Influence of Obesity and Unemployment on Fertility Rates: A Multinational Analysis of 30 Countries from 1976 to 2014.

Background: The rationale of a postulated decrease in fertility rate development is still being debated. Among the multiple influencing factors, socioeconomic variables and their complex influence are of particular interest. Methods: Data on socioeconomic and health variables from 1976−2014 of 30 countries within the OECD region were analysed for their respective influence on fertility rates by using mixed-effect regression models. Results: A significant negative influence of the increase in unemployment rate on the following year's changes in fertility rate in Western (−0.00256; p < 0.001) as well as Eastern European (−0.0034; p < 0.001) countries was revealed. The effect of being overweight was significant for Western European (−0.00256; p < 0.001) countries only. When analysing the whole OECD region, an increase in unemployment retained its significant negative influence on the fertility rate (−0.0028; p < 0.001), while being overweight did not. Interestingly, divergent influences of time were revealed and fertility rates increased with time in Eastern Europe while they decreased in Western Europe. Conclusion: Importantly, a significant negative influence of increase in unemployment on the fertility rate was revealed­irrespective of the region and time analysed. Furthermore, an adverse effect of being overweight on the fertility rate in Western European countries was revealed. Interestingly, time was associated with a decreasing fertility rate in Western but not in Eastern Europe.

Determination of Anatomical Levels in Spina Bifida Fetuses with Ultrasound and MRI.

PURPOSE: The goal of this study was to assess the accuracy of prenatal anatomical level determination by ultrasound (US) and magnetic resonance imaging (MRI) by analyzing the congruence with the "true" anatomical level identified by postnatal MRI. PATIENTS AND METHODS: The first 60 patients undergoing fetal myelomeningocele surgery at The Zurich Center for Fetal Diangosis and Therapy were included in this study. Anatomical levels (i. e., first dysraphic vertebra) determined by prenatal US and MRI were compared to postnatal MRI. The level of agreement between the imaging modalities was evaluated with a Cohen's kappa test. Results > 0.6 were interpreted as good agreement, > 0.8 as excellent. RESULTS: The exact congruence between prenatal US and MRI compared to postnatal MRI was 33 % and 48 %, respectively, for an accuracy within one level difference of 80 % and 90 %, and within two levels difference of 95 % and 98 %, respectively. The level of agreement of prenatal US and MRI compared to postnatal MRI was 0.62 and 0.79, respectively. Most of the prenatally incorrectly assigned levels were assigned too high (worse) than the "true" level (US 88 % vs. MRI 65 %). CONCLUSION: Reliable exact prenatal level determination by US and MRI is not possible. However, the prenatal determination of the anatomical level of the lesion is good within one level margin of error. Prenatal US as well as MRI demonstrate a systematic error towards higher levels. The above considerations must be integrated into prenatal counselling.

Removal of nonpalpable etonogestrel implants after fixation with a curved needle-A case series.

OBJECTIVE: To report our experiences with an extraction technique using a prebent, curved needle placed under deeply located single-rod implants to aid in removal. STUDY DESIGN: We conducted a retrospective case series of all patients who were referred for removal of a deeply located or nonpalpable implant to one single specialized center between 2002 and 2019 by screening the database of the private office for "complex implants removals" or "nonpalpable implant" as a result for consultation. After implant-localization via high-resolution ultrasound, we performed a standard incision along the axis of the rod under local anesthesia. We fixed the rod by insertion of a curved needle directly beneath it piercing it through the tissue to the opposite side of the skin. After dissection of the subcutaneous tissue, we palpated the rod above the needle, grasped and removed it. In case of subfascial or intramuscular locations, we applied retractors and opened the fascia along the axis of the device to attempt removal. RESULTS: Of 117 referrals, medical records of 95 patients provided sufficient information to be included in our analysis. We could not palpate 81 (85%) devices and questionably palpate 14 (15%) implants. We successfully extracted all implants using this technique with an average removal duration of 30 minutes (SD +/- 6.8). Five (5.3%) patients noted intraoperative discomfort with 3 of them describing transient dysesthesia in the fingers innervated by the median nerve, which disappeared within a maximum of 48 hours. CONCLUSION: Following the described protocol, this novel technique reliably facilitates removal of nonpalpable or deeply located etonogestrel implants. IMPLICATIONS: This series of nonpalpable implants, all of which have been removed with the same standardized technique provides evidence that the given protocol permits successful extraction.

Risk Factors for Preterm Birth following Open Fetal Myelomeningocele Repair: Results from a Prospective Cohort.

BACKGROUND: Fetal myelomeningocele (fMMC) repair is a therapeutic option in selected cases. This study aimed to identify risk factors for preterm birth (PTB) following open fMMC repair. METHODS: Sixty-seven women underwent fMMC repair and delivered a baby between 2010 and 2018 at our center. Demographic, surgical, and pregnancy complications, including potential risk factors for PTB such as preterm premature rupture of membranes (PPROM), chorioamniotic membrane separation (CMS), and placental abruption were evaluated. RESULTS: Maternal body mass index, maternal age, parity, previous uterine surgery, gestational age at fetal surgery, total surgery duration, surgical subcutaneous hematoma, oligohydramnios, and amniotic fluid leakage were not identified as risk factors for PTB. CMS (p = 0.028, 92 vs. 52%) and PPROM (p = 0.001, 95 vs. 52%) were highly associated with PTB. Placental abruption was found more often in women after fMMC repair than in a general obstetrical population (12 vs. 1%) and ended in premature birth in all cases (p = 0.024, 100 vs. 60%). However, the majority of women delivered at a gestational age >35 weeks. CONCLUSIONS: In our study cohort, risk factors for PTB were PPROM, CMS, and placental abruption, whereas surgery duration did not influence outcome. We conclude that the surgery technique should aim to minimize CMS and amniotic fluid leakage.

Validation of a quantitative system for real-time measurement of postpartum blood loss.

PURPOSE: Reliable real-time estimation of blood loss is crucial for the prompt management of postpartum hemorrhage (PPH), which is one of the major obstetric complications worldwide. Our study aims at the validation of feasibility and precision of measured blood loss (MBL) with a quantitative real-time measurement system during (1) vaginal delivery and (2) cesarean section by comparison with a hemoglobin-based formula for blood loss as an objective control. This is the first study to include a reasonable number of patients in an everyday clinical setting. METHODS: 921 patients were prospectively enrolled into this study (vaginal delivery: n = 461, cesarean delivery: n = 460) at a tertiary care hospital in Switzerland. Blood loss was measured by quantitative fluid collection bags. "Calculated blood loss" (CBL) was determined by modified Brecher`s formula based on the drop of hemoglobin after delivery. MBL based on our measurement system was compared to CBL by correlation analysis and stratified by the mode of delivery. RESULTS: During vaginal delivery, MBL as determined by our quantitative measurement system highly correlated with CBL (p < 0.001, r = 0.683). This was also true for patients with cesarean deliveries (p < 0.001, r = 0.402), however, in a less linear amount. In women with cesarean deliveries, objectively low blood loss tended to be rather overestimated, while objectively high blood loss was more likely underestimated. CONCLUSIONS: The technique of real-time measurement of postpartum blood loss after vaginal delivery as presented in this study is practicable, reliable and strongly correlated with the actual blood loss and, therefore, poses an actual improvement in the management of PPH.