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Purpose of review Evidence-based women's healthcare is underpinned by systematic reviews and guidelines. Generating an evidence synthesis to support guidance for clinical practice is a time-consuming and labour-intensive activity that delays transfer of research into practice. Artificial intelligence has the potential to rapidly collate, combine, and update high-quality medical evidence with accuracy and precision, and without bias. Recent findings This article describes the main fields of artificial intelligence with examples of its application to systematic reviews. These include the capabilities of processing natural language texts, retrieving information, reasoning, and learning. The complementarity and interconnection of the various artificial intelligence techniques can be harnessed to solve difficult problems in automation of reviews. Computer science can advance evidence-based medicine through development, testing, and refinement of artificial intelligence tools to deploy automation, creating 'living' evidence syntheses. Summary Groundbreaking, high-quality, and impactful artificial intelligence will accelerate the transfer of individual research studies seamlessly into evidence syntheses for contemporaneously improving the quality of healthcare.

Introduction: Unsafe abortion is the cause of a substantial number of maternal mortalities and morbidities globally, but specifically in low- and middle-income countries. Medical abortion methods provided by non-physicians may be a way to reduce the burden of unsafe abortions. Currently, only one systematic review comparing non-physicians with physicians for medical abortion exists. However, the review does not have any setting restrictions and newer evidence has since been published. Therefore, this review aims to evaluate the effectiveness, acceptability, and safety of first-trimester abortion managed by non-physicians compared with physicians in low- and middle-income countries. Material and methods: The databases PubMed, Cochrane Library, Global Health Library, and EMBASE were searched using a structured search strategy. Further, the trial registries clinicaltrials.gov and The International Clinical Trial Registry Platform were searched for published and unpublished trials. Randomized controlled trials comparing provision of medical abortion by non-physicians with that by physicians in low- or middle-income countries were included. Risk of bias was assessed using the Cochrane Risk of Bias tool. Trials that reported effect estimates on the effectiveness of medical methods on complete abortion were included in the meta-analysis. The protocol was prospectively registered in the PROSPERO database, ID: CRD42020176811. Results: Six papers from four different randomized controlled trials with a total of 4021 participants were included. Two of the four included trials were assessed to have overall low risk of bias. Four papers had outcome data on complete abortion and were included in the meta-analyses. Medical management of first-trimester abortion and medical treatment of incomplete abortion were found to be equally effective when provided by a non-physician as when provided by a physician (risk ratio 1.00; 95% CI 0.99-1.01). Further, the treatment was equally safe, and women were equally satisfied when a non-physician provided the treatment compared with a physician. Conclusions: Provision of medical abortion or medical treatment for incomplete abortion in the first trimester is equally effective, safe, and acceptable when provided by non-physicians compared with physicians in low- and middle-income countries. We recommend that the task of providing medical abortion and medical treatment for incomplete abortion in low- and middle-income countries should be shared with non-physicians.

Infection with Chlamydia trachomatis in pregnancy is linked to increased risk of miscarriage, stillbirth, and preterm birth. Currently, PCR or DNA-based tests are the gold standard when detecting the infection; however, they are costly and require access to specialist equipment. The aim of this systematic review was to assess the accuracy of available tests to detect infection in an asymptomatic pregnant population.There was evidence of the superior accuracy of nucleic acid amplification tests to cell culture in nonpregnant asymptomatic women; however, there are multiple commercial nucleic acid amplification tests with varying sensitivities and specificities. There is a gap in current literature on accuracy studies in an asymptomatic pregnant population, particularly within routine antenatal settings.There is a need for a point-of-care test for Chlamydia in pregnancy. Future test accuracy studies for this population should aim to use a universally established reference standard. Further research should provide relevant evidence to guide practice.

Caesarean section rates are increasing across the world. Postpartum haemorrhage is a major cause of morbidity and mortality; major haemorrhage is more common after caesarean delivery. There is a wide range of practice in the prevention and treatment of postpartum haemorrhage at caesarean section. The aim of this review is to summarize current opinion in the management of postpartum haemorrhage at caesarean section.Recent large randomized controlled trials have shown a possible effect from the routine use of tranexamic acid and ergometrine. Small randomized controlled trials have shown a possible benefit from using carbetocin.The impact of postpartum haemorrhage can be reduced by antenatal correction of anaemia. Intraoperative medical management consists of oxytocinon, additional oxytocics +/- tranexamic acid, with at present limited evidence as to the order in which these should be considered. Trials of routine use of cell salvage and tranexamic acid are currently underway.

Chronic pelvic pain (CPP) has an annual prevalence of 38/1000 in the UK, with coexisting pathologies often present. Diagnostic laparoscopy has long been the gold standard diagnostic test, but with up to 40% showing no abnormality, we explore the value of noninvasive imaging, such as pelvic ultrasound and MRI.A literature review from inception until January 2015 of the following databases: PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica database, and System for Information on Grey Literature in Europe were performed to identify published studies assessing the usefulness of ultrasound, MRI, and laparoscopy in the diagnosis of CPP. Three studies (194 women) addressed their comparative performance in patients with endometriosis, showing the sensitivity of ultrasound ranged between 58 and 88.5%; MRI was 56-91.5% and in the one study using histology as its reference standard, the sensitivity of laparoscopy was 85.7%. Noninvasive imaging has the additional benefit of being well tolerated, safer, and cheaper than surgery.CPP, by nature of its multifactorial causation, can be difficult to manage and often requires a multidisciplinary team. Ultrasound and MRI may provide information about the presence or lack of abnormality, which would allow general practitioners or office gynaecologists to initiate treatment and think about surgery as a second-line investigative tool.

The term idiopathic is often used to describe a disease with no identifiable cause. It may be a diagnosis of exclusion; however, what specific minimum investigations need to be performed to define idiopathic is not always clear. This commentary describes the problems inherent in reaching a definition for the term idiopathic.There is limited literature describing methodology to define a condition with no clear diagnostic criteria. This article offers chronic pelvic pain (CPP) syndrome as an example, in which structured qualitative interviews, literature searches and group consensus discussions were undertaken to produce a working definition for idiopathic CPP.It is important to correctly develop these standardized definitions for use as outcome measures in research and as clinical indicators in healthcare.

Background Chronic pelvic pain (CPP), a common gynaecological presentation, may be due to bladder pain syndrome (BPS) or the co-existence of BPS and endometriosis, known as the ‘evil twins syndrome'. Objectives To estimate the prevalence of BPS and the co-existence of BPS and endometriosis in women with CPP. Data sources We searched until March 2012: The Cochrane Library, DARE (1997–2012), EMBASE (1980–2012), Medline (1950–2012), PSYCHINFO (1806–2012), Web of knowledge (1900–2012), LILACS (1982–2012) and SIGLE (1990–2012) with no language restrictions. We manually searched through bibliographies and conference proceedings of the International Continence Society. Study selection Observational studies of women suffering from CPP, who were not pregnant or suffering from cancer, who underwent a laparoscopy and cystoscopy to investigate their symptoms. Study selection, data extraction and quality assessment was performed independently by two reviewers. Statistical analysis was performed to estimate prevalence and confidence intervals (CI). Results Nine studies were included with 1016 patients with CPP. Study quality and diagnostic assessment varied. The mean prevalence of BPS was 61% (range 11–97%, CI 58–64%, I 2 = 98%). The mean prevalence of endometriosis was 70% (range 28–93%, CI 67–73%, I 2 = 93%) and co-existing BPS and endometriosis was 48% (range 16–78%, CI 44–51%, I 2 = 96%). Conclusion Almost two thirds of women presenting with CPP have BPS. Large variations in prevalence may be due to variable study selection and quality. Clinicians need to actively investigate patients for BPS, a condition that appears to co-exist with endometriosis.

PURPOSE OF REVIEW Spontaneous preterm birth complicates 3-11% of pregnancies and is a major cause of neonatal mortality and morbidity worldwide. If accurate tests can be identified, a potentially effective screening strategy with an adjunct preventive therapy may be trialled to reduce the rate of spontaneous preterm birth or effective measures be deployed at an early stage of a suspected spontaneous preterm labour before the onset of cervical changes to ameliorate prematurity complications. RECENT FINDINGS There are many tests predicting spontaneous preterm births, published in the literature individually or in a systematic review. The information has not been collated about all candidate tests simultaneously in a systematic review incorporating a framework on how these tests may be evaluated, modelled with an intervention to provide a number needed to treat and test to inform decision-making. SUMMARY There were 319 studies evaluating 22 tests. There are many promising tests, for example, history of previous spontaneous preterm birth, cervicovaginal swabs for markers such as fibronectin or HCG, cervical ultrasound, serum CRP and amniotic fluid interleukins for predicting spontaneous preterm birth, but none have exceptional accuracy and the quality of studies was generally poor. Some tests were able to achieve high LR+, but at the expense of LR-, that is, tests good for ruling in disease were poor for ruling out disease and vice versa.

Defective nitric oxide synthesis and nitric oxide-mediated vasodilatation is widely documented in the pathophysiology of preeclampsia, a leading cause of maternal and perinatal morbidity and mortality worldwide. Several studies demonstrated the beneficial role of nitric oxide agents, especially glyceryl trinitrate and L-arginine in reducing the blood pressure and improving the uteroplacental blood flow velocities. However, there is insufficient evidence on the efficacy and safety of these agents in the prevention of preeclampsia and its complications, as there are very few randomized controlled trials with small number of women. The aim of this review is to summarize and evaluate the role of nitrates in the prevention of preeclampsia based on the available evidence in the literature till date and suggestions for future research.Supplementation with L-arginine and antioxidant vitamins reduced the incidence of preeclampsia in women at high risk of preeclampsia [P 0.001, absolute risk reduction 0.17 (confidence interval 0.12-0.21)].On the basis of the recent evidence, nitric oxide agents may be beneficial in the prevention of preeclampsia. Randomized controlled trials initiated in the first trimester and using long-acting nitrates are needed in high-risk women to validate these findings.

OBJECTIVE: To estimate the accuracy of endometrial thickness measurement in the detection of endometrial cancer among women with postmenopausal bleeding with individual patient data using different meta-analytic strategies. DATA SOURCES: Original data sets of studies detected after reviewing the included studies of three previous reviews on this subject. An additional literature search of published articles using MEDLINE databases was preformed from January 2000 to December 2006 to identify articles reporting on endometrial carcinoma and sonographic endometrial thickness measurement in women with postmenopausal bleeding. METHODS OF STUDY SELECTION: We identified 90 studies reporting on endometrial thickness measurements and endometrial carcinoma in women with postmenopausal bleeding. TABULATION, INTEGRATION, AND RESULTS: We contacted 79 primary investigators to obtain the individual patient data of their reported studies, of which 13 could provide data. Data on 2,896 patients, of which 259 had carcinoma, were included. Several approaches were used in the analyses of the acquired data. First, we performed receiver operator characteristics (ROC) analysis per study, resulting in a summary area under the ROC curve (AUC) calculated as a weighted mean of AUCs from original studies. Second, individual patient data were pooled and analyzed with ROC analyses irrespective of study with standardization of distributional differences across studies using multiples of the median and by random effects logistic regression. Finally, we also used a two-stage procedure, calculating sensitivities and specificities for each study and using the bivariate random effects model to estimate summary estimates for diagnostic accuracy. This resulted in rather comparable ROC curves with AUCs varying between 0.82 and 0.84 and summary estimates for sensitivity and specificity located along these curves. These curves indicated a lower AUC than previously reported meta-analyses using conventional techniques. CONCLUSION: Previous meta-analyses on endometrial thickness measurement probably have overestimated its diagnostic accuracy in the detection of endometrial carcinoma. We advise the use of cutoff level of 3 mm for exclusion of endometrial carcinoma in women with postmenopausal bleeding. (Obstet Gynecol 2010;116:160-7)

OBJECTIVE: To undertake a systematic review to determine the effects of fetal therapy interventions compared with amniodrainage for twin-twin transfusion syndrome on perinatal survival and outcome. METHODS: Searching MEDLINE (1966-2004), EMBASE (1988-2004), a hand search of specialist journals, and the Cochrane library (2004:2) identified relevant articles. Studies were selected if the effects of fetal therapeutic interventions for twin-twin transfusion syndrome (laser photocoagulation, serial amnioreduction, septostomy, and selective feticide) on perinatal survival, complications, and morbidity were compared. Study selection, quality assessment, and data abstraction were performed independently and in duplicate. RESULTS: Only 3 controlled observational studies (comparing treatment in 306 twins) and 1 randomized controlled trial (of 142 twins) were identified. Laser photocoagulation significantly improved perinatal survival of at least 1 fetus and reduced neurologic morbidity compared with serial amnioreduction. No such differences were observed in the comparison of serial amnioreduction with septostomy. CONCLUSION: In a systematic review of observational and randomized controlled studies, laser photocoagulation of chorionic plate vessels at the intertwin membrane seems to be more effective than serial amnioreduction in the treatment of twin-twin transfusion syndrome with less associated perinatal morbidity and mortality. However, septostomy and selective fetidde have not been robustly evaluated.

Objective We reviewed the outcomes and outcome measures reported in randomized controlled trials and their relationship with methodological quality, year of publication, commercial funding, and journal impact factor. Data Sources We searched the following sources: (1) Cochrane Central Register of Controlled Trials, (2) Embase, and (3) MEDLINE from inception to November 2014. Study Eligibility We included all randomized controlled trials evaluating a surgical intervention with or without a medical adjuvant therapy for the treatment of endometriosis symptoms. Study Design Two authors independently selected trials, assessed methodological quality (Jadad score; range, 1-5), outcome reporting quality (Management of Otitis Media with Effusion in Cleft Palate criteria; range, 1-6), year of publication, impact factor in the year of publication, and commercial funding (yes or no). Univariate and bivariate analyses were performed using Spearman Rh and Mann-Whitney U tests. We used a multivariate linear regression model to assess relationship associations between outcome reporting quality and other variables. Results There were 54 randomized controlled trials (5427 participants), which reported 164 outcomes and 113 outcome measures. The 3 most commonly reported primary outcomes were dysmenorrhea (10 outcome measures; 23 trials), dyspareunia (11 outcome measures; 21 trials), and pregnancy (3 outcome measures; 26 trials). The median quality of outcome reporting was 3 (interquartile range 4–2) and methodological quality 3 (interquartile range 5–2). Multivariate linear regression demonstrated a relationship between outcome reporting quality with methodological quality (β = 0.325; P = .038) and year of publication (β = 0.067; P = .040). No relationship was demonstrated between outcome reporting quality with journal impact factor (Rho = 0.190; P = .212) or commercial funding ( P = .370). Conclusion Variation in outcome reporting within published endometriosis trials prohibits comparison, combination, and synthesis of data. This limits the usefulness of research to inform clinical practice, enhance patient care, and improve patient outcomes. In the absence of a core outcome set for endometriosis we recommend the use of the 3 most common pain (dysmenorrhea, dyspareunia, and pelvic pain) and subfertility (pregnancy, miscarriage, and live birth) outcomes. International consensus among stakeholders is needed to establish a core outcome set for endometriosis trials.

Summary Background Antenatal care of women with epilepsy is varied. The association of epilepsy and antiepileptic drug exposure with pregnancy outcomes needs to be quantified to guide management. We did a systematic review and meta-analysis to investigate the association between epilepsy and reproductive outcomes, with or without exposure to antiepileptic drugs. Methods We searched MEDLINE, Embase, Cochrane, AMED, and CINAHL between Jan 1, 1990, and Jan 21, 2015, with no language or regional restrictions, for observational studies of pregnant women with epilepsy, which assessed the risk of obstetric complications in the antenatal, intrapartum, or postnatal period, and any neonatal complications. We used the Newcastle-Ottawa Scale to assess the methodological quality of the included studies, risk of bias in the selection and comparability of cohorts, and outcome. We assessed the odds of maternal and fetal complications (excluding congenital malformations) by comparing pregnant women with and without epilepsy and undertook subgroup analysis based on antiepileptic drug exposure in women with epilepsy. We summarised the association as odds ratio (OR; 95% CI) using random effects meta-analysis. The PROSPERO ID of this Systematic Review's protocol is CRD42014007547. Findings Of 7050 citations identified, 38 studies from low-income and high-income countries met our inclusion criteria (39 articles including 2 837 325 pregnancies). Women with epilepsy versus those without (2 809 984 pregnancies) had increased odds of spontaneous miscarriage (OR 1·54, 95% CI 1·02–2·32; I 2 =67%), antepartum haemorrhage (1·49, 1·01–2·20; I 2 =37%), post-partum haemorrhage (1·29, 1·13–1·49; I 2 =41%), hypertensive disorders (1·37, 1·21–1·55; I 2 =23%), induction of labour (1·67, 1·31–2·11; I 2 =64%), caesarean section (1·40, 1·23–1·58; I 2 =66%), any preterm birth ( I 2 =64%), and fetal growth restriction (1·26, 1·20–1·33; I 2 =1%). The odds of early preterm birth, gestational diabetes, fetal death or stillbirth, perinatal death, or admission to neonatal intensive care unit did not differ between women with epilepsy and those without the disorder. Interpretation A small but significant association of epilepsy, exposure to antiepileptic drugs, and adverse outcomes exists in pregnancy. This increased risk should be taken into account when counselling women with epilepsy. Funding EBM CONNECT Collaboration.

OBJECTIVE: To develop a multivariable approach to determine the added value of tests in routine practice where some diagnostic information is already available from clinical history. METHODS: Multivariable logistic regression models were built in a stepwise fashion, considering the clinical sequence used in the rapid access ambulatory diagnosis clinic (clinical history followed by transvaginal ultrasonography and hysteroscopy). The reference standard for confirmation of diagnosis was endometrial biopsy. The diagnostic accuracy of the models was determined by the area under the receiver operating characteristic curve. RESULTS: The area under the receiver operating characteristic curve for the model including historical features alone was 0.78. When hysteroscopy and ultrasonography were each added to the model, it increased to 0.81 (P = .008 for improvement) and 0.82 (P = .02 for improvement), respectively. CONCLUSION: The type of stepwise analysis we have developed is crucial in facilitating meaningful clinical interpretation about the value of diagnostic technology. Our finding that hysteroscopy or ultrasonography marginally but significantly increased the prediction of serious endometrial pathology above that predicted from patient history alone needs validation in an independent data set. The use of this approach is recommended when evaluating strategies for diagnosis.

OBJECTIVE: To determine the effectiveness of aspirin to prevent preeclampsia in women identified as high risk for preeclampsia by an abnormal second-trimester uterine artery Doppler examination. DATA SOURCES: Searches were conducted in MEDLINE, Embase, the Cochrane Controlled Trials Register, and Science Citation Index for randomized trials published from 1966 to 2000, using the following medical subject headings and key words: “aspirin,” “antiplatelet∗,” “salicyl∗,” “acetylsalicyl∗,” “platelet aggregation inhibitors,” “ultrasonography,” “ultraso∗,” and “Doppler.” STUDY SELECTION: We included all randomized trials that evaluated the effectiveness of aspirin compared with placebo or no treatment in women with an abnormal uterine artery Doppler and that reported clinically relevant perinatal and maternal outcomes. Study selection, quality assessment, and data extraction were performed in duplicate. TABULATION, INTEGRATION, AND RESULTS: There were five relevant trials. Pooling of results from these trials showed a significant benefit of aspirin in reducing preeclampsia (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.32, 0.95). The baseline risk of preeclampsia in women with abnormal uterine artery Doppler was 16%, and the number of women needed to be treated with aspirin to prevent one case of preeclampsia was 16 (95% CI 8, 316). Women on aspirin had babies who were on average 82 g heavier than controls, but this result did not reach statistical significance (weighted mean difference 81.5, 95% CI 40.27, 203.27). CONCLUSION: Uterine artery Doppler assessment identifies high-risk women in whom aspirin therapy results in a significant reduction in preeclampsia.

Objective: To evaluate the reporting of multivariable logistic regression analyses and assess variations in quality over time in the obstetrics and gynecology literature. Methods: Methodologic criteria for reporting logistic regression analyses were developed to identify problems affecting accuracy, precision, and interpretation of this approach to multivariable statistical analysis. These criteria were applied to 193 articles that reported multivariable logistic regression in the issues of four generic obstetrics and gynecology journals in 1985, 1990, and 1995. Rates of compliance with the methodologic criteria and their time trends were analyzed. Results: The proportion of articles using logistic regression analysis increased over time: 1.7% in 1985, 2.8% in 1990, and 6.5% in 1995 ( P .001 for trend). Violations and omissions of methodologic criteria for reporting logistic models were common. The research question, in terms of dependent and independent variables, was not clearly reported in 32.1%. The process of variable selection was inadequately described in 51.8% of the articles. Among articles with ranked independent variables, 85.1% did not report assessment of conformity to linear gradient. Tests for goodness of fit were not given in 93.2% of articles. The contribution of the independent variables could not be evaluated in 36.2% of the articles because of a lack of coding of the variables. Interactions between variables were not assessed in 86.4% of articles. Analysis of variations in the quality of logistic regression analyses over time showed no increase in reporting of the criteria concerning variable selection and goodness of fit. However, the proportion of articles reporting one quality criterion concerning interpretation of the substantive significance of independent variables showed a trend toward improvement: 42.3% in 1985, 73.6% in 1990, and 75.4% in 1995 ( P = .004 for trend). Conclusion: The reporting of multivariable logistic regression models in the obstetrics and gynecology literature is poor, and the time trends of improvement in quality of reporting are not particularly encouraging.

Objective: To develop and test a simple MEDLINE search strategy for identification of randomized controlled trials (RCTs) in obstetrics and gynecology. Methods: To develop our search strategy, we asked clinicians in our department to indicate, from a list of search terms, the terms they would use to identify RCTs in MEDLINE. The two most common terms, controlled-clinical-trial (publication type) and randomized-controlled-trial (publication type), were combined with the link word, OR, and then used to identify RCTs in four obstetrics and gynecology journals for the years 1975, 1980, 1985, 1990, and 1995. Concurrently, a handsearch of these same journals and years was performed to identify RCTs. The sensitivity and precision of MEDLINE and handsearch were calculated using the total number of RCTs identified by both methods as a reference standard. Sensitivity is the RCTs identified by search strategy as a percentage of all RCTs identified by reference standard. Precision is the RCTs identified by a search strategy as a percentage of all articles identified by it. Results: The overall sensitivity of our MEDLINE search strategy was 72.5%, and the precision was 83.4%. Over 2 decades, sensitivity of our MEDLINE search increased from 0% to 94.9% ( P P = .003). For 1990 and 1995 combined, sensitivity and precision of our MEDLINE search strategy were 90.3% and 79.6%, respectively. Overall sensitivity for handsearch was 96.5%; its precision was 5.0%. Over 2 decades, the sensitivity of handsearch dropped insignificantly from 100% to 92.3% ( P = .05), while the precision increased from 2.6% to 6.3% ( P Conclusion: Our simple MEDLINE search strategy has a high sensitivity and precision, especially in more recent years. Obstetricians and gynecologists may use it to search quickly for RCTs to guide patient care.

Summary Background Screening for critical congenital heart defects in newborn babies can aid in early recognition, with the prospect of improved outcome. We assessed the performance of pulse oximetry as a screening method for the detection of critical congenital heart defects in asymptomatic newborn babies. Methods In this systematic review, we searched Medline (1951–2011), Embase (1974–2011), Cochrane Library (2011), and Scisearch (1974–2011) for relevant citations with no language restriction. We selected studies that assessed the accuracy of pulse oximetry for the detection of critical congenital heart defects in asymptomatic newborn babies. Two reviewers selected studies that met the predefined criteria for population, tests, and outcomes. We calculated sensitivity, specificity, and corresponding 95% CIs for individual studies. A hierarchical receiver operating characteristic curve was fitted to generate summary estimates of sensitivity and specificity with a random effects model. Findings We screened 552 studies and identified 13 eligible studies with data for 229 421 newborn babies. The overall sensitivity of pulse oximetry for detection of critical congenital heart defects was 76·5% (95% CI 67·7–83·5). The specificity was 99·9% (99·7–99·9), with a false-positive rate of 0·14% (0·06–0·33). The false-positive rate for detection of critical congenital heart defects was particularly low when newborn pulse oximetry was done after 24 h from birth than when it was done before 24 h (0·05% [0·02–0·12] vs 0·50 [0·29–0·86]; p=0·0017). Interpretation Pulse oximetry is highly specific for detection of critical congenital heart defects with moderate sensitivity, that meets criteria for universal screening. Funding None.

Objective To determine the accuracy of using systolic and diastolic blood pressure, mean arterial pressure, and increase of blood pressure to predict pre-eclampsia. Design Systematic review with meta-analysis of data on test accuracy. Data sources Medline, Embase, Cochrane Library, Medion, checking reference lists of included articles and reviews, contact with authors. Review methods Without language restrictions, two reviewers independently selected the articles in which the accuracy of blood pressure measurement during pregnancy was evaluated to predict pre-eclampsia. Data were extracted on study characteristics, quality, and results to construct 2×2 tables. Summary receiver operating characteristic curves and likelihood ratios were generated for the various levels and their thresholds. Results 34 studies, testing 60 599 women (3341 cases of pre-eclampsia), were included. In women at low risk for pre-eclampsia, the areas under the summary receiver operating characteristic curves for blood pressure measurement in the second trimester were 0.68 (95% confidence interval 0.64 to 0.72) for systolic blood pressure, 0.66 (0.59 to 0.72) for diastolic blood pressure, and 0.76 (0.70 to 0.82) for mean arterial pressure. Findings for the first trimester showed a similar pattern. Second trimester mean arterial pressure of 90 mm Hg or more showed a positive likelihood ratio of 3.5 (95% confidence interval 2.0 to 5.0) and a negative likelihood ratio of 0.46 (0.16 to 0.75). In women deemed to be at high risk, a diastolic blood pressure of 75 mm Hg or more at 13 to 20 weeks’ gestation best predicted pre-eclampsia: positive likelihood ratio 2.8 (1.8 to 3.6), negative likelihood ratio 0.39 (0.18 to 0.71). Additional subgroup analyses did not show improved predictive accuracy. Conclusion When blood pressure is measured in the first or second trimester of pregnancy, the mean arterial pressure is a better predictor for pre-eclampsia than systolic blood pressure, diastolic blood pressure, or an increase of blood pressure.

Reported prevalence rates of endometrial cancer in women with postmenopausal bleeding (PMB) range from 3% to 10%, and endometrial cancer presents with PMB in more than 95% of cases. Today, inpatient cervical dilatation and curettage has been replaced by miniature endometrial biopsy (EB) in an outpatient setting, ultrasound (US) study, and outpatient hysteroscopy. The authors used a decision analytic model, made to reflect currently provided services, to evaluate 12 diagnostic strategies using EB, US, and hysteroscopy. Both 4-mm and 5-mm cutoff points were applied to US measurements of endometrial thickness. Diagnostic probability estimates were derived from systematic quantitative reviews, clinical outcomes from literature reports, and cost estimates from local sources and the National Health Service. The major measure of outcome was the cost per additional life year gained (LYG). When compared with a strategy of doing no initial study for PMB, all 12 diagnostic strategies were associated with improved survival. The least expensive approach used US with a 5-mm cutoff. Initial EB or US with a 4-mm cutoff was comparably cost-effective at their most favorable diagnostic performance levels and when the prevalence of disease was 10% or greater. US with a 5-mm cutoff was an attractive option when no cancer upstaging was assumed. Strategies based on combinations of tests or hysteroscopy were not cost-effective for initial evaluation. Initial testing by EB was potentially more cost-effective than strategies based on US at relatively high disease prevalence rates. At a cancer prevalence rate of 5%, US-based strategies were relatively cost-effective. The investigators conclude that women presenting for the first time with PMB should be evaluated by US or EB. The choice between these measures rests on age and patient preference as well as the prevalence of endometrial cancer and the availability of high-quality US. A threshold of either 4 or 5 mm may be used to denote abnormal endometrial thickness on US examination.

The role of vitamin D in maintaining a healthy pregnancy has seen emerging interest among clinicians and researchers in recent years. The functions of this hormone are widespread and complex, and during pregnancy and breastfeeding it facilitates crucial transfer of calcium from mother to child for skeletal development. Aside from the role of vitamin D in bone development and health, a myriad of other physiological actions are now known, and it is hypothesized that maternal deficiency may increase susceptibility to adverse pregnancy events during pregnancy such as pre-eclampsia. The role of vitamin D in pregnancy and breastfeeding is summarized and applied to the knowledge from studies associating vitamin D deficiency with a range of adverse pregnancy outcomes, including pre-eclampsia and childhood asthma. Current clinical guidelines for vitamin D supplementation in pregnancy are discussed in the context of the available evidence. The need for robust randomized controlled trials to address areas of existing uncertainty is highlighted.

To assess the effectiveness of strategies incorporating training and support of traditional birth attendants on the outcomes of perinatal, neonatal, and maternal death in developing countries.Systematic review with meta-analysis.Medline, Embase, the Allied and Complementary Medicine database, British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, BioMed Central, PsycINFO, Latin American and Caribbean Health Sciences Literature database, African Index Medicus, Web of Science, Reproductive Health Library, and Science Citation Index (from inception to April 2011), without language restrictions. Search terms were "birth attend*", "traditional midwife", "lay birth attendant", "dais", and "comadronas". Review methods We selected randomised and non-randomised controlled studies with outcomes of perinatal, neonatal, and maternal mortality. Two independent reviewers undertook data extraction. We pooled relative risks separately for the randomised and non-randomised controlled studies, using a random effects model.We identified six cluster randomised controlled trials (n=138 549) and seven non-randomised controlled studies (n=72 225) that investigated strategies incorporating training and support of traditional birth attendants. All six randomised controlled trials found a reduction in adverse perinatal outcomes; our meta-analysis showed significant reductions in perinatal death (relative risk 0.76, 95% confidence interval 0.64 to 0.88, P0.001; number needed to treat 35, 24 to 70) and neonatal death (0.79, 0.69 to 0.88, P0.001; 98, 66 to 170). Meta-analysis of the non-randomised studies also showed a significant reduction in perinatal mortality (0.70, 0.57 to 0.84, p0.001; 48, 32 to 96) and neonatal mortality (0.61, 0.48 to 0.75, P0.001; 96, 65 to 168). Six studies reported on maternal mortality and our meta-analysis showed a non-significant reduction (three randomised trials, relative risk 0.79, 0.53 to 1.05, P=0.12; three non-randomised studies, 0.80, 0.44 to 1.15, P=0.26).Perinatal and neonatal deaths are significantly reduced with strategies incorporating training and support of traditional birth attendants.

Objective To evaluate the association between umbilical cord pH at birth and long term outcomes. Design Systematic review and meta-analysis. Data sources Medline (1966-August 2008), Embase (1980-August 2008), the Cochrane Library (2008 issue 8), and Medion, without language restrictions; reference lists of selected articles; and contact with authors. Study selection Studies in which cord pH at birth was compared with any neonatal or long term outcome. Cohort and case-control designs were included. Results 51 articles totalling 481 753 infants met the selection criteria. Studies varied in design, quality, outcome definition, and results. Meta-analysis carried out within predefined groups showed that low arterial cord pH was significantly associated with neonatal mortality (odds ratio 16.9, 95% confidence interval 9.7 to 29.5, I 2 =0%), hypoxic ischaemic encephalopathy (13.8, 6.6 to 28.9, I 2 =0%), intraventricular haemorrhage or periventricular leucomalacia (2.9, 2.1 to 4.1, I 2 =0%), and cerebral palsy (2.3, 1.3 to 4.2, I 2 =0%). Conclusions Low arterial cord pH showed strong, consistent, and temporal associations with clinically important neonatal outcomes that are biologically plausible. These data can be used to inform clinical management and justify the use of arterial cord pH as an important outcome measure alongside neonatal morbidity and mortality in obstetric trials.