A diverse portfolio of marine protected areas can better advance global conservation and equity

Marine protected areas (MPAs) are widely used for ocean conservation, yet the relative impacts of various types of MPAs are poorly understood. We estimated impacts on fish biomass from no-take and multiple-use (fished) MPAs, employing a rigorous matched counterfactual design with a global dataset of >14,000 surveys in and around 216 MPAs. Both no-take and multiple-use MPAs generated positive conservation outcomes relative to no protection (58.2% and 12.6% fish biomass increases, respectively), with smaller estimated differences between the two MPA types when controlling for additional confounding factors (8.3% increase). Relative performance depended on context and management: no-take MPAs performed better in areas of high human pressure but similar to multiple-use in remote locations. Multiple-use MPA performance was low in high-pressure areas but improved significantly with better management, producing similar outcomes to no-take MPAs when adequately staffed and appropriate use regulations were applied. For priority conservation areas where no-take restrictions are not possible or ethical, our findings show that a portfolio of well-designed and well-managed multiple-use MPAs represents a viable and potentially equitable pathway to advance local and global conservation.

Diversification of refugia types needed to secure the future of coral reefs subject to climate change

Identifying locations of refugia from the thermal stresses of climate change for coral reefs and better managing them is one of the key recommendations for climate change adaptation. We review and summarize approximately 30 years of applied research focused on identifying climate refugia to prioritize the conservation actions for coral reefs under rapid climate change. We found that currently proposed climate refugia and the locations predicted to avoid future coral losses are highly reliant on  excess heat metrics, such as degree heating weeks. However, many existing alternative environmental, ecological, and life-history variables could be used to identify other types of refugia that lead to the desired diversified portfolio for coral reef conservation. To improve conservation priorities for coral reefs, there is a need to evaluate and validate the predictions of climate refugia with long-term field data on coral abundance, diversity, and functioning. There is also the need to identify and safeguard locations displaying resistance toprolonged exposure to heat waves and the ability to recover quickly after thermal exposure. We recommend using more metrics to identify a portfolio of potential refugia sites for coral reefs that can avoid, resist, and recover from exposure to high ocean temperatures and the consequences of climate change, thereby shifting past efforts focused on avoidance to a diversified risk-spreading portfolio that can be used to improve strategic coral reef conservation in a rapidly warming climate.

Assessing the potential for demographic restoration and assisted evolution to build climate resilience in coral reefs

Interest is growing in developing conservation strategies to restore and maintain coral reef ecosystems in the face of mounting anthropogenic stressors, particularly climate warming and associated mass bleaching events. One such approach is to propagate coral colonies ex situ and transplant them to degraded reef areas to augment habitat for reef-dependent fauna, prevent colonization from spatial competitors, and enhance coral reproductive output. In addition to such "demographic restoration" efforts, manipulating the thermal tolerance of outplanted colonies through assisted relocation, selective breeding, or genetic engineering is being considered for enhancing rates of evolutionary adaptation to warming. Although research into such "assisted evolution" strategies has been growing, their expected performance remains unclear. We evaluated the potential outcomes of demographic restoration and assisted evolution in climate change scenarios using an eco-evolutionary simulation model. We found that supplementing reefs with pre-existing genotypes (demographic restoration) offers little climate resilience benefits unless input levels are large and maintained for centuries. Supplementation with thermally resistant colonies was successful at improving coral cover at lower input levels, but only if maintained for at least a century. Overall, we found that, although demographic restoration and assisted evolution have the potential to improve long-term coral cover, both approaches had a limited impact in preventing severe declines under climate change scenarios. Conversely, with sufficient natural genetic variance and time, corals could readily adapt to warming temperatures, suggesting that restoration approaches focused on building genetic variance may outperform those based solely on introducing heat-tolerant genotypes.

Participation, not penalties: Community involvement and equitable governance contribute to more effective multiuse protected areas

Accelerating ecosystem degradation has spurred proposals to vastly expand the extent of protected areas (PAs), potentially affecting the livelihoods and well-being of indigenous peoples and local communities (IPLCs) worldwide. The benefits of multiuse PAs that elevate the role of IPLCs in management have long been recognized. However, quantitative examinations of how resource governance and the distribution of management rights affect conservation outcomes are vital for long-term sustainability. Here, we use a long-term, quasi-experimental monitoring dataset from four Indonesian marine PAs that demonstrates that multiuse PAs can increase fish biomass, but incorporating multiple governance principles into management regimes and enforcing rules equitably are critical to achieve ecological benefits. Furthermore, we show that PAs predicated primarily on enforcing penalties can be less effective than those where IPLCs have the capacity to engage in management. Our results suggest that well-governed multiuse PAs can achieve conservation objectives without undermining the rights of IPLCs.

A novel framework for analyzing conservation impacts: evaluation, theory, and marine protected areas

Environmental conservation initiatives, including marine protected areas (MPAs), have proliferated in recent decades. Designed to conserve marine biodiversity, many MPAs also seek to foster sustainable development. As is the case for many other environmental policies and programs, the impacts of MPAs are poorly understood. Social-ecological systems, impact evaluation, and common-pool resource governance are three complementary scientific frameworks for documenting and explaining the ecological and social impacts of conservation interventions. We review key components of these three frameworks and their implications for the study of conservation policy, program, and project outcomes. Using MPAs as an illustrative example, we then draw upon these three frameworks to describe an integrated approach for rigorous empirical documentation and causal explanation of conservation impacts. This integrated three-framework approach for impact evaluation of governance in social-ecological systems (3FIGS) accounts for alternative explanations, builds upon and advances social theory, and provides novel policy insights in ways that no single approach affords. Despite the inherent complexity of social-ecological systems and the difficulty of causal inference, the 3FIGS approach can dramatically advance our understanding of, and the evidentiary basis for, effective MPAs and other conservation initiatives.

Integrating impact evaluation in the design and implementation of monitoring marine protected areas

Quasi-experimental impact evaluation approaches, which enable scholars to disentangle effects of conservation interventions from broader changes in the environment, are gaining momentum in the conservation sector. However, rigorous impact evaluation using statistical matching techniques to estimate the counterfactual have yet to be applied to marine protected areas (MPAs). While there are numerous studies investigating 'impacts' of MPAs that have generated considerable insights, results are variable. This variation has been linked to the biophysical and social context in which they are established, as well as attributes of management and governance. To inform decisions about MPA placement, design and implementation, we need to expand our understanding of conditions under which MPAs are likely to lead to positive outcomes by embracing advances in impact evaluation methodologies. Here, we describe the integration of impact evaluation within an MPA network monitoring programme in the Bird's Head Seascape, Indonesia. Specifically we (i) highlight the challenges of implementation 'on the ground' and in marine ecosystems and (ii) describe the transformation of an existing monitoring programme into a design appropriate for impact evaluation. This study offers one potential model for mainstreaming impact evaluation in the conservation sector.

A global map of human impact on marine ecosystems

The management and conservation of the world's oceans require synthesis of spatial data on the distribution and intensity of human activities and the overlap of their impacts on marine ecosystems. We developed an ecosystem-specific, multiscale spatial model to synthesize 17 global data sets of anthropogenic drivers of ecological change for 20 marine ecosystems. Our analysis indicates that no area is unaffected by human influence and that a large fraction (41%) is strongly affected by multiple drivers. However, large areas of relatively little human impact remain, particularly near the poles. The analytical process and resulting maps provide flexible tools for regional and global efforts to allocate conservation resources; to implement ecosystem-based management; and to inform marine spatial planning, education, and basic research.

Recovery from blast fishing on coral reefs: a tale of two scales

Dynamite or "blast" fishing is one of the most immediate and destructive threats to coral reefs worldwide. However, little is known about the long-term ecosystem effects of such blasts or the dynamics of recovery. Here, we examine coral reef recovery in the simplest case of acute single blasts of known age, as well as recovery from chronic blasting over greater spatial and temporal scales. Rubble resulting from single blasts slowly stabilized, and craters filled in with surrounding coral and new colonies. After five years, coral cover within craters no longer differed significantly from control plots. In contrast, extensively bombed areas showed no significant recovery over the six years of this study, despite adequate supply of coral larvae. After extensive blasting, the resulting coral rubble shifts in ocean currents, forming unstable "killing fields" for new recruits. While recently tested rehabilitation methods might be feasible on a small scale, human intervention is unlikely to be effective on large spatial scales, highlighting the need for effective management to prevent blast fishing in the first place.

Variation in caregiver perceptions of teamwork climate in labor and delivery units

OBJECTIVE

To test the psychometric soundness of a teamwork climate survey in labor and delivery, examine differences in perceptions of teamwork, and provide benchmarking data.

DESIGN

Cross-sectional survey of labor and delivery caregivers in 44 hospitals in diverse regions of the US, using the Safety Attitudes Questionnaire teamwork climate scale.

RESULTS

The response rate was 72% (3382 of 4700). The teamwork climate scale had good internal reliability (overall alpha = 0.78). Teamwork climate scale factor structure was confirmed using multilevel confirmatory factor analyses (CFI = 0.95, TLI = 0.92, RMSEA = 0.12, SRMR(within) = 0.04, SRMR(between) = 0.09). Aggregation of individual-level responses to the L&D unit-level was supported by ICC (1) = 0.06 (P < 0.001), ICC (2) = 0.83 and mean r (wg(j)) = 0.83. ANOVA demonstrated differences between caregivers F (7, 3013) = 10.30, P < 0.001 and labor and delivery units, F (43, 1022) = 3.49, P < 0.001. Convergent validity of the scale scores was measured by correlations with external teamwork-related items: collaborative decision making (r = 0.780, P < 0.001), use of briefings (r = 0.496, P < 0.001) and perceived adequacy of staffing levels (r = 0.593, P < 0.001).

CONCLUSION

We demonstrate a psychometrically sound teamwork climate scale, correlate it to external teamwork-related items, and provide labor and delivery teamwork benchmarks. Further teamwork climate research should explore the links to clinical and operational outcomes.

Gaps and mismatches between global conservation priorities and spending

Several international conservation organizations have recently produced global priority maps to guide conservation activities and spending in their own and other conservation organizations. Surprisingly, it is not possible to directly evaluate the relationship between priorities and spending within a given organization because none of the organizations with global priority models tracks how they spend their money relative to their priorities. We were able, however to evaluate the spending patterns of five other large biodiversity conservation organizations without their own published global priority models and investigate the potential influence of priority models on this spending. On average, countries with priority areas received greater conservation investment; global prioritization systems, however explained between only 2 and 32% of the U.S. dollars 1.5 billion spent in 2002, depending on whether the United States was removed from analyses and whether conservation spending was adjusted by the per capita gross domestic product within each country. We also found little overlap in the spending patterns of the five conservation organizations evaluated, suggesting that informal coordination or segregation of effort may be occurring. Our results also highlight a number of potential gaps and mismatches in how limited conservation funds are spent and provide the first audit of global conservation spending patterns. More explicit presentation of conservation priorities by organizations currently withoutpriority models and better tracking of spending by those with published priorities are clearly needed to help make future conservation activities as efficient as possible.

Recovery in rubble fields: long-term impacts of blast fishing

This paper presents initial results from a study of factors that inhibit or enhance hard coral recovery in rubble fields created by blast fishing in Komodo National Park and Bunaken National Park, Indonesia. Within nine sites monitored since 1998, there was no significant natural recovery. Levels of potential source coral larvae were assessed with settlement tiles in the rubble fields and in nearby high coral cover sites. Rubble movement was measured and shown to be detrimental to small scleractinians, especially in high current areas. In shallow water (2-6 m deep), rubble is often overgrown by soft corals and corallimorpharians, which inhibit hard coral survival. There is increased scleractinian recruitment in quadrats cleared of soft coral, and Acropora nubbins transplanted into soft coral fields suffer greater mortality than those transplanted above the soft coral canopy. Gaining an understanding of the prognosis for coral recovery is essential not only in order to assess the long-term impacts of blast fishing, but also to improve management decisions about protection of intact reefs and potential restoration of damaged areas.

Effect of student ethnicity on interpersonal skills and objective standardized clinical examination scores

OBJECTIVE

To determine whether standardized patients' perceptions of medical students' ethnicity influenced ratings on the interpersonal skills subsection of the objective standardized clinical examination (OSCE) and performance overall on the OSCE.

METHODS

The OSCE is used to evaluate medical students' performances in the obstetrics and gynecology basic clerkship at the Johns Hopkins University School of Medicine. It is based on a series of standardized patient interviews conducted by medical students and incorporates ratings by standardized patients on each student's interpersonal skills. Medical students (n = 353) enrolled in the obstetrics and gynecology basic clerkship from 1995-1998 were classified according to ethnicity. Overall OSCE scores according to ethnicity were analyzed using one-way analysis of variance. Total interpersonal skills scores and scores on the individual components of the interpersonal skills section of the OSCE were analyzed according to students' ethnicity using the Kruskal-Wallis test for nonparametric analysis of variance.

RESULTS

There were no statistically significant differences among ethnic groups in overall OSCE scores, total interpersonal skills scores, or scores on the individual components of the interpersonal skills section of the OSCE.

CONCLUSION

No bias attributable to perceived medical student ethnicity that affects performance on the OSCE exists.

Stress and dominance in a social fish

Many aspects of reproductive physiology are subject to regulation by social interactions. These include changes in neural and physiological substrates of reproduction. How can social behavior produce such changes? In experiments reported here, we manipulated the social settings of teleost fish and measured the effect (1) on stress response as reflected in cortisol production, (2) on reproductive potential as measured in production of the signaling peptide, gonadotropin-releasing hormone, and (3) on reproductive function measured in gonad size. Our results reveal that the level of the stress hormone cortisol depends critically on both the social and reproductive status of an individual fish and on the stability of its social situation. Moreover, the reproductive capacity of an individual fish depends on these same variables. These results show that social encounters within particular social contexts have a profound effect on the stress levels as well as on reproductive competence. Social behavior may lead to changes in reproductive state through integration of cortisol changes in time. Thus, information available from the stress pathway may provide socially relevant signals to produce neural change.

Fetal bradycardia and uterine hyperactivity following subarachnoid administration of fentanyl during labor

BACKGROUND AND OBJECTIVES

Changes in uterine tone have been postulated as the cause of fetal bradycardia following subarachnoid administration of fentanyl for labor analgesia. Such a case occurred in a 20-year-old parturient with an intrauterine pressure catheter in place.

METHODS

The patient was given intravenous terbutaline, after which contractions ceased for 20-30 minutes and then resumed.

RESULTS

The patient underwent successful cesarean delivery. Retrospective analysis of the data revealed a significant increase in uterine tone and contractions following fentanyl administration.

CONCLUSIONS

This case supports the view that changes in uterine tone, producing a hyperdynamic contractile state and a resulting decrease in uteroplacental perfusion, may explain the fetal bradycardia following subarachnoid opioid administration. Cases that do not resolve spontaneously may respond to intravenous terbutaline.

Patterns of fetal perinasal fluid flow in cases of congenital diaphragmatic hernia

OBJECTIVE(S)

Our purpose was to expand the previous reported series of observations of fetal perinasal fluid flow in cases of antenatally diagnosed congenital diaphragmatic hernia, characterize the timing parameters of the fetal breath cycle, and define the relationship of fetal perinasal fluid flow and the diaphragmatic component of fetal breathing movements. Our hypothesis was that characteristics of diaphragm-related and nondiaphragm-related perinasal fluid flow and other breath cycle characteristics differ in cases of congenital diaphragmatic hernia compared with controls.

STUDY DESIGN

Fetal perinasal fluid flow velocity and fetal chest wall movements were studied in 24 cases of uncomplicated pregnancy, and flow was studied in 24 cases of antenatally diagnosed congenital diaphragmatic hernia at gestational ages ranging from 30 to 41 weeks. The examination of fetal perinasal fluid flow velocity was performed with use of an ultrasonography system applying color flow and spectral Doppler analysis. Breath-to-breath interval, time of inspiration, time of expiration, and peak inspiratory and expiratory velocities were determined for each type of perinasal flow.

RESULTS

The study revealed that the time of expiration in cases of congenital diaphragmatic hernia at 30 to 36 and 37 to 41 weeks of gestation was significantly shorter than in cases of uncomplicated pregnancy. The ratio of time of inspiration and breath-to-breath interval in cases of diaphragmatic hernia was approximately 30% higher (p = 0.001) at 30 to 36 weeks of gestation than in cases of uncomplicated pregnancy. The study also showed that in cases of congenital diaphragmatic hernia the expiratory peak velocity ratio at 30 to 36 weeks of gestation was significantly lower than in cases of uncomplicated pregnancy.

CONCLUSIONS

We conclude that by Doppler ultrasonography measurements of fetal perinasal fluid flow, in cases of congenital diaphragmatic hernia, we can evaluate the timing parameters of fetal diaphragm-related breath cycles, the relationship of intraalveolar and intraamniotic pressures, and fetal upper respiratory tract resistance. Fetuses with diaphragmatic hernia spent significantly more time with diaphragm-nonrelated perinasal flow than did fetuses in cases of uncomplicated pregnancy, which can cause the increased loss of lung liquid and consequently be associated with pulmonary insufficiency in the early neonatal period.

Patterns of perinasal fluid flow and contractions of the diaphragm in the human fetus

Our aim was to identify patterns of fetal perinasal fluid flow, and to determine the relationship of pattern of flow to the diaphragmatic component of fetal breathing movements. Twenty-four fetuses were studied with the use of two ultrasound systems simultaneously. Continuous video-tape records of the color and spectral Doppler imaging of fluid flow velocity in the nose and of the movements of the fetal diaphragm were made on two video recorders during 30-min study sessions. Two different patterns of fetal perinasal flow were recognized. One type had a rapid rate and low amplitude, and was independent of ultrasonographically observed movements of the fetal diaphragm. The other type had a lower rate and higher amplitude, and was uniformly related to diaphragmatic contractions. The breath-to-breath interval, time of inspiration, time of expiration and peak inspiratory and expiratory velocities were determined for each type of perinasal flow. Two ratios were used to quantify the change of peak flow velocity. There were significant differences in the values of all timing parameters between diaphragm-related perinasal flow velocities and those not related to the diaphragm, at both 30-36 and 37-41 weeks of gestation. The rate of perinasal flow related to diaphragmatic contraction cycles was one-third that of the flow cycles not related to diaphragmatic contraction (approximately 50 vs. 148 cycles/min). For both patterns of perinasal flow velocity, the expiratory peak velocity ratio was about 1.6 times higher than the inspiratory peak velocity ratio. We conclude that, in uncomplicated pregnancy, one pattern of fetal perinasal fluid flow reflects activity of the diaphragm. We speculate that the contractions of the fetal airway smooth muscle or oropharyngeal-laryngeal muscle groups are the origin of the second pattern of perinasal flow.

Doppler ultrasound characteristics of fetal nasal flow in pregnancies complicated by diabetes mellitus

The purpose of our study was to determine the Doppler ultrasound characteristics of fetal breathing-related nasal fluid flow velocity in pregnancies complicated by diabetes mellitus and to examine any changes in the timing parameters of fetal breath cycle relative to maternal blood glucose level. Fetal nasal fluid flow velocity was studied in 67 women at 30-41 weeks of gestation. In 37 cases, the pregnancy was uncomplicated; in 13 cases, the pregnancy was complicated by type I diabetes mellitus; and in 17 cases, the pregnancy was complicated by gestational diabetes. At the examination, subjects with diabetes mellitus were grouped by glucose control (normoglycemic and hyperglycemic) and by gestational age: 30-36 weeks and 37-41 weeks. Maternal hyperglycemia was defined as a plasma glucose value ranging from 140 to 205 mg per 100 ml. A continuous videotape record of the spectral Doppler imaging of fluid flow velocity in the nose was made during each study session. Based on a sample of 25 consecutive fetal breaths, the timing components of breath cycles were determined: time of inspiration (Ti), time of expiration (Te), breath-to-breath interval (Ttotal), and ratio of Ti and Te (Ti/Te). There was a statistically significant difference between the Ttotal (msec) at 30-36 weeks' gestation in the cases of diabetes mellitus with maternal normoglycemia (1,050 +/- 68 SEM) and uncomplicated pregnancy with maternal normal carbohydrate intolerance (1,221 +/- 52). There was a similar difference in the values of Te (552 +/- 37 and 660 +/- 29, respectively) at 30-36 weeks. In cases of maternal hyperglycemia at 30-36 weeks' gestation, the value of Te (689 +/- 84) was significantly higher than in cases of normoglycemia (552 +/- 37). At 37-41 weeks' gestation, only the fetal Ti/Te ratio in normoglycemic diabetic patients was significantly lower than in an uncomplicated pregnancy. No differences were found in the other timing parameters at this gestational age group in cases of diabetes mellitus relative to maternal blood glucose level. No relationship was found between the value of maternal blood glucose and either fetal Ttotal (r2 = 0.003), or Ti/Te ratio (r2 = 0.0001) in cases of diabetes mellitus. Expiratory phase of fetal breath cycle even in well-controlled normoglycemic diabetic women, is significantly shorter than in uncomplicated pregnancies before 37 weeks of gestation. Maternal hyperglycemia in these cases prolonged the duration of expiratory phase of fetal breath cycle and significantly decreased the Ti/Te ratio more than 15% at 30-36 weeks of gestation. It is suggested that blood glucose level is involved in the regulation of fetal respiratory center in pregnancies complicated by diabetes mellitus.

Obstetrical factors and the transmission of human immunodeficiency virus type 1 from mother to child. The Women and Infants Transmission Study

BACKGROUND

A substantial proportion of perinatally acquired infections with the human immunodeficiency virus type 1 (HIV-1) occur at or near delivery, which suggests that obstetrical factors may have an important influence on transmission. We evaluated the relation of such factors and other variables to the perinatal transmission of HIV-1.

METHODS

The Women and Infants Transmission Study is a prospective, observational study of HIV-1-infected women who were enrolled during pregnancy and followed with their infants for three years after delivery. We studied obstetrical, clinical, immunologic, and virologic data on 525 women who delivered live singleton infants whose HIV-1-infection status was known as of August 31, 1994.

RESULTS

Among mothers with membranes that ruptured more than four hours before delivery, the rate of transmission of HIV-1 to the infants was 25 percent, as compared with 14 percent among mothers with membranes that ruptured four hours or less before delivery. In a multivariate analysis, the presence of ruptured membranes for more than four hours nearly doubled the risk of transmission (odds ratio, 1.82; 95 percent confidence interval, 1.10 to 3.00; P = 0.02), regardless of the mode of delivery. The other maternal factors independently associated with transmission were illicit-drug use during pregnancy (odds ratio, 1.90; 95 percent confidence interval, 1.14 to 3.16; P = 0.01), low antenatal CD4+ lymphocyte count (<29 percent of total lymphocytes) (odds ratio, 2.82; 1.67 to 4.76; P<0.001), and birth weight <2500 g (odds ratio, 1.86; 1.03 to 3.34; P = 0.04).

CONCLUSIONS

The risk of transmission of HIV-1 from mother to infant increases when the fetal membranes rupture more than four hours before delivery.

Association of maternal drug use during pregnancy with maternal HIV culture positivity and perinatal HIV transmission

OBJECTIVE

To evaluate the relationship of drug use with maternal HIV culture positivity at delivery and perinatal HIV transmission.

DESIGN

Multicenter prospective cohort study.

SETTING

Obstetric and pediatric clinics in five cities in the United States.

PARTICIPANTS

Five hundred and thirty HIV-infected pregnant women and their infants.

MAIN OUTCOME MEASURES

Multivariate logistic regression was used to evaluate the association of 'hard drug' use (one or more of the following: cocaine, heroin/opiates, methadone, injecting drug use) assessed by self-report and urine toxicology with positive maternal HIV culture at delivery and perinatal HIV transmission.

RESULTS

Forty-two per cent of women used hard drugs during pregnancy. Increased probability of a positive maternal delivery HIV culture was significantly associated with prenatal hard drug use [odds ratio (OR), 3.08] and maternal cocaine use (OR, 2.98) among HIV-infected women with > 29% CD4+ lymphocytes. After adjusting for maternal culture positivity at delivery, CD4+ lymphocyte percentage and gestational age, significantly greater transmission risk was observed with hard drug use among women with membrane rupture > 4 h.

CONCLUSIONS

On the basis of self-report and urine toxicology, overall maternal hard drug use and cocaine use in the WITS cohort were associated with maternal HIV culture positivity at delivery, and maternal hard drug use was associated with perinatal transmission.

Vibratory acoustic stimulation and fetal gasping

OBJECTIVE

Vibratory acoustic stimulation (VAS) has been used to shorten the duration of antepartum fetal heart rate monitoring. Questions have been asked regarding the possible effects of VAS on the fetus. VAS was used to investigate whether the acute effect of VAS is associated with gasping in the normal fetus.

STUDY DESIGN

Thirty-seven normal patients at 37-42 weeks' gestation with singleton fetuses were studied. All had normal amniotic fluid volume on ultrasound. These 37 subjects had a five-minute baseline sonographic assessment of fetal breathing and body movements. A fetal gasp was defined as an isolated, slow, irregularly occurring, deep, inspiratory-type movement, or series of them, of the chest and abdomen. Three-second VAS was then delivered with an artificial larynx placed directly over the fetal head. Fetal breathing, body and gasping movements were assessed at the time of this stimulus.

RESULTS

A significant increase in fetal body movements (P < .001), a significant decrease in fetal breathing (P < .003) and absence of gasping movements were noted.

CONCLUSION

The results suggest that gasping does not occur in response to VAS in the normal, term fetus.

Mycobacterium tuberculosis infection in pregnant and nonpregnant women infected with HIV in the Women and Infants Transmission Study

BACKGROUND

Prevalence of Mycobacterium tuberculosis (TB) infection and anergy were evaluated in a cohort of pregnant and nonpregnant women infected with the human immunodeficiency virus who were enrolled in a prospective natural history study (the Women and Infants Transmission Study) conducted in New York, NY; Boston and Worcester, Mass; Chicago, Ill; and San Juan, Puerto Rico.

METHODS

One hundred eighty-three women (65 pregnant, 118 nonpregnant) were evaluated for TB. The TB history and risk factors were assessed by interview and medical record review. Intradermal skin testing with tuberculin, mumps, and tetanus antigens and CD4+ lymphocyte count were performed.

RESULTS

Overall prevalence of TB infection or disease by documented medical history and/or a tuberculin skin test induration of 5 mm or more was 14% (26 of 183). History of TB infection or disease was documented in 11% of the women who were interviewed. Tuberculin and anergy skin test results were evaluable for 124 women; 6% (seven of 124) had tuberculin skin test induration of 5 mm or more, including 11% (five of 46) of the pregnant women who were tested. Induration between 2 and 5 mm was observed in four more women, three of whom were pregnant. Anergy was observed in 42% (52 of 124); prevalence of anergy was higher in nonpregnant women (38 [49%] of 78) than in pregnant women (14 [30%] of 46). While anergy was more common in women with a CD4+ cell count of 0.5 x 10(9)/L or less, 27% of those with a CD4+ cell count of more than 0.5 x 10(9)/L were also anergic.

CONCLUSION

These data support current Public Health Service recommendations for tuberculin skin testing in persons infected with the human immunodeficiency virus, and emphasize that evaluation should include pregnant as well as nonpregnant women. The prevalence of anergy does not appear increased in pregnancy in women infected with the human immunodeficiency virus. Health care providers should include tuberculin and anergy skin testing as part of the standard prenatal care for women infected with the human immunodeficiency virus.

Fetal breathing characteristics and postnatal outcome in cases of congenital diaphragmatic hernia

OBJECTIVE

Our purpose was to determine characteristics of fetal breathing activity by recording fetal nasal fluid flow velocity in cases of congenital diaphragmatic hernia.

STUDY DESIGN

Fetal breathing-related nasal fluid flow was studied in 47 patients at 34 to 41 weeks of gestation, 16 cases of antenatally diagnosed congenital diaphragmatic hernia and 31 cases of uncomplicated pregnancy. The examination was performed by ultrasonography combined with color-flow and spectral Doppler analysis. An average of 25 breath cycles from each case was determined for each of the following timing parameters: breath-to-breath interval, time of inspiration, time of expiration, and ratio of time of inspiration and time of expiration.

RESULTS

In all cases with uncomplicated pregnancy fetal breathing-related nasal fluid flow was seen at the level of the nose, and the timing components of this flow were determined as control values. In two cases with diaphragmatic hernia no perinasal flow was demonstrated, although fetal breathing movements observed as chest wall movements were present. The other 14 cases with congenital diaphragmatic hernia who demonstrated perinasal flow had the following postnatal outcome: one stillbirth, five neonatal deaths (group I), and eight survived and were discharged (group II). The study revealed that the time of expiration (in milliseconds) in group II (493.2 +/- 34.3 SEM) was significantly (p = 0.0030) shorter than in group I (653.4 +/- 38.4) and in cases of uncomplicated pregnancy (633.6 +/- 18.5). The value of the time of inspiration/time of expiration ratio in group II was approximately 15% higher than in group I and approximately 30% higher than in cases of uncomplicated pregnancies.

CONCLUSIONS

Observation of fetal breathing-related nasal fluid flow velocity in cases of antenatally diagnosed congenital diaphragmatic hernia provides a rationale for the hypothesis that time of expiration and the time of inspiration/time of expiration ratio may be useful in the prediction of postnatal outcome. We speculate that the changes in the group of survivors may represent a compensatory phenomenon by causing intermittent changes in the volume of fluid within the lungs.

Transvaginal ultrasonographic evaluation of the cervix before labor: presence of cervical wedging is associated with shorter duration of induced labor

OBJECTIVE

Our purpose was to test the hypothesis that transvaginal ultrasonographically determined characteristics of the cervix are associated with duration of induced labor.

STUDY DESIGN

Fifty-three patients scheduled for induction of labor underwent transvaginal ultrasonography and digital cervical examinations before labor induction. Cox proportional-hazards multiple regression analysis was performed to determine the variables that made a significant contribution to the prediction of latent-phase and total labor duration. In the analysis the possible confounding effects of exogenous prostaglandin, previous vaginal delivery, and previous termination of pregnancy were controlled.

RESULTS

Latent-phase and total labor duration were significantly associated with the presence of cervical wedging noted on transvaginal ultrasonography and administration of prostaglandin but not with the result of digital examination of cervical effacement or dilatation. Latent-phase duration was also associated with cervical length measured by transvaginal ultrasonography. The presence of wedging was significantly associated with shorter latent (15.9 +/- 1.7 vs 34.1 +/- 3.8 hours, p = 0.0001) and total (22.0 +/- 1.8 vs 38.3 +/- 3.6 hours, p = 0.0001) labor length.

CONCLUSION

The presence of wedging and decreased cervical length observed by transvaginal ultrasonography is associated with a shorter duration of induced labor and may be useful in the evaluation of induction candidates.

The gynecologic contribution to intestinal obstruction in females

This study was done to identify the cause of intestinal obstruction with particular emphasis on the gynecologic and perioperative related causes. All medical records from females with the discharge diagnosis "intestinal obstruction" from 1988 to 1991 at Columbia Presbyterian Medical Center were requested. The patient series consisted of the first 100 completed charts received. Forty-eight percent of those patients with intestinal obstruction had experienced a previous gynecologic or obstetric event that could account for the obstruction. Primarily, the gynecologist managed more than 20 percent of all female patients with intestinal obstruction. The most common causative factors contributing to intestinal obstruction were postoperative adhesions (59 percent) and tumor (17 percent). Fifty-six percent of the patients with intestinal obstruction associated with postoperative adhesions had a history of previous gynecologic and obstetric operation. Hysterectomy was the most common previously performed operation. In this series, cesarean section was less likely and myomectomy was more likely to cause subsequent intestinal obstruction than expected. Of 59 female patients with postoperative adhesions associated with intestinal obstruction, 31 had the original operative reports available for analysis. Eleven of these patients were taken to the operating room for management of the obstruction. In the nine patients who had surgical peritoneal closure in the original operation, the adhesions causing the obstruction were always to the site of reperitonealization. In the two patients in whom the peritoneum was left open, the adhesions causing obstruction were remote from the site of spontaneous reperitonealization. In an unselected patient series of intestinal obstruction, a history of previous gynecologic pathology is a significant factor contributing to the total number of instances of intestinal obstruction in females. Also, surgical peritoneal closure may result in an increase in the incidence of intestinal obstruction.

Ultrasound prediction of fetal pulmonary hypoplasia in pregnancies complicated by oligohydramnios and in cases of congenital diaphragmatic hernia: a review

The objective of this review is to discuss the current knowledge of fetal pulmonary hypoplasia and to summarize the clinical significance of the many ultrasound methods for predicting pulmonary hypoplasia in pregnancies complicated by oligohydramnios due to spontaneous rupture of the fetal membranes and in cases complicated by fetal congenital diaphragmatic hernia. We concluded that the presence or absence of polyhydramnios, fetal breathing movements, mediastinal shift, thoracic position of the stomach, fetal breathing-related nasal and oropharyngeal fluid flow, ductal flow velocity modulation, and gestational age at onset and severity of ventricular disproportion as useful markers for predicting fetal pulmonary hypoplasia is a productive area for continued research. All studies show that there is a clear association between most of these markers and pulmonary hypoplasia. However, these markers have not been studied together in a large number of cases, and comparisons between each of the markers is unknown.

Misdiagnosed HIV infection in pregnant women: implications for clinical care

Out of nearly 900 women in a research study of human immunodeficiency virus infection in pregnancy, 8 were subsequently found not to be infected. Misdiagnoses could have resulted from (a) laboratory errors or specimen mixups; (b) failure to follow the testing algorithm recommended by the Centers for Disease Control and Prevention to confirm results; (c) women perceiving they were infected by high-risk behavior in the absence of testing, despite the receipt of negative test results, or based on screening results only; or (d) factitious disorder, HIV Munchausen syndrome, or malingering. Because of the potentially devastating impact of an HIV diagnosis and the toxicity of HIV therapies, health care providers should obtain independent confirmation of the diagnosis before initiating treatment or followup for HIV based on patient report or provider referral. Quality test interpretation and counseling must be ensured. Therapeutic interventions may be indicated for persons intentionally and falsely presenting themselves as HIV-infected.

Human immunodeficiency virus infection of early passage cervical epithelial cultures

Women are infected with HIV in increasing numbers; the predominant mode of spread is through heterosexual transmission. Little is known regarding the mechanism of HIV transit through the female genital tract. We investigated whether early passage cervical epithelial cells could be directly infected with HIV-1LAI. Virus production was measured using the reverse transcriptase (RT) assay and direct assay for syncytia-forming units. In-situ hybridization was performed on infected cervical cell cultures. Immunostaining was carried out using a monoclonal antibody to leukocyte common antigen (LCA). Virus was recovered in the supernatants of all infected cervical cultures. Localization of HIV infection using in-situ hybridization identified rare cells in the population which gave a strong signal. These infected cells had a lymphoid morphology and were also detected using immunostaining for LAC. Cervical epithelial cells were uninfected in this in vitro model; cells in this population which supported viral replication were most likely of the macrophage/monocyte lineage.

Pregnancy after orthotopic continent urinary diversion

Continent urinary diversion has become a common form of bladder management for the female exstrophy patient in whom primary reconstruction has failed. Reported are the results of successful pregnancies in four young adult females, who had previously undergone a flap vaginoplasty as part of earlier management and more recently a continent right colonic urinary reservoir with a perineal stoma (Indiana pouch). Pregnancy in each of these patients was characterized by several urinary tract infections, cervical prolapse and mild to severe maternal hydronephrosis. All of the patients had some degree of difficulty with clean intermittent catheterization. One patient required an indwelling catheter with prolonged bed rest. Maternal hydronephrosis resolved after delivery in all instances. All four patients delivered their infants by way of cesarean section, either emergently for maternal or fetal distress or electively. Cervical prolapse did not resolve in three patients and will require surgical repair. After delivery, all patients returned to their previous pattern of clean intermittent catheterization without loss of continence. All the infants delivered were healthy with appropriate weights and high Apgar scores (more than 8). Orthotopic (perineal stoma) continent urinary diversion is not a contraindication to pregnancy. However, our experience mandates delivery by cesarean section with close monitoring for maternal or fetal distress during gestation.

Fetal movement in response to vibroacoustic stimulation: a review

Fetal movement in response to vibroacoustic stimulation (VAST) depends on functional maturation of the fetal central nervous system and related to changes in fetal behavior. Researchers have associated the presence of fetal movement with fetal well-being. Use of the maternal perception of sound-provoked fetal movement as a test for predicting fetal health is questionable and may suggest further research. All studies show that there is a clear association between this test and favorable neonatal outcomes. This test is inexpensive and easily obtainable. However, because the test has not been studied on large numbers of patients and maternal reporting at times is biased, its adaptation for clinical use should cautiously wait for clear theoretical advantages.

Fetal breathing-related nasal fluid flow velocity in uncomplicated pregnancies

OBJECTIVE

Our purpose was to determine the Doppler ultrasonographic characteristics of fetal breathing-related nasal fluid flow velocity in uncomplicated pregnancies.

STUDY DESIGN

Fetal nasal flow velocity was studied in 52 uncomplicated pregnancies at gestational ages ranging from 22 to 41 weeks. The evaluation of fetal breathing-related nasal fluid flow velocity was performed with ultrasonography combined with color flow and spectral Doppler analysis.

RESULTS

The study revealed that the breath-to-breath interval and duration of the inspiratory phase of the fetal breathing-related nasal flow increased from 22 to 35 weeks and decreased thereafter. The breath-to-breath interval (milliseconds) at 33 to 35 weeks (1203.9 +/- 295.7 SD) was approximately twice what it was in the earliest age group (22 to 25 weeks); subsequently it decreased by approximately 25% in the term group (38 to 41 weeks). A positive correlation existed between the mean breathing-related nasal peak inspiratory flow velocity and advancing gestational age (r = 0.56, p = 0.0008), and between the inspiratory flow velocity acceleration and advancing gestational age (r = 0.53, p = 0.0076).

CONCLUSION

Changes in fetal breathing activity during uncomplicated pregnancies can be determined by measurement of fetal breathing-related nasal fluid flow velocity. Our observations in uncomplicated pregnancies may be useful in future studies of these parameters in complicated pregnancies such as those at risk for pulmonary hypoplasia.

Fetal upper respiratory tract function in cases of antenatally diagnosed congenital diaphragmatic hernia: preliminary observations

Fetal upper respiratory tract function was studied in five cases of antenatally diagnosed congenital diaphragmatic hernia and in 16 cases of uncomplicated pregnancy at gestational ages ranging from 27 to 38 weeks. The evaluation of fetal upper respiratory tract function was performed using ultrasonography combined with color-flow and spectral Doppler analysis. In all cases with uncomplicated pregnancy, fetal breathing-related nasal and oropharyngeal fluid flow was seen at the level of the nose. The five cases with congenital diaphragmatic hernia all demonstrated fetal breathing activity by thoracic wall movement. In four of the fetuses, perinasal fluid flow was seen by the Doppler technique. The fetus with no demonstrated perinasal flow during breathing movements died in the early neonatal period and had pulmonary hypoplasia. Observation of the fetal breathing-related nasal and oropharyngeal fluid flow in cases of antenatally diagnosed congenital diaphragmatic hernia provides a rationale to hypothesize that the absence of this phenomenon is a useful marker for prenatal prediction of pulmonary hypoplasia.

Magnetic resonance imaging and computed tomography scan for the diagnosis of acute fatty liver of pregnancy

Magnetic resonance imaging (MRI) and computed tomography were used to diagnose fatty liver of pregnancy in a patient with preeclampsia and thrombotic thrombocytopenia purpura. The clinical course included multiple system failure that necessitated mechanical ventilation, dialysis, and plasmapheresis. The MRI picture is described in this entity for the first time. Both imaging techniques are discussed and compared.

Prevalence of use of cocaine and other substances in an obstetric population

Increasing use of cocaine among pregnant women has been reported. This study was conducted to determine the prevalence of positive urine toxicologic screens for cocaine and other substances of patients admitted to the Sloane Hospital for Women. Urine samples were obtained from 509 women admitted to the delivery suite. The overall prevalence of cocaine was 10% (n = 51). Cocaine use was 10 times more prevalent in the clinic population (14%) than in the private population, (1.4%). In addition, women whose urine samples were positive for cocaine were more likely to have no prenatal care, previous induced abortions, to be human immunodeficiency virus-positive, and admitted previous use of cigarettes, alcohol, cocaine, and other drugs. Amphetamines were detected in 13% (n = 65) of patients. However, the screens did not distinguish between metabolites of amphetamines and other drugs such as cold medications. The medical history alone predicted only 37% (n = 19) of the cocaine-positive screens and none of the amphetamine-positive screens.

HIV-1 in trophoblastic and villous Hofbauer cells, and haematological precursors in eight-week fetuses

AIDS in children is usually caused by vertical transmission of human immunodeficiency virus type 1 (HIV-1). Aborted eight-week fetal and placental tissue from HIV-1 positive and negative (enzyme-linked immunosorbent assay and Western blot) women was analysed by immunocytochemistry and in-situ hybridisation. Maternal decidual leucocytes, villous trophoblastic derivatives, villous mesenchymal cells, and embryonic blood cell precursors in tissues from seropositive patients all stained for HIV-1 antigen and hybridised for nucleic acids. These observations suggest that a cytological pathway for vertical transmission of HIV-1 is established by eight weeks gestational age.

Elevated maternal plasma corticotropin releasing hormone levels in twin gestation

The placenta secretes large amounts of the hypothelamic hormone, corticotropin releasing hormone (CRH) into the maternal and fetal circulation during pregnancy. We and other investigators have shown that during normal pregnancy, maternal plasma CRH levels begin to rise in the second trimester with a dramatic increase in CRH levels during the 5-6 weeks preceding the onset of labor. This rise in maternal plasma CRH is parallel to the rise of placental CRH mRNA which has been reported to occur with gestational maturation. Mechanisms underlying the control of CRH secretion by the placenta have not yet been determined. In twin gestation, increased fetal-placental mass has been shown to be associated with elevated maternal levels of several placental hormones as compared to singleton gestation. We measured maternal plasma CRH in both twin and singleton gestation to investigate whether the larger size of the fetal-placental unit in twin gestation is associated with elevated maternal CRH levels. Seventy-six serial venous blood samples were collected from 20 women with twin gestation and 40 samples were obtained from 27 women with uncomplicated singleton gestation. Gestational age was determined by history of a known last menstrual period and first trimester clinical examination and confirmed by ultrasound examination. CRH was extracted from 1-2 ml plasma with SEP-Pak C18 cartridges and eluted with triethylamine-formic-acid propranolol. CRH was measured by radioimmunoassay (RIA) with human CRH standard and antiserum to human CRH raised in our laboratory. Mean CRH levels were calculated for four week intervals. In both singleton and twin gestation, the maternal plasma CRH levels increased with advancing gestational age. After 29 weeks of gestation, maternal plasma CRH levels in twin gestation were significantly higher than those in singleton gestation (p less than 0.01). At 37 to 40 weeks of gestation, mean maternal CRH was 1167 +/- 237 pg/ml in singleton gestation as compared to 6927 +/- 1725 pg/ml in twin gestation (p less than 0.05). In addition, the rapid rise in plasma CRH levels which occurs near term in singleton gestation, occurred earlier in twin gestation. This early rise in maternal CRH levels persisted when the data from twin pregnancies complicated by preterm labor were removed from the analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

The development and implementation of a computerized on-line obstetric record

We developed and implemented a completely paperless and on-line obstetric record in the high-risk obstetric clinics at Columbia Presbyterian Medical Center. Patient care and interactions are input directly into the computer by the health care providers. Laboratory information is transferred automatically from the Laboratory Information Service into the computerized prenatal record. The system has been in continuous operation for 2 years and is highly regarded. Problems such as illegible handwriting, missing records, and missing laboratory data have disappeared. Research and data query capabilities have been facilitated. The feasibility and applicability of a computerized record replacing the paper record has been demonstrated.