IMMUNE-ANGIOGENESIS MECHANISMS ASSOCIATED WITH PORCINE PREGNANCY SUCCESS AND FAILURE

Spontaneous fetal loss (25-40%) leading to decrease in litter size is a significant concern to the pork industry. A deficit in the placental vasculature has emerged as one of the important factors associated with fetal loss. During early pig pregnancy, the endometrium becomes enriched with immune cells recruited by conceptus-derived signals including specific chemokine stimuli. These immune cells assist in various aspects of placental development and angiogenesis. Recent evidence suggests that microRNAs (miRNAs: small non-coding RNAs that regulate gene expression) regulate immune cell development and their functions. In addition, intercellular communication including exchange of biomolecules (e.g. miRNAs) between the conceptus and endometrium regulate key developmental processes during pregnancy. To understand the biological significance of immune cell enrichment, regulation of their functions by miRNAs and transfer of miRNAs across the maternal fetal-interface, we screened specific sets of chemokines and pro- and anti-angiogenic miRNAs in endometrial lymphocytes (ENDO LY), endometrium, and chorioallantoic membrane (CAM) isolated from conceptus attachment sites (CAS) during early, gestation day (gd)20 and mid-pregnancy (gd50). We report increased expression of selected chemokines including CXCR3 and CCR5 in ENDO LY and CXCL10, CXCR3, CCL5, CCR5 in endometrium associated with arresting CAS at gd20. Some of these differences were also noted at the protein level (CXCL10, CXCR3, CCL5, and CCR5) in endometrium and CAM. We report for the first time significant differences for miRNAs involved in immune cell-derived angiogenesis (miR-296-5P, miR-150, miR-17P-5P, miR-18a, and miR-19a) between ENDO LY associated with healthy and arresting CAS. Significant differences were also found in endometrium and CAM for some miRNAs (miR-17-5P, miR-18a, miR-15b-5P, and miR-222). Finally, we confirm that placenta specific-exosomes contain proteins and 14 select miRNAs including miR-126-5P, miR-296-5P, miR-16, and miR-17-5P that are of relevance to early implantation events. We further demonstrated the bidirectional exosome shuttling between porcine trophectoderm cells (PTr2) and porcine aortic endothelial cells (PAOEC). PTr2-derived exosomes were able to modulate the endothelial cell proliferation that is crucial for the establishment of pregnancy. Our data unravels the selected chemokines and miRNAs associated with immune cell-regulated angiogenesis and reconfirm that exosome mediated cell-cell communication opens-up new avenues to understand porcine pregnancy.

Beyond the numbers of maternal near-miss in Rwanda - a qualitative study on women's perspectives on access and experiences of care in early and late stage of pregnancy.

BACKGROUND: Rwanda has made remarkable progress in decreasing the number of maternal deaths, yet women still face morbidities and mortalities during pregnancy. We explored care-seeking and experiences of maternity care among women who suffered a near-miss event during either the early or late stage of pregnancy, and identified potential health system limitations or barriers to maternal survival in this setting. METHODS: A framework of Naturalistic Inquiry guided the study design and analysis, and the 'three delays' model facilitated data sorting. Participants included 47 women, who were interviewed at three hospitals in Kigali, and 14 of these were revisited in their homes, from March 2013 to April 2014. RESULTS: The women confronted various care-seeking barriers depending on whether the pregnancy was wanted, the gestational age, insurance coverage, and marital status. Poor communication between the women and healthcare providers seemed to result in inadequate or inappropriate treatment, leading some to seek either traditional medicine or care repeatedly at biomedical facilities. CONCLUSION: Improved service provision routines, information, and amendments to the insurance system are suggested to enhance prompt care-seeking. Additionally, we strongly recommend a health system that considers the needs of all pregnant women, especially those facing unintended pregnancies or complications in the early stages of pregnancy.

Assessing the Association between Receipt of Antimalarial Drugs and Adverse Pregnancy Outcomes using Pooled Data

Thesis (Ph.D.)--University of Washington, 2016-08

Intimate Partner Violence and Pregnancy Intentions: A Qualitative Study

Aim and Objective In this qualitative study we explored women’s pregnancy intentions and experiences of intimate partner violence before, during and after pregnancy. Background Unintended pregnancies in the context of intimate partner violence can have serious health, social and economic consequences for women and their children. Design Feminist and phenomenological philosophies underpinned the study to gain a richer understanding of women’s experiences. Methods Eleven women who had been pregnant in the previous two years were recruited from community-based women’s refuges in one region of the United Kingdom. Of the eleven women, eight had unplanned pregnancies, two reported being coerced into early motherhood, and only one woman had purposively planned her pregnancy. Multiple in-depth interviews focused on participants’ accounts of living with intimate partner violence. Experiential data analysis was used to identify, analyse and highlight themes. Results Three major themes were identified: men’s control of contraception, partner’s indiscriminate response to the pregnancy, and women’s mixed feelings about the pregnancy. Participants reported limited influence over their sexual relationship and Accepted Article This article is protected by copyright. All rights reserved. birth control. Feelings of vulnerability about themselves and fear for their unborn babies’ safety were intensified by their partners’ continued violence during pregnancy. Conclusion Women experiencing intimate partner violence were more likely to have an unintended pregnancy. This could be attributed to male dominance and fear, which impacts on a woman’s ability to manage her birth control options. The women’s initial excitement about their pregnancy diminished in the face of uncertainty and ongoing violence within their relationship. Relevance to clinical practice Women experiencing violence lack choice in relation to birth control options leading to unintended pregnancies. Interpreting the findings from the victim-perpetrator interactive spin theory of intimate partner violence provides a possible framework for midwives and nurses to better understand and respond to women’s experiences of violence during pregnancy.

Pancreatic large mucinous cystoadenoma with invasive ductal carcinoma in pregnancy. Case report

Background. Cystic tumour of the pancreas are infrequent and malignancy of the pancreas during pregnancy is extremely rare. Mucinous cystoadenomas is the most frequent cystic pancreatic neoplasm and it is seen mainly in women suggesting a sex hormone influence. Its presentation during pregnancy is extremely rare and entails difficulties in diagnosis and therapy. Case report. A 28 year old woman was referred to our service for abdominal mass. She had given birth to her second child two weeks previously. Ultrasound and CT scan showed a large cystic lesion, with sepitation and inner solid growth portions, involved mainly the left sovramesocolic space. An ultrasound-guided aspiration of the cystic fluid showed high level of CEA and CA. 19-9. The patient underwent laparotomic body-tail pancreatectomy and splenectomy. The histological examination showed mucinous cystoadenoma with associated invasive ductal carcinoma, with ovarian-like stroma and a well delimited fibrous capsule. Hystochemical study revealed a strong positivity for progesterone receptors. Conclusions. To our knowledge this is the eighth case of mucinous cystoadenoma reported in English literature and the forth with an invasive adenocarcinoma associated. This pathological entity should always be kept in mind in case of patient with an hepigastric mass during or soon after pregnancy. Aggressive approach is mandatory.

Adult attachment style and cortisol responses in women in late pregnancy

Suporte financeiro e não financeiro da Maternidade Alfredo da Costa, Lisboa, Portugal

Regulatory T and B cells in asthmatic women: variations from pregnancy to postpartum Treg and Breg: pregnancy to postpartum

BACKGROUND: Allergic asthma and rhinitis are common in pregnancy. The immune mechanisms underlying the effects of pregnancy in asthma and vice-versa are not completely understood. OBJECTIVES: This work aimed to study the evolution of regulatory T and B cells in asthmatic pregnant women, from late pregnancy till postpartum. METHODS: Four groups of women were enrolled for this study: third trimester pregnant women, asthmatic (n=24) and healthy (n=43), and non-pregnant women, asthmatic (n=33) and healthy (n=35). Pregnant women were also evaluated postpartum (>6 weeks after delivery). Blood samples were taken from each woman and flow cytometry was used to characterize circulating regulatory T and B cells. Foxp3 expression was assessed within CD4DimCD25Hi regulatory T cells. RESULTS: In asthmatic and healthy pregnant women, regulatory T cells did not oscillate significantly from pregnancy to postpartum, but CD24HiCD38Hi regulatory B cells, decreased in pregnancy, rose significantly postpartum. Foxp3 expression in regulatory T cells was also impaired during pregnancy in asthmatic and healthy pregnant women, recovering postpartum. Nevertheless, asthmatic pregnant women presented higher Foxp3 expression than healthy pregnant women (p=0.007), probably due to the use of control medication. CONCLUSIONS: Women with controlled asthma present variations in regulatory cell subsets during pregnancy and postpartum. The similar pattern observed for Foxp3 expression and CD24HiCD38Hi regulatory B cells during this period corroborates the interaction established between regulatory T and B cells in immune responses. Considering the immunomodulatory potential of these immune mediators, more studies are needed to evaluate their relation with asthma and rhinitis complications in pregnancy.

Three-dimensional kinetic adaptations of gait throughout pregnancy and postpartum

Biomechanical adaptations that occur during pregnancy can lead to changes on gait pattern. Nevertheless, these adaptations of gait are still not fully understood. The purpose was to determine the effect of pregnancy on the biomechanical pattern of walking, regarding the kinetic parameters. A three-dimensional analysis was performed in eleven participants. The kinetic parameters in the joints of the lower limb during gait were compared at the end of the first, second, and third trimesters of pregnancy and in the postpartum period, in healthy pregnant women. The main results showed a reduction in the normalized vertical reaction forces, throughout pregnancy, particularly the third peak. Pregnant women showed, during most of the stance phase, medial reaction forces as a motor response to promote the body stability. Bilateral changes were observed in hip joint, with a decrease in the participation of the hip extensors and in the eccentric contraction of hip flexors. In ankle joint a decrease in the participation of ankle plantar flexors was found. In conclusion, the overall results point to biomechanical adjustments that showed a decrease of the mechanical load of women throughout pregnancy, with exception for few unilateral changes of hip joint moments.

Three-dimensional kinetic adaptations of gait throughout pregnancy and postpartum

Biomechanical adaptations that occur during pregnancy can lead to changes on gait pattern. Nevertheless, these adaptations of gait are still not fully understood. The purpose was to determine the effect of pregnancy on the biomechanical pattern of walking, regarding the kinetic parameters. A three-dimensional analysis was performed in eleven participants. The kinetic parameters in the joints of the lower limb during gait were compared at the end of the first, second, and third trimesters of pregnancy and in the postpartum period, in healthy pregnant women. The main results showed a reduction in the normalized vertical reaction forces, throughout pregnancy, particularly the third peak. Pregnant women showed, during most of the stance phase, medial reaction forces as a motor response to promote the body stability. Bilateral changes were observed in hip joint, with a decrease in the participation of the hip extensors and in the eccentric contraction of hip flexors. In ankle joint a decrease in the participation of ankle plantar flexors was found. In conclusion, the overall results point to biomechanical adjustments that showed a decrease of the mechanical load of women throughout pregnancy, with exception for few unilateral changes of hip joint moments.

The role of inflammation in vascular function and pregnancy outcome in the pregnant stroke prone spontaneously hypertensive rat

During pregnancy, the maternal cardiovascular system undergoes major adaptation. One of these changes is a 40-50 % increase in circulating blood volume which requires a systemic remodelling of the vasculature in order to regulate maternal blood pressure and maximise blood supply to the developing placenta and fetus. These changes are broadly conserved between humans and rats making them an appropriate pre-clinical model in which to study the underlying mechanisms of pregnancy-dependent cardiovascular remodelling. Whilst women are normally protected against cardiovascular disease; pregnancy marks a period of time where women are susceptible to cardiovascular complications. Cardiovascular disease is the leading cause of maternal mortality in the United Kingdom; in particular hypertensive conditions are among the most common complications of pregnancy. One of the main underlying pathologies of these pregnancy complications is thought to be a failure of the maternal cardiovascular system to adapt. The remodelling of the uterine arteries, which directly supply the maternal-fetal interface, is paramount to a healthy pregnancy. Failure of the uterine arteries to remodel sufficiently can result in a number of obstetric complications such as preeclampsia, fetal growth restriction and spontaneous pregnancy loss. At present, it is poorly understood whether this deficient vascular response is due to a predisposition from existing maternal cardiovascular risk factors, the physiological changes that occur during pregnancy or a combination of both. Previous work in our group employed the stroke prone spontaneously hypertensive rat (SHRSP) as a model to investigate pregnancy-dependent remodelling of the uterine arteries. The SHRSP develops hypertension from 6 weeks of age and can be contrasted with the control strain, the Wistar Kyoto (WKY) rat. The phenotype of the SHRSP is therefore reflective of the clinical situation of maternal chronic hypertension during pregnancy. We showed that the SHRSP exhibited a deficient uterine artery remodelling response with respect to both structure and function accompanied by a reduction in litter size relative to the WKY at gestational day (GD) 18. A previous intervention study using nifedipine in the SHRSP achieved successful blood pressure reduction from 6 weeks of age and throughout pregnancy; however uterine artery remodelling and litter size at GD18 was not improved. We concluded that the abnormal uterine artery remodelling present in the SHRSP was independent of chronic hypertension. From these findings, we hypothesised that the SHRSP could be a novel model of spontaneously deficient uterine artery remodelling in response to pregnancy which was underpinned by other as yet unidentified cardiovascular risk factors. In Chapter 1 of this thesis, I have characterised the maternal, placental and fetal phenotype in pregnant (GD18) SHRSP and WKY. The pregnant SHRSP exhibit features of left ventricular hypertrophy in response to pregnancy and altered expression of maternal plasma biomarkers which have been previously associated with hypertension in human pregnancy. I developed a protocol for accurate dissection of the rat uteroplacental unit using qPCR probes specific for each layer. This allowed me to make an accurate and specific statement about gene expression in the SHRSP GD18 placenta; where oxidative stress related gene markers were increased in the vascular compartments. The majority of SHRSP placenta presented at GD18 with a blackened ring which encircled the tissue. Further investigation of the placenta using western blot for caspase 3 cleavage determined that this was likely due to increased cell death in the SHRSP placenta. The SHRSP also presented with a loss of one particular placental cell type at GD18: the glycogen cells. These cells could have been the target of cell death in the SHRSP placenta or were utilised early in pregnancy as a source of energy due to the deficient uterine artery blood supply. Blastocyst implantation was not altered but resorption rate was increased between SHRSP and WKY; indicating that the reduction in litter size in the SHRSP was primarily due to late (>GD14) pregnancy loss. Fetal growth was not restricted in SHRSP which led to the conclusion that SHRSP sacrifice part of their litter to deliver a smaller number of healthier pups. Activation of the immune system is a common pathway that has been implicated in the development of both hypertension and adverse pregnancy outcome. In Chapter 2, I proposed that this may be a mechanism of interest in SHRSP pregnancy and measured the pro-inflammatory cytokine, TNFα, as a marker of inflammation in pregnant SHRSP and WKY and in the placentas from these animals. TNFα was up-regulated in maternal plasma and urine from the GD18 SHRSP. In addition, TNFα release was increased from the GD18 SHRSP placenta as was the expression of the pro-inflammatory TNFα receptor 1 (Tnfr1). In order to investigate whether this excess TNFα was detrimental to SHRSP pregnancy, a vehicle-controlled intervention study using etanercept (a monoclonal antibody which works as a TNFα antagonist) was carried out. Etanercept treatment at GD0, 6, 12 and 18 resulted in an improvement in pregnancy outcome in the SHRSP with an increased litter size and reduced resorption rate. Furthermore, there was an improved uterine artery function in GD18 SHRSP treated with etanercept which was associated with an improved uterine artery blood flow over the course of gestation. In Chapter 3, I sought to identify the source of this detrimental excess of TNFα by designing a panel for maternal leukocytes in the blood and placenta at GD18. A population of CD3- CD161+ cells, which are defined as rat natural killer (NK) cells, were increased in number in the SHRSP. Intracellular flow cytometry also identified this cell type as a source of excess TNFα in blood and placenta from pregnant SHRSP. I then went on to evaluate the effects of etanercept treatment on these CD3- CD161+ cells and showed that etanercept reduced the expression of CD161 and the cytotoxic molecule, granzyme B, in the NK cells. Thus, etanercept limits the cytotoxicity and potential damaging effect of these NK cells in the SHRSP placenta. Analysing the urinary peptidome has clinical potential to identify novel pathways involved with disease and/or to develop biomarker panels to aid and stratify diagnosis. In Chapter 4, I utilised the SHRSP as a pre-clinical model to identify novel urinary peptides associated with hypertensive pregnancy. Firstly, a characterisation study was carried out in the kidney of the WKY and SHRSP. Urine samples from WKY and SHRSP taken at pre-pregnancy, mid-pregnancy (GD12) and late pregnancy (GD18) were used in the peptidomic screen. In order to capture peptides which were markers of hypertensive pregnancy from the urinary peptidomic data, I focussed on those that were only changed in a strain dependent manner at GD12 and 18 and not pre-pregnancy. Peptide fragments from the uromodulin protein were identified from this analysis to be increased in pregnant SHRSP relative to pregnant WKY. This increase in uromodulin was validated at the SHRSP kidney level using qPCR. Uromodulin has previously been identified to be a candidate molecule involved in systemic arterial hypertension but not in hypertensive pregnancy thus is a promising target for further study. In summary, we have characterised the SHRSP as the first model of maternal chronic hypertension during pregnancy and identified that inflammation mediated by TNFα and NK cells plays a key role in the pathology. The evidence presented in this thesis establishes the SHRSP as a pre-clinical model for pregnancy research and can be continued into clinical studies in pregnant women with chronic hypertension which remains an area of unmet research need.

El concepto y la práctica de la actividad física y su relación con calidad de vida en los modelos teóricos de la salud

Los estudios acerca del concepto actividad física (AF) son diversos, presentando diferentes concepciones; su relación con calidad de vida suele estar generada dentro del discurso médico, que propende por la ejecución de la Actividad Física desde una mirada netamente biológica. Si bien esta disertación es importante, se debe tener en cuenta que los estudios relacionados con calidad de vida y la AF se basan en la condición de bienestar y percepción frente al estado de salud; dichos estudios no se han realizado desde las condiciones de vida y del contexto social. Si bien es cierto que la mirada médica y lo estudios objetivos son relevantes, ya que arrojan estadísticas que permiten abordar recomendaciones en cuanto a la actividad física, en este documento se elaboró una investigación de tipo cualitativo por medio de la revisión documental del concepto de actividad física, sus prácticas y su relación con calidad de vida, que abordan diferentes autores. Para ello se elige la base de datos PubMed por su énfasis en las publicaciones de salud; se seleccionan artículos publicados del 2004 y 2014, que estudien el concepto de actividad física, sus prácticas y relaciones con calidad de vida, para finalmente hacer un análisis desde los modelos de determinación y determinantes sociales. De esta forma se analiza la posición de los autores con respecto al concepto, sus prácticas y las relaciones que puede llegar a surgir con la calidad de vida. En esta investigación se obtuvo como resultados tendencias biológicas, psicológicas, sociales y culturales, en los cuales los autores dejan clara la posición médica ya que en la mayoría de investigaciones centran sus relaciones en la funcionalidad, y es a través de la visión terapéutica donde buscan el bienestar, la satisfacción de los pacientes que padecen cualquier enfermedad. Además, aparecen categorías emergentes como: cuerpo como medio de publicidad, cibernética que avanza vertiginosamente y el papel del poder en la actividad física que pueden ser contempladas para otros estudios.

Intimate partner violence in pregnancy: planning and pregnancy monitoring

The intimate partner violence (IPV) in pregnancy results in risk factors with an impact on maternal and fetal health. There is a tendency to unwanted pregnancies, unplanned and poor adherence to health services, increasing the risk of complications during pregnancy. The aim is describe the prevalence rates of IPV during pregnancy in the Central Region of Portugal and analyse their association with pregnancy planning and frequency of prenatal consultations. There was prevalence of IPV during pregnancy with a significant association to pregnancy planning. Although most women have attended prenatal consultations in the last pregnancy, the late start is associated with the probability of frequency of some type of IPV.

Intimate partner violence in pregnancy: Communicate better to unveil the problem.

The intimate partner violence (IPV) is defined as any behavior within an intimate relationship that causes physical, psychological or sexual damage to members of relationship (Organización Panamericana de la Salud, Oficina Regional para las Américas de la Organización Mundial de la Salud 2003). Exposure to the IPV during pregnancy leads to a number of risk factors with significant impact on the physical, mental and social well-being of women, as well in perinatal outcomes. The prevalence rates, existing throughout the world, have demonstrated the importance of further enhance the attention given to the woman / couple / family, from prenatal care to the postpartum. (World Health Organization, WHO Collaborating Centre for Violence Prevention 2010), challenges the health professionals to monitor the phenomenon of IPV and compare national and international indicators in order to adjust and qualify interventions. This requires awareness of health professionals in the early identification of these indicators using appropriate communication strategies and safe environments.

Intimate partner violence in pregnancy: planning and pregnancy monitoring.

The aim is describe the prevalence rates of IPV during pregnancy in the Central Region of Portugal and analyse their association with pregnancy planning and frequency of prenatal consultations.

Intimate partner violence in pregnancy: Communicate better to unveil the problema.

Describe the prevalence of IPV during pregnancy in the Central Region of Portugal. Reflect on the need to improve the effectiveness of communication between nurse or midwife and pregnant woman or couple, for easier identification of violence exposure during pregnancy.