Use of labour induction and risk of cesarean delivery: A systematic review and meta-analysis

Background: Induction of labour is common, and cesarean delivery is regarded as its major complication. We conducted a systematic review and meta-analysis to investigate whether the risk of cesarean delivery is higher or lower following labour induction compared with expectant management. Methods: We searched 6 electronic databases for relevant articles published through April 2012 to identify randomized controlled trials (RCTs) in which labour induction was compared with placebo or expectant management among women with a viable singleton pregnancy. We assessed risk of bias and obtained data on rates of cesarean delivery. We used regression analysis techniques to explore the effect of patient characteristics, induction methods and study quality on risk of cesarean delivery. Results: We identified 157 eligible RCTs (n = 31 085). Overall, the risk of cesarean delivery was 12% lower with labour induction than with expectant management (pooled relative risk [RR] 0.88, 95% confidence interval [CI] 0.84-0.93; I2 = 0%). The effect was significant in term and post-term gestations but not in preterm gestations. Meta-regression analysis showed that initial cervical score, indication for induction and method of induction did not alter the main result. There was a reduced risk of fetal death (RR 0.50, 95% CI 0.25-0.99; I2 = 0%) and admission to a neonatal intensive care unit (RR 0.86, 95% CI 0.79-0.94), and no impact on maternal death (RR 1.00, 95% CI 0.10-9.57; I2 = 0%) with labour induction. Interpretation: The risk of cesarean delivery was lower among women whose labour was induced than among those managed expectantly in term and post-term gestations. There were benefits for the fetus and no increased risk of maternal death. © 2014 Canadian Medical Association or its licensors

Maternal and perinatal mortality and morbidity associated with tuberculosis during pregnancy and the postpartum period: a systematic review and meta-analysis

Ammalife and Elly Appeal (Barts Charity), Charities with a focus on maternal health research in developing countries funded SS. The Charities had no influence on the development, conduct or reporting of this work

Diagnosis of pelvic endometriosis: a systematic review and accuracy meta-analysis of non-invasive tests available in primary care

Background: Endometriosis is a chronic, often debilitating condition with a current significant delay from symptom onset to diagnosis with much of this in primary care. Methods: Systematic review and meta-analysis of the primary literature to investigate the accuracy of symptoms, clinical history and first-line non-invasive tests to predict pelvic endometriosis (PROSPERO: CRD42020187543). We searched Medline, Embase, Web of Science and Scopus from conception to September 2022 for primary test accuracy studies assessing non-invasive tests against reference standard diagnosis for endometriosis. Two authors independently conducted data extraction and quality assessment. Grading of evidence was performed using a novel visual pentagon model. Meta-analyses of test accuracy was estimated using bivariate random effects models. Results: The 125 included studies (250,574 participants) showed mixed quality. Studies applying non-surgical (database/self-reporting) reference standard had a greater risk of bias. In 98 studies applying surgical reference standard, summary diagnostic odds ratios for endometriosis were: dysmenorrhoea 2.56 (95% confidence interval 1.99-3.29); pelvic pain 2.56 (1.73-3.74); dyschezia 2.05 (1.36-3.10); dyspareunia 2.45 (1.71-3.52); family history of endometriosis 6.79 (4.08-11.3); nulligravidity of 2.01 (1.62-2.50); BMI ≥30kg/m2 0.37 (0.19-0.68); TVUSS endometrioma 91.2 (44.0-189); TVUSS invasive endometriosis 26.1 (9.28-73.5); and CA-125 >35U/mL 16.0 (8.09-31.7). Sensitivity analysis excluding all high-risk studies found concordant results. Conclusions: This meta-analysis collated the performance of non-invasive tests for endometriosis across a comprehensive and geographically varied population. Study quality was mixed, however results were consistent with high-risk studies excluded. These findings will inform future prediction models for triage in primary care

Qualitative study exploring which research outcomes best reflect women's experiences of heavy menstrual bleeding: stakeholder involvement in development of a core outcome set.

OBJECTIVE: This work contributed to the development of a core outcome set (COS) for heavy menstrual bleeding (HMB). The objective was to determine which research outcomes best reflect how HMB affects women's lives and to identify additional research outcomes, not previously reported. It was important to explore and record participants' reasoning for prioritising outcomes and use this information to reinforce the patients' voice during later phases of the COS development. DESIGN: Patient workshop discussions and telephone interviews. SETTING: East London teaching hospital. PARTICIPANTS: Inclusion criteria were that participants must be over 18 years old, that either they or their partner had a history of HMB and that they had a good understanding of written and spoken English. RESULTS: 41 participants were recruited for the study. 8 women and 1 man completed the study. The eight female participants were representative of the different underlying causes and treatments for HMB. Participants ranged in age from their early 20s to their 60s and represented a range of ethnic groups. The five main themes that were identified as being important to patients were: 'restriction', 'relationships and isolation', 'emotions and self-perception', 'pain' and 'perceptions of treatment'. We identified eight coding nodes that did not correspond with our list of previously reported outcomes in studies of HMB. These nodes were consolidated and became five new outcomes for potential inclusion in the COS. CONCLUSIONS: HMB stops women living their lives as they would wish. It affects their relationships, education, careers, reproductive wishes, social life and mental health. This is a condition of girls and women in the prime of their lives, but for many, the constant threat of a heavy period starting means that they sacrifice that freedom. The societal and economic costs of women being incapacitated every month has an effect on everyone. TRIAL REGISTRATION: The COS study is registered with the COMET (Core Outcome Measures in Effectiveness Trials) Initiative-project reference number 789

Management of first-trimester miscarriage: a systematic review and network meta-analysis

Background First-trimester miscarriage affects up to a quarter of women worldwide. With many competing treatment options available, there is a need for a comprehensive evidence synthesis. Objectives and rationale We conducted a systematic review and network meta-analysis to assess the effectiveness and safety of treatment options for first-trimester miscarriage: expectant management (EXP), sharp dilation and curettage (D+C), electric vacuum aspiration (EVAC), manual vacuum aspiration (MVA), misoprostol alone (MISO), mifepristone+misoprostol (MIFE+MISO) and misoprostol plus electric vacuum aspiration (MISO+EVAC). Search methods We searched MEDLINE, Embase, CINAHL, AMED and Cochrane Library from inception till June 2018. We included randomized trials of women with first-trimester miscarriage (<14 weeks gestation) and conducted a network meta-analysis generating both direct and mixed evidence on the effectiveness and side effects of available treatment options. The primary outcome was complete evacuation of products of conception. We assessed the risk of bias and the global network inconsistency. We compared the surface under the cumulative ranking curve (SUCRA) for each treatment. Outcomes A total of 46 trials (9250 women) were included. The quality of included studies was overall moderate with some studies demonstrating a high risk of bias. We detected unexplained inconsistency in evidence loops involving MIFE+MISO and adjusted for it. EXP had lower effectiveness compared to other treatment options. The effectiveness of medical treatments was similar compared to surgery. Mixed evidence of low confidence suggests increased effectiveness for MIFE+MISO compared to MISO alone (RR 1.49, 95% CI: 1.09–2.03). Side effects were similar among all options. Fewer women needed analgesia following EVAC compared to MISO (RR for MISO 0.43, 95% CI: 0.27–0.68) and in the EXP group compared to EVAC (RR 2.07, 95% CI: 1.25–3.41). MVA had higher ranking (low likelihood) for post-treatment infection and serious complications (SUCRA 87.6 and 79.2%, respectively) with the highest likelihood for post-treatment satisfaction (SUCRA 98%). Wider implications Medical treatments for first-trimester miscarriage have similar effectiveness and side effects compared to surgery. The addition of MIFE could increase the effectiveness of MISO and reduce side effects, although evidence is limited due to inconsistency. EXP has lower effectiveness compared to other treatment options

A hierarchy of effective teaching and learning to acquire competence in evidenced-based medicine

BACKGROUND: A variety of methods exists for teaching and learning evidence-based medicine (EBM). However, there is much debate about the effectiveness of various EBM teaching and learning activities, resulting in a lack of consensus as to what methods constitute the best educational practice. There is a need for a clear hierarchy of educational activities to effectively impart and acquire competence in EBM skills. This paper develops such a hierarchy based on current empirical and theoretical evidence. DISCUSSION: EBM requires that health care decisions be based on the best available valid and relevant evidence. To achieve this, teachers delivering EBM curricula need to inculcate amongst learners the skills to gain, assess, apply, integrate and communicate new knowledge in clinical decision-making. Empirical and theoretical evidence suggests that there is a hierarchy of teaching and learning activities in terms of their educational effectiveness: Level 1, interactive and clinically integrated activities; Level 2(a), interactive but classroom based activities; Level 2(b), didactic but clinically integrated activities; and Level 3, didactic, classroom or standalone teaching. SUMMARY: All health care professionals need to understand and implement the principles of EBM to improve care of their patients. Interactive and clinically integrated teaching and learning activities provide the basis for the best educational practice in this field

Total phenolic and flavonoid content, antioxidant effects and antidiarrheal activity of balacaturbhadrika churna – an Ayurvedic preparation

485-492Balacaturbhadrika churna (BC) is an important pediatric preparation in Ayurveda. It is used to treat various diseases of gastro-intestinal tract particularly diarrhea in children. Free radicals cause oxidative damage in the intestine and are correlated with its diseases. In the current study, total phenolic and flavonoid contents of BC extracts were determined and their antioxidant evaluation in various in vitro models was carried out. Procedures mentioned in The Ayurvedic Formulary of India were followed to prepare in-house BC; alcoholic (BCAL) and aqueous (BCAQ) extracts were prepared and tested by standard procedures. BCAL was tested for antidiarrheal activity in castor oil induced model. The ethanolic extract showed better antioxidant activity in many of the models as compared to aqueous extract. The present study showed substantial amounts of flavonoids and phenolics in churna extracts. BCAL showed significant antidiarrheal activity against the tested model. The potential antioxidant and antidiarrheal activities displayed by Balacaturbhadrika churna extracts could be attributed to these contents

Predictors of Risky Sex Behavior among Adolescents in a Traditional Indian Society: Implications for Program Intervention Strategies

Objective: The purpose of the study was to assess the risk behavior and its effect on involvement in sex among school-going adolescents as a part of assessing implementation of Adolescent Reproductive and Sexual Health Scheme (ARSH) in a state of India.Methods: The sample covered 3069 randomly selected adolescents (students) from 9th to 12th standard in various government, private and missionary-run schools from two districts, namely, Aizawl and Champhai in the state of Mizoram.Results: It was found that more than one-third of adolescents (37%) accepted taking alcohol and 72% of adolescents accepted seeing pornographic movies. Nearly 23% respondents were aware about premarital pregnancy among friends and 7.5% were aware about complication due to unsafe abortion among them. About 10% accepted involvement in premarital sex and majority of them (70%) had premarital sex between age group 15 and 19 years and 54% never used condom. Influence of peer group who were taking alcohol, tobacco and drug and exposure to erotic materials was found to be the major risk factors for indulgence in unsafe sex practices among adolescents.Conclusion: Better awareness and counseling against tobacco, alcohol and drug abuse, and pornographic literature among adolescents is needed through school health education.