifically IgG1 and IgG3, concentrations at the time of PE in previously healthy women compared to uncomplicated pregnancies at term. Beta-2-microgobulin levels had comparable diagnostic association for PE with sFLT-1/PIGF. • Healthy pregnant women who subsequently develop PE had lower levels of circulating IgM compared to matched healthy pregnant women who had uncomplicated pregnancies. Higher IgG levels were independently predictive of adverse pregnancy outcomes in the PE but not in the non-PE group. • In CKD pregnancies, immune system and angiogenic markers were not associated with, or strongly predictive of, superimposed PE. This is in contrast to findings in the healthy pregnant cohort and suggests that the pathophysiological mechanisms involved in the development of PE differ between the two groups.

Introduction: Vitamin D deficiency is common during pregnancy but its impact on maternal and foetal health is still unclear. The placenta is a key target for vitamin D: the vitamin D activating enzyme 1α-hydroxylase (CYP27B1), vitamin D receptor (VDR) and vitamin D binding protein (DBP) are all expressed by trophoblast cells early in pregnancy. This PhD aimed to identify new effects of the vitamin D system on trophoblast cell function. Hypothesis: We hypothesised that vitamin D plays a key role in trophoblast behaviour and that this may be important for healthy placental development. Methods: In vitro studies were carried out using trophoblast cell lines JEG3, BeWo and HTR8, with thyroid cancer cells (TPC) as a non-trophoblast comparator. Expression of mRNA and protein was compared for cells grown on plastic and extra-cellular matrix. Cells were assessed for motility (wound closure assay), proliferation (BrdU assay) and matrix invasion (Boyden chambers). Protein and mRNA expression were assessed following treatments using an ERK1/2 blocker (U0126), a megalin blocker (RAP), VDR siRNA, and DBP free serum. Pregnancy serum samples from 1st-trimester healthy pregnancy patients and 1st-trimester pre-eclampsia patients were assessed for DBP concentration and in vitro matrix invasion of trophoblast cells. Results: In plasticware cultures, JEG3, BeWo and HTR8 cells showed weak expression of VDR and no induction of the vitamin D-response gene CYP24A1 by 1,25-dihydroxyvitamin D (1,25D). TPC cells showed strong nuclear VDR expression and potent 1,25D-mediated induction of CYP24A1. Conversely, for matrix-grown trophoblast cells there was abundant intracellular VDR and DBP, with apparent nuclear localisation of both, in the presence of 1,25D, but no induction of CYP24A1. Treatment with 1,25D significantly enhanced the invasion of MatrigelTM by trophoblast cells. Cells cultured on matrix with serum from DBP knockout mice (DBP-/-) or in the presence of an inhibitor of megalin-mediated endocytosis (RAP) showed no intracellular DBP, indicating uptake of exogenous DBP by these cells. These treatments also resulted in low matrix invasion by trophoblast cells. Trophoblast and TPC cells showed non-genomic induction and nuclear localisation of phospho-ERK1/2 (pERK1/2) in response to 1,25D, and inhibition of pERK1/2 blocked DBP uptake and trophoblast matrix invasion. DBP is also an actin-binder and decreased cellular uptake of DBP resulting in impaired matrix invasion were associated with elevated intracellular levels of G-actin and concomitant lower F-actin. Levels of DBP and 1,25D from 1st-trimester pregnancy serum samples significantly correlated with JEG3 matrix invasion, suggesting that this mechanism may be important for normal healthy pregnancies. In 1st-trimester serum samples, the concentration of DBP was lower in women who subsequently went on to develop pre-eclampsia. Discussion: These data suggest that 1,25D enhances cellular uptake of serum DBP by pERK-mediated signalling and that this is important for maintaining homeostasis of intracellular actin. We, therefore, propose that optimal trophoblast function and healthy placentation requires the actions of maternal 1,25D and DBP. Both factors should be measured in studies of vitamin D and pregnancy.

Male fertility is routinely assessed by basic semen analysis, but this is poorly predictive of fertility outcome. One promising advanced diagnostic is assessing sperm DNA damage, but there is a lack of method standardisation, clinical thresholds and comparison data for different assays. The objective of this study was to validate standardised methods for the assessment of sperm DNA quality using TUNEL, Acridine orange (AO) and Chromomycin A3 (CMA3) in slide-based assays; and assess prognostic value for fertility and miscarriage. The data obtained reveals that using differing optimal mounting solution for different assays is key to reliable results. The use of DNA fragmentation inductors such as DNase and hydrogen peroxide in donor samples confirmed and validated the use of AO and TUNEL for detecting DNA damaged cells. A novel semi-automated computer-based scoring system for fluorescence microscopy images was devised and compared with visual operator results for intra-assay variability of AO and TUNEL assays. This system allowed objective and consistent results free of operator subjectivity. The assessment of TUNEL, AO and CMA3 values in a subset of patients from the HABSelect trial showed no correlation between the assays corroborating that different assays measure different aspects of DNA quality. The number of patient samples assessed were insufficiently powered to draw firm conclusions related to clinical outcome, but we believe they are useful in making a case for further investigations in the field.

Research Aim: To conduct a study evaluating the feasibility of undertaking an RCT on the effects of Yoga on the wellbeing of pregnant women post infertility treatments. Methods: A mixed methods study starting with a systematic review to identify RCTs of Yoga in pregnancy, examine the successful trial designs, and evaluate existing evidence. A waitlist-control feasibility RCT of Yoga in pregnancy post treatment for infertility was conducted in Fernandez Hospital, India, followed by interviews of all involved in the study. Finally, a focus group with NHS obstetricians. Results: a) Systematic Review: 15 trials were reviewed, identifying no evidence of harm from Yoga and potential benefits on a range of mental and physical health outcomes. b) Feasibility Study: 61 patients contacted, nine gave consent, three attended Yoga sessions. Attendees showed improved wellbeing levels. Reasons for dropout were mental health stigma and relocation. c) Interviews: eight doctors, two Yoga instructors, three participants and one family member consented. There was little knowledge on the effects of stress on maternal and infant health outcomes. Participants and family believed that exercise should be avoided in pregnancy, and reported problems discussing mental health due to stigma. Patients were afraid of participating in research. d) Focus Group: UK doctors are aware of the effects of stress on maternal and infant health. There were mixed opinions on Yoga. There is interest in further research on the physiological effects of Yoga on patients. RCTs are the preferred research design. Conclusion: There is no evidence that Yoga is harmful in pregnancy and some evidence suggesting positive effects on mental and physical health. A full RCT with the post infertility population in India is unlikely to be successful unless the problems identified could be addressed. A three step process ending with a pilot preference trial has been suggested.

Hypertension affects one in ten pregnancies and its sequelae can affect women and their offspring in later life. The placenta has been the focus of much of the research into the pathogenesis of hypertension in pregnancy. A functioning placenta requires a functioning cardiovascular system, hence investigating whether concepts from hypertension research (echocardiographic structure and function, altered ventricular and arterial elastance and monocyte biology) apply to pregnancy hypertension is of great interest. Evidence for cardiovascular changes in hypertensive disorders of pregnancy is mounting, but the adaptations in subsequent pregnancy are unclear. The aim of this study was to compare cardiovascular (patho)physiology in pregnant women with and without previous hypertension in pregnancy. Monocyte subset heterogeneity was studied to provide mechanistic insight. Prospective changes in study parameters were analysed in each trimester of pregnancy and healthy non-pregnant women were studied as a control group at baseline. I found more prehypertension and increased arterial stiffness in pregnant women with prior hypertension and a corresponding increase in the CD14++CD16-CCR2+ (Mon1) and CD14+CD16++CCR2- (Mon3) monocyte subsets and their aggregates with platelets in these women. Changes in cardiovascular performance and their relationship to monocyte subsets may potentially be mechanisms leading to increased long-term cardiovascular risk.

This thesis introduces the idea of caring for the past in a way that makes visible the complex entanglement of power and agency in traditional practices of care. Using and combining key ideas from the fields of social studies of time and feminist studies of care, it analyses interviews and fieldwork observations conducted with two groups of carers in Ecuador throughout different settings. One group practices agroecology and the other practises traditional midwifery. The thesis starts by examining how different pasts are embedded and becoming meaningful in carers' relations to plants, animals, people, and other non-human beings. The discussion then moves on to consider the re-configuration of these traditional practices of care when confronted with a different setting where power-relations are deeply enrooted in colonial histories. The different stories illustrate what is termed as a 'past multiple' whereby care maintains vital connections among individuals across time and space, including power relations. In doing so, the research highlights both the agency of carers in the connection to different pasts and the power structures that care itself reproduces and maintains. Moreover, the research critically engages with detemporalised readings of the practices that render the labour of the carers invisible. Thus highlighting the contribution of doing politics of care in the context of traditional practices of care. In sum, this thesis contributes to and extends the scholarship on care by introducing the notions of detemporalisation and temporal structures as a conceptual lens through which to examine social spaces where a multiple temporal ontology is continually re-enacted.

Introduction: Recurrent pregnancy loss (RPL) is defined as two or more consecutive pregnancy losses before 24 weeks of gestation, which affects between 3-5 % of couples. There are psychological, emotional, physical and financial costs associated with miscarriages. The majority of the losses happen in the first trimester before 13 weeks and are due to chromosomal abnormalities in the embryo. Standard care involves investigations after which around 50% of the couples are labelled as "unexplained RPL" and current management options are limited to supportive care in the next pregnancy. Endometrial factors are being explored to explain and treat this enigmatic condition. Women with RPL may share a common contributory endometrial factor as women with recurrent implantation failure. Prior to starting this thesis, evidence suggested that women with RIF had improved pregnancy outcomes, if they underwent an endometrial scratch in the cycle preceding embryo transfer. The feasibility study was to explore this option in women with RPL. Hypothesis: Preconception endometrial scratching prevents miscarriage in women with recurrent miscarriage. Method: The SiM study (Scratch in Miscarriage), was a single centre randomised controlled trial of the effects of endometrial scratch on pregnancy outcomes in women with RPL, in women aged 18-42 with two or more previous miscarriages. The women were randomised to either having a luteal phase endometrial scratch or a 'sham' procedure. Primary outcome: Livebirth after 24 weeks of gestation in women who conceived within the three cycles following randomisation. Results: The study showed a trend toward improvement of livebirth rate in the endometrial scratch group. However, this did not reach statistical significance. Conclusions: The role of the scratch in improving implantation in some women needs to be explored in a bigger RCT.

Practices during the third stage of labour are likely to be influenced by a range of factors, not just findings from studies. Also, little is known regarding the incidence of and treatment for postpartum haemorrhage (PPH) in women giving birth solely in midwife-led units or what factors midwives feel influence their use of third stage management approaches in this birth setting. Therefore, a research project (using a multi-method research design) exploring third stage of labour management approaches and incidents of PPH, as well as the acceptability and practicability of third stage approaches for women, giving birth in midwife-led units was conducted. This consisted of a quantitative and qualitative study. Findings from the studies revealed a statistically significant increase in the incidence of PPH (defined as blood loss 500 mL or over) with expectant compared to active management. There was also a statistically non-significant incidence in the relationship between third stage management approaches and incidence of severe PPH (defined as blood loss of more than 1000 mL). Also, although more women who initially received expectant management needed treatment for excessive bleeding, once these women received this first-line treatment their need for further treatment, to manage continual bleeding was slightly reduced. This is compared to women who initially received active management and experienced a PPH. Additionally, from interviews with midwives four themes were developed capturing midwives' understanding of the factors they felt influenced their use of third stage management approaches in midwife-led units. It was evident that tensions were present within and between these themes and midwives need to balance these tensions when trying to provide woman-centred care. The themes generated from these interviews need to be addressed to facilitate third stage of labour management approaches. This is because this research project, with support from other studies, found that expectant management was a reasonable option for women at low risk of PPH, who wanted to labour and birth with minimal intervention in a midwife-led unit.

Rationale: Infertility is the inability to conceive following 12 months of unprotected intercourse and affects 20% of couples worldwide. In vitro fertilisation (IVF) therapy has become more common in recent times. In mice, IVF associates with glucose intolerance. In humans, there is controversy regarding possible deleterious effects of IVF hormones in pregnancy, including worsening of metabolic, diabetogenic and inflammatory status. Objectives: To explore effects of IVF therapy in pregnancy on glucose and lipid homeostasis, and other metabolic and inflammatory parameters. To explore early predictors of onset of gestational diabetes mellitus (GDM), including whether use of IVF therapy may hasten the onset of GDM. Methodology: Adult non-diabetic women (n=275), BMI: 18.5-38kg/m2 , age ≤39years were recruited (n=158 pregnant, 117 non-pregnant). Collection of blood samples occurred throughout IVF cycle: baseline, 2, 4 and 12 weeks. Outcome variables included reproductive hormones, glucose, lipid profiles, insulin sensitivity, thyroid, gut microflora and inflammatory status. Results: At 12 weeks, non-pregnant women experienced increased levels of glucose (86.04 to 87.62mg/dL), insulin (8.72 to 9.37µIU/mL), HOMA-IR (2.1 to 1.9), p<0.01; and lipid profile: T-Chol (169.5 to 174.9mg/dL), TG (71.0 to 83.7mg/dL), HDL-C (52.0 to 54.11mg/dL), with p<0.001. For pregnants, glucose (86.15 to 82.19mg/dL), HbA1c (5.3 to 5.08%) and TSH (1.71 to 1.36µIU/mL) were significantly lower and lipids were higher: TG (73.5 to 126.78mg/dL), T-Chol (177.5 to 199.5mg/dL), HDL-C (55.3 to 65.1mg/dL); all p<0.001. Prenatal BMI (OR=1.11; p<0.05) was the main predictor of GDM risk. Conclusion: IVF therapy worsens lipid profile regardless of IVF outcome. Divergent effect of IVF therapy on glucose homeostasis depends on pregnancy status, with improved glycaemia in early IVF-conceived pregnancy, and worsened in the short term following unsuccessful IVF. The possible longer-term metabolic effects of IVF should be a focus for future research. Prenatal BMI appears to be the best predictor for future onset of GDM.

Human embryo implantation is the rate-limiting step for successful pregnancy in assisted reproductive technology, and inappropriate endometrial embryo-quality biosensing is also associated with recurrent pregnancy loss. Elucidating the mechanisms underpinning the peri-implantation endometrium would enable the development of treatments for patients suffering with chronic fertility disorders. However, implantation is difficult to study. Therefore, simple in vitro models of human endometrial cells have been developed. However, the endometrium is a complex tissue made up of stromal cells (EnSC), epithelial glands, vasculature, and immune cells. An in vitro model that encompasses all aspects of the human endometrium would require a complex co-culture system. Therefore, three-dimensional (3D) culturing techniques are the most suitable. This study aimed to establish a protocol for a novel in vitro model of the peri-implantation endometrium by co-culturing primary EnSC and epithelial cells (EEC) using 3D culture techniques. In this study, two approaches were undertaken. The first involved the use of the Endometrial Regenerative Bodies (ERB) model, which was unsuccessful in achieving the study’s aim. However, the second approach, involving the 3D co-culture of EnSC with endometrial gland organoids led to the establishment of a complex organoid culture. The growth conditions of the complex organoids were optimised by modifying the 3D matrix and medium conditions. The standard organoid growth matrix, Matrigel, a basement membrane derived hydrogel, was replaced with a purified Type I collagen hydrogel to provide a more physiological ECM for the EnSC. Direct interaction between the EnSC and EEC in the complex organoids was examined through the establishment of a minimal differentiation medium and single cell RNA-sequencing of a decidual time course of gland organoids and complex organoids. EnSC were able to induce the differentiation of EEC into a secretory phenotype in complex organoid cultures. The established complex organoid protocol offers a starting point for developing a faithful in vitro model of the human peri-implantation endometrium, which will provide a step change in our collective ability to study human embryo implantation. A system that would be patient-specific, and in the long term developed into a high-throughput system for personalised medicine for the treatment of infertility.

Attending a breast biopsy and receiving the results can be an anxious process. The method of delivering biopsy results could affect women's experience of screening and resultant anxiety. The NHS Breast screening programme (NHSBSP) guidelines state that telephone results 'should not be routinely offered'. Despite this, most English Breast Screening centres now deliver benign results by telephone, believing they are reducing the amount of time women spend anxiously waiting. However, concerns remain about the potential 'harm' of telephoning women with results. This thesis aimed to investigate the impact of communication methods (telephone versus in-person) on women receiving a benign biopsy result from the NHSBSP, exploring the outcomes of patient anxiety, understanding of results and preferences for communication. This will inform future updates to policy guidelines for the communication of breast screening results in the NHSBSP. Methods A mixed methods approach was used with the overall research designed in 5 phases: Phase 1) A mixed-methods systematic review of current communication methods used in cancer screening programmes and the impact on attendees; Phase 2) A cross-sectional survey to record how results are currently being delivered in the NHSBSP, including qualitative data on NHSBSP staff views on communication methods; Phase 3) A cluster randomised crossover trial comparing women who have received a benign result by telephone versus in-person to measure anxiety and understanding of results. Phase 4) Qualitative interviews with women who have received a benign result from screening to explore communication preferences and reasons for these preferences; Phase 5) Mixed methods synthesis of the quantitative and qualitative data on attendee communication preferences from Phase 3 and Phase 4.

Childhood obesity has reached epidemic proportions globally. There is increasing evidence that factors acting during early development, such as maternal obesity, excessive gestational weight gain and gestational diabetes mellitus increase the chances of obesity and metabolic syndrome in later life. However, the major limitation of the available literature is the lack of accurate body composition measurement. In order to understand the mechanisms underpinning the developmental origins of metabolic diseases in adulthood, data on the evolution of body composition in early childhood is required. We hypothesize that offspring born to high metabolic risk mothers have altered body composition at birth and early infancy, which leads to adverse developmental programming of obesity and metabolic diseases. Objective and methods: Purpose of the current research work was to study the effect of maternal adverse metabolic profile on infant's body composition. Secondary aim was to assess whether early life biomarkers can predict infant and early childhood adiposity, allowing the implementation of targeted prevention strategies on high risk groups from the early stages of life. A longitudinal observational study was performed. Air displacement plethysmography was used to assess infant body composition up to 5 months of age. A systematic review looking at the association between cord blood leptin, adiponectin and infant adiposity was also conducted. Results: Maternal obesity, gestational weight gain and hyperglycaemia independently predict infant adiposity. Maternal insulin resistance seems to be the "missing link" between adverse maternal metabolic profile and neonatal adiposity. Current practices in the management of gestational diabetes that reduce the incidence of macrosomia happens at the expense of fat free mass. This may drive early adiposity rebound, which itself has shown to be an independent driver for metabolic diseases in adult life. Ethnic subgroup analysis revealed no difference in infant body composition, provided that maternal characteristics and intrauterine environment remain constant across ethnicity. Cord blood leptin is strongly and positively associated with fat mass at birth but inversely predicts adiposity up to 3 years of age. Conclusion: Despite genotype being determined at conception, the phenotype is modulated and determined by maternal and intrauterine factors. Antenatal and early postnatal life are critical periods of developmental plasticity for offspring fat and fat free mass. Such adverse body composition at birth and early infancy are setting lifelong metabolic trajectories.

This PhD thesis aimed to explore the impact of the maternity journey on low-risk nulliparous women to develop a long-form women-derived maternity-specific Patient Reported Outcome Measure (PROM): the Wellbeing Of Women in MATernity (WOWMAT). A mixed-method approach involving three phases included stakeholders and women in all stages. Phase 1 developed the conceptual framework that underpinned the new PROM and its items (questions), through literature reviews and qualitative interviews. The reviews showed the limited focus of existing PROMs, the limited exploration of woman's perspective with regards to how their health and wellbeing is affected by the maternity journey, and the lack of a maternity-specific PROM applicable throughout their maternity journey. A new theoretical model of maternity was created to inform the preliminary conceptual framework. Qualitative interviews identified issues that affect how women feel, function and live their lives supporting the development of a new conceptual model of the wellbeing of women during their maternity journey that underpinned the final conceptual framework. Phase 2 involved best practice methods for item generation, selection, and refinement to craft a preliminary long-form WOWMAT questionnaire ready for pre-testing. Phase 3 used cognitive interviews (pre-testing) with low-risk nulliparous women to explore the relevance, clarity, and acceptability of the new PROM. This informed item reduction and modification of the PROM, and produced a long-form WOWMAT questionnaire, ready for future psychometric testing. This PhD has contributed a new understanding of the impact of the maternity journey and in doing so, developed a PROM grounded in women's perspective.

This thesis focuses on young women's experiences of health-related psychosocial difficulties. Fertility-related difficulties are a common and distressing issue for young women following cancer. Chapter one describes a meta-ethnography of qualitative literature that explores how young women experience their fertility following cancer treatment. Two meta-themes are described, which illustrate the multiple losses women experience related to their threatened or lost fertility, and the complex grieving process they engage in to come to terms with these losses. Clinical implications are highlighted. Polycystic ovary syndrome (PCOS) is a common chronic endocrine condition associated with physical, psychological and sexual difficulties. Chapter two describes the experience of being in intimate partner relationship as a young woman with PCOS. Seven young women were interviewed using an Interpretative Phenomenological Analysis methodology. Two superordinate themes emerged. The study identifies how the women's threatened feminine identities undermined their relationship security and sometimes created a power imbalance between them and their partners. The battles to repair their feminine identities, and how these are experienced in the context of their intimate partner relationships, are then discussed. Difficulties with sexual intimacy are also described. A number of clinical implications are identified. Chapter three presents a reflective account of the research process, both regarding how the researcher may have influenced the research, and how the research influenced them. A number of areas of reflection are outlined, including the challenge of being a clinician and a researcher and managing being an 'outsider'. The chapter ends by reflecting on the role research can play in reinforcing or challenging social norms.

Perinatal depression (PND) has profound consequences for family life, social functioning as well as long-term cognitive development for the offspring. Current screening is ineffective, with half of all cases undetected. Understanding which factors provide the highest risk of PND will benefit screening and the targeting of treatment. PND involves interplay between individual chronic and acute disease burdens, biological and psychosocial environmental behavioural factors. The predictive potential of specific factors and their contribution to severity scores on the Edinburgh Postnatal Depression Scale (EPDS) screening tool is explored here. This study has employed a multidisciplinary approach to combine psycho-sociodemographic factors with biomarkers from a population of women screened for antenatal (N=1579) and postpartum (N=872) depressive symptoms. Different methods of regression modelling have been explored to determine predictors of perinatal depression, which has also been compared with a machine learning approach. The heterogeneous presentation of symptoms has additionally been explored with statistical analysis. History of anxiety or depression, young maternal age (18-24) low social status and smoking pre-pregnancy were identified as the strongest contributions to antenatal scores, whereas depressive symptoms in pregnancy and a history of depression or PND exhibited the strongest association with postpartum EPDS. Circulating concentration of IL-10 was significantly associated with antenatal EPDS, in addition to the ratio of IL-6/IL-10. The inclusion of IL-6 and IL-10 data improves prediction of antenatal scores. IL-6 and BDNF concentration were predictive of lower infant birth weights. In general the available covariates are better suited to predict EPDS scores antenatally than postpartum. Risk factor profiles for antenatal and postpartum depression appear to be largely different, supporting the theory that PND is a heterogeneous disease and that underlying pathologies are also heterogeneous.

Risk of postpartum psychosis (PP) is high in bipolar disorder (BD), however, factors influencing this risk are poorly understood. In particular, whether adverse childhood experiences (ACEs), anxiety disorders and a range of within-pregnancy factors increase risk of PP in BD is yet to be examined. Of within-pregnancy factors that have been investigated, most have been assessed retrospectively. Prospective studies examining risk of PP in BD are scarce. The main aims of this thesis were to a) examine the relationship between ACEs, anxiety disorders and the lifetime occurrence of PP in BD and b) investigate potential within-pregnancy risk factors for PP in BD using a prospective follow-up design. ACEs, anxiety disorders and lifetime occurrence of PP were assessed via semi-structured interview and self-report questionnaires in 504 parous women with DSM-IV BD-I. Withinpregnancy potential risk factors (including medication, sleep, obstetric and psychosocial factors) were assessed prospectively in 103 pregnant women with DSM-5 BD (n=84 BD-I/SA-BD; n=19 BD-II/BD-NOS) via semi-structured interview in late pregnancy (baseline); perinatal psychopathology was assessed via interview at 12-weeks postpartum. All data were supplemented by clinician questionnaires and/or psychiatric case-notes. Neither history of ACEs (p-values of 0.06-0.95) nor anxiety disorders (of any type; p=0.47, phobias; p=0.23, panic; p=0.53) were significantly associated with the lifetime occurrence of PP. 21% women in the prospective sample experienced PP within 6 weeks of delivery. In unadjusted analyses, an episode of mania/affective psychosis during pregnancy (p=0.001; OR 11.67, 95% CI 2.61-52.21) and loss of at least one complete night of sleep across labour/delivery (p=<0.01; OR 5.35, 95% CI 1.50-19.11) significantly increased risk of PP. After adjusting for known lifetime correlates of PP, mania/affective psychosis in pregnancy remained a significant predictor of PP (p=<0.01; OR 16.49, 95% CI 2.76-98.48). Further adjustment revealed prophylactic mood stabilising medication in the postpartum period had little influence in moderating risk of PP (p=0.61; OR 0.67 95% CI 0.14-3.16). No significant associations were found between withinpregnancy psychosocial or psychological factors and PP. This prospective study demonstrated that risk of PP is high in women with BD, despite use of prophylactic mood stabilising medication. History of ACEs or anxiety disorders did not influence lifetime risk of PP. Mania/affective psychosis with onset during pregnancy significantly increased risk of PP, over and above associations with known lifetime risk factors. Sleep loss associated with labour may act as a final common pathway in the triggering of PP. If replicated, these findings have clinical implications for managing risk of PP in women with BD. The role of neurobiological and medication related factors in the pathophysiology of PP requires further investigation in larger samples.