Objectives:  Pre-eclampsia is a hypertensive disorder of pregnancy which, left untreated, can cause significant foeto-maternal morbidity. Accordingly, the National Institution for Health and Care Excellence (NICE) recommends that high-risk women be prescribed daily prophylaxis with 75-150mg aspirin from twelve weeks’ gestation until delivery. NICE stratifies risk using eleven maternal risk factors; however, no secondary research has been published evaluating the diagnostic accuracy of this algorithm. This systematic review and meta-analysis evaluates the sensitivity and specificity of the NICE risk‑stratification algorithm in predicting pre‑eclampsia in pregnant women ≥16 years. Methods: Systematic searches were conducted using PubMed, Cochrane Library and SCOPUS to identify relevant papers with a CBEM Level of Evidence ≤4. A total of twenty eligible studies and 892,061 pregnancies were included in our analyses. The logit-transformed sensitivities and specificities from each study were modelled as a bivariate distribution with random effects in order to generate maximum-likelihood estimates (MLEs) for the overall sensitivity and specificity of the algorithm in predicting pre-eclampsia. Results: MLEs for the NICE algorithm’s sensitivity and specificity were 44.4% (95% CI 33.7-55.5) and 88.3% (95% CI 83.9-91.6), respectively. Significant heterogeneity was exhibited between the sensitivities  (I2=99.8%, 95% CI = 99.54-99.65) and specificities (I2=99.88%, 95% CI = 99.87-99.89) calculated by each of the included studies. Consequently, there is a low degree of certainty in these estimates. Conclusions: The NICE risk‑stratification algorithm performs remarkably poorly when used to predict pre‑eclampsia in any of three gestational categories. Clinicians should advise women that around 1 in 5 high-risk patients and 1 in 25 low-risk patients go on to develop pre‑eclampsia. However, future studies will likely alter the values of these statistics and the confidence therein. Key Words: Pre-eclampsia, High-risk Pregnancy, Sensitivity and Specificity, Predictive Value of Tests, Clinical Decision Rules.

Background: The prevalence of infertility has rarely been synthesized at the global level. Objective: To conduct a systematic review and meta-analysis to assess the community-based global prevalence of infertility. Search Strategy: PubMed, MEDLINE, Web of Science, and Science Direct were searched from inception until October 2022. Selection Criteria: Studies were included if they were published in English, had quantitative data, and reported the community-based prevalence of infertility. Data Collection and Analysis: Two authors independently extracted data. Random-effects meta-analysis was used to derive the pooled prevalence of infertility. Variations in the prevalence estimates in different subgroups. Univariate meta-regression was used to explore possible sources of heterogeneity. Main Results: The findings indicated the pooled prevalence of infertility was 12.87% (95% CI,12.41%-13.33%). The prevalences of primary infertility and secondary infertility were 7.34% and 6.01%, respectively. The overall prevalence of infertility among people was the highest in Africa (16.73%) and lowest in the North America (8.84%). Lower prevalence in cohort or prospective follow-up studies (9.75%) than in cross-sectional studies (12.93%). Women aged 35 and above had a higher prevalence of infertility (11.68%) compared to women below 35 years old (5.92%). The prevalence of infertility increased with the number of years, and increased with the degree of literature bias from low to high. Conclusions: This community-based study estimated the global prevalence of infertility to be 12.87% and suggested that an upward trend of the prevalence of infertility may persist in the future.

Objective: Evaluate NHS-funded fertility treatment policies across England, Scotland, and Wales, assessing their alignment with the needs of those trying to conceive and comparing eligibility against NICE guidance. Design: Review of current NHS-funded fertility treatment policies and retrospective analysis of participant data. Setting: Not applicable. Population: Reproductive-age UK-based women using Hertility Health services from 2021-2023, focusing on those actively trying to conceive (TTC) or planning future pregnancies. Methods: Policy evaluation and data review without interventions. Main Outcome Measures: Eligibility for NHS-funded fertility treatment under UK regional policies versus NICE guidance. Results: In total, out of 2980 individuals actively trying to conceive and 6282 individuals planning for future pregnancies, 1700 (57.0%) and 2750 (43.8%) respectively would be ineligible for state-funded treatment under current regional policies: 1551 (57.7%) in England, 123 (53.2%) in Scotland, and 26 (41.9%) in Wales for those actively trying to conceive, and 2558 (43.9%), 146 (41.7%), and 46 (44.2%) for those planning future pregnancies respectively. In contrast, only 248 (8.3%) of those actively trying to conceive and 149 (2.4%) of those planning for future pregnancies would be ineligible if the NICE guidance were universally applied. Conclusions: By imposing outdated clinical and non-clinical qualifying criteria, the current NHS-funded fertility treatment policies exclude a substantial number of individuals requiring treatment. This necessitates a swift policy overhaul, as promised in the 2022 UK Women’s Health Strategy, to avoid further age-related fertility loss in women who require treatment imminently.

Background Abdominal wall endometriosis (AWE) is the most common type of extrapelvic endometriosis in women of reproductive age, and several studies have compared high-intensity focused ultrasound (HIFU) ablation with surgical resection in the management of AWE; however, the results are controversial. Objective To compare the efficiency and safety of HIFU ablation with surgery in the treatment of AWE. Search strategy Literature on surgery versus HIFU ablation for treating AWE was identified using the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, WANFANG Database and the Cochrane Library databases. Selection Criteria Full-text manuscripts comparing HIFU ablation and surgery for treating AWE were included. Data collection and analysis Two independent reviewers reviewed and extracted data from the articles, and the risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. Data analysis was performed using RevMan 5.4. Main results We included 7 studies involving 405 patients. Compared with the surgery group, the immediate posttreatment visual analogue scale (VAS) score was lower in the HIFU group (mean difference [MD] -1.58, 95% CI -2.56 to -0.59), the length of hospitalization was shorter in the HIFU group (MD -1.95 days, 95% CI −2.43 to −1.48), and the incidence of adverse events was lower in the HIFU group (relative risk 0.32, 95% CI 0.15 to 0.65). There was no significant difference in the symptom recurrence rate, VAS score at the 3-, 6- and 12-month follow-ups, or treatment time between the two groups. Conclusions Compared with surgery, immediate postoperative VAS scores were lower, hospitalization times were shorter, and the risk of adverse events were lower in patients receiving HIFU ablation treatment for AWE.

ABSTRACT Objective To evaluate the impact of screening and treating asymptomatic pregnant women for C. trachomatis and N. gonorrhoeae infections on the frequency of preterm birth or low birth weight infants in Botswana. Design Non-randomized, cluster-controlled trial. Setting Four antenatal care clinics in Gaborone, Botswana. Population Pregnant women aged ≥15 years, attending a first antenatal care visit, ≤27 weeks gestation, and without urogenital symptoms were eligible. Methods Participants in the intervention clinics received screening (GeneXpert®, Cepheid) during pregnancy and at the post-natal visit. Participants in the standard-of-care clinics received screening at the postnatal visit only. We used multivariable logistic regression and post-estimation predictive margins analysis. Post-hoc analysis was conducted among sub-samples stratified by parity. Main outcome measures Preterm birth (<37 weeks gestation) and low birth weight (<2500g). Results After controlling for parity, hypertension, antenatal care visits, and clinic site, the predicted prevalence of preterm or low birth weight was lower in the intervention arm (11%) compared to the standard-of-care (16%) (AOR: 0.59; 95% CI: 0.28 to 1.24), but confidence intervals were wide. In post-hoc analysis, the intervention was more effective than the standard-of-care (AOR: 0.20; 95% CI: 0.07-0.64) among nulliparous participants. Conclusion A C. trachomatis and N. gonorrhoeae infection screening and treatment intervention among asymptomatic pregnant women did not significantly reduce preterm or low birth weight outcomes. Post hoc analysis found the intervention reduced adverse outcomes among nulliparous participants.

Objective: To compare the carbon footprint of caesarean and vaginal birth. Design: Life cycle assessment. Setting: Tertiary maternity units and home births in the UK and the Netherlands Methods: A life cycle assessment, including: equipment use, energy, analgesia, hospital stay, waste, sterilisation and laundry, was conducted using primary data combined with data from published sources. Main Outcome Measures: ‘Carbon footprint’ (in kgCO 2e) Results: Excluding analgesia, the carbon footprint of a caesarean birth in the UK was 31.21 kgCO 2e, compared with 12.47 kgCO 2e for vaginal birth in hospital and 7.63 kgCO 2e at home. In the Netherlands the carbon footprint of a caesarean was higher (32.96 kgCO 2e), but lower for vaginal birth in hospital and home (10.74 and 6.27 kgCO 2e respectively). Emissions associated with analgesia for vaginal birth were: 0.08 kgCO 2e (opioid analgesia), 0.75 kgCO 2e (remifentanil), 1.2 kgCO 2e (epidural) and 237.33 kgCO 2e (nitrous oxide with oxygen). Differences in analgesia use resulted in a lower average carbon footprint for vaginal birth in the Netherlands than the UK (11.64 vs. 193.26 kgCO 2e). Conclusion: The carbon footprint of a caesarean is higher than for vaginal birth if analgesia is excluded, but this is very sensitive to the analgesia used; use of nitrous oxide with oxygen multiplies the carbon footprint of vaginal birth 25-fold. Alternative methods of pain relief or nitrous oxide destruction systems would lead to a substantial improvement in carbon footprint. Although clinical need and maternal choice are paramount, protocols should consider the environmental impact of different choices.

Objectives To investigate the risk of stillbirth in relation to; 1) a previous CD compared to those following a vaginal birth (VB); and 2) vaginal birth after caesarean (VBAC) compared to a repeat CD. Design Population-based cohort study. Setting The Swedish Medical Birth registry Population Women with their first and second singletons between 1982 and 2012. Methods Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum). Main outcome measures Stillbirth (antepartum and intrapartum fetal death). Results Of the 1,771,700 singleton births from 885,850 women,117,114 (13.2%) women had a CD in the first pregnancy, and 51,755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR:1.37 [95% CI, 1.23–1.52]) in women with a previous CD compared to VB. The odds of intrapartum stillbirth was higher in previous pre-labour CD group (aOR:2.72 [95% CI, 1.51–4.91]) than the previous in-labour CD group (aOR:1.35 [95% CI, 0.76–2.40,]), although not statistically significant in the latter case. No increased odds was found for intrapartum stillbirth in women who had VBAC (aOR:0.99 [95% CI, 0.48–2.06]) compared to women who had a repeat CD, whereas women with antepartum stillbirth were more likely to have a VBAC (aOR:4.49 [95% CI, 3.55–5.67]). Conclusions This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help health care providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.

This review article considers the physiology, differential diagnosis and immediate management of vasovagal response, vascular injury and carbon dioxide embolism caused during creation of the laparoscopic pneumoperitonium. These pathologies account for over half of all laparoscopic complications and therefore, by taking a systematic approach to these possibly life-threatening events, laparoscopy can become even safer.

Objectives To study effects of physiotherapist-guided pelvic floor muscle training on pelvic organ prolapse (POP) early postpartum period. Design Assessor-blinded, randomized controlled trial. Setting Physiotherapy Clinic, Reykjavik. Sample Eighty-four primiparous women with a singleton delivery. Methods Participants were screened for eligibility 6-13 weeks postpartum. Women randomized to the training group conducted 12 weekly individual sessions with a physiotherapist, starting on average 9 weeks after childbirth. Outcomes were assessed after the last session (short-term) and at 12 months postpartum (long-term). The control group received no instructions after the initial assessment. Main outcome measures Self-evaluated POP symptoms by the Australian Pelvic Floor Questionnaire. Results Forty-one and 43 women were randomized to the training and control groups, respectively. At recruitment, 17 (42.5%) of the training and 15 (37%) of the control group reported prolapse symptoms (p=0.6). Five (13%) from the training and 9 (21%) controls were bothered by the symptoms (p=0.3). There was a gradual decrease in the number of women with symptoms and no significant short-term (p=0.08 at 6 months) or long-term (p=0.6 at 12 months) differences between the groups regarding rates of women with POP sympoms. No difference was between groups regarding bother in the short (p=0.3) or longer term (p=0.4). Repeated measure analyses using Proc Genmod in SAS did not indicate a significant effect of the intervention over time, p>0.05. Conclusions There was an overall decrease in postpartum symptoms of POP and bother during the first year. Physiotherapist-lead pelvic floor muscle training did not change the outcomes.

Objective: Evaluation of the implementation of a new guideline for diagnosis and treatment of women with pregnancy of unknown location (PUL) or ectopic pregnancy (EP). Design: Multicenter retrospective cohort study Setting: Six hospitals in the Northern part of the Netherlands Population and methods: Women above 18-years old with a final diagnosis of PUL or EP between January 2012 to April 2020. Main outcome measures: Diagnostic findings, type of treatment and outcomes, before and after implementation of the guideline. User interpretation of the guidelines. Results: 1306 women with PUL or EP were included. The amount of women diagnosed with PUL has significantly increased between the guideline cohorts (28.4%;174/693 versus 16.6%;115/613 P<0.001). A significantly lower percentage of women using the new guideline underwent surgical management versus treatment with MTX (odds ratio [OR] =0.516, 95% confidence interval [CI] 0.399 – 0.668 P<0.001). Among women treated with MTX, the overall success rate was significantly lower compared to surgery (80.5%;103/128 versus 95.2%; 943/991 P=0.007). There was no observed difference in adverse events or guideline adherence between the guidelines. Conclusion: The implementation of the new guideline contributes to an increase in women diagnosed with PUL and treated with MTX. Treatment with MTX caused more complications and a lower treatment success compared to women undergoing surgery. This did not lead to an increase in adverse events between the guidelines. The overall adherence to the guidelines was equal.

Objective: Lifestyle factors including education, coffee intake, tea consumption, dietary fat intake, obesity, physical activities, smoking and alcohol drinking, sleep duration, and insomnia, have been linked to Ovarian Cancer (OC) in observational studies. We assessed whether the concerning factors are causally associated with the risk of OC by histological subtypes. Design: Mendelian Randomization (MR) study. Setting: Independent genetic instruments associated with thirteen lifestyle behaviors were selected from ten genome-wide association studies. Summary-level data for OC subtypes were obtained from the Ovarian Cancer Association Consortium. Population: Exposures population were including 375,833 to 1,232,091 European individuals, outcomes population were including up to 25,509 cases and 40,941 controls. Methods: Two-sample and multivariable MR study, and multiple complementary sensitivity analyses were conducted. Main Outcome Measures: Histological subtypes of OC. Results: We provided unconfounded genetic evidence of inverse associations of genetically predicted years of education and fat intake with specific OC subtypes, which are independent of BMI. Whereas consumption of coffee or tea was positively associated with endometroid OC, which may be partly mediated by BMI. Although physical activity and sleep characteristics have been reported to be the risk factors for OC, no causal associations were observed in our study. Conclusions: Our study clarified the protective and independent role of high level education and relative fat intake in particularly OC subtypes. We also showed detrimental effects of higher coffee or tea consumption on OC histotypes. Our results may provide insight into the corresponding interventions as lifestyle factors can easily be modified.

Objectives: To investigate the cost-effectiveness of preimplantation genetic testing for aneuploidy (PGT-A) versus conventional technology in in vitro fertilization (IVF) from the perspective of the healthcare system in China. Design: Economic evaluation based on a large multi-center randomized trial (CESE-PGS study). Population: Infertile women with a good prognosis for a live birth in China Methods: Following the exact steps in the IVF protocol, a decision tree model was developed, based on the data from the CESE-PGS trial and using cost scenarios for IVF in China. The scenarios were compared for costs per patient and cost-effectiveness. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to confirm the robustness of the findings. Main Outcome Measures: Costs per live birth, Costs per patient, Incremental cost-effectiveness for miscarriage prevention Results: The average costs per live birth of PGT-A were estimated as ¥39230.71, which is about 16.8% higher than that of the conventional group. Threshold analysis revealed that PGT-A would need to increase the pregnancy rate of 26.24% to 98.24% or a cost reduction of ¥4649.29 to ¥1350.71 to achieve the same cost-effectiveness. The incremental costs per prevented miscarriage was approximately ¥45600.23. Probabilistic sensitivity analysis indicated a probability of 97.50% that PGT-A is cost-effective when the willingness to pay was ¥ 21,7113.00 per prevented miscarriage. Conclusions: The present cost-effectiveness analysis demonstrates that embryo selection with PGT‑A is not suitable for routine applications from the perspective of healthcare providers in China, given the cumulative live birth rate (CLBR) and the high costs of PGT‑A.

Objective The role of surgery for patients with advanced ovarian cancer is well established but wide variations in the percentage of patients undergoing surgery exist. Design Observational Study Setting The 19 cancer alliances in England, UK Methods We undertook a comparative analysis to examine the effects of rates of surgery on one and five year disease specific survival across the 19 English Cancer Alliances. We also undertook a propensity score analysis of a single cohort of patients with advanced ovarian cancer to compare patients who did, and did not, undergo surgery as part of their primary management. Main outcome measures Correlations between rates of surgery, demographics, and cancer alliance performance against one and five year survival Results In multivariable analysis, rates of surgery undertaken by a Cancer Alliance remained an independent predictor of both one and five year survival (correlation coefficient 0.81, and 0.70, respectively) although this relationship is likely non linear with optimal rates of surgery still to be defined. Using propensity score analysis a subgroup of patients who gain no benefit from surgery can be identified. Conclusions Overall survival of patients with advanced ovarian cancer is likely to be improved with an increase in overall rates of surgery however there are likely to be optimal maximal rates, above which patients will be disadvantaged. Mechanisms for identifying individual outcome predictions are required.

Objective Studies have shown that chronobiological factors may adversely affect glycemic control in patients with type 2 diabetes mellitus (T2DM). Our objective was to assess the association of chronobiological disorders with glycemic control and neonatal birthweight in women with GDM. Design A prospective observational study was conducted. Setting Israel Population 208 women aged 18-45 years with a singleton pregnancy who were randomly selected from among women undergoing follow-up for GDM at the Maternal-Fetal Medicine Unit of a tertiary medical center in 2016 and 2017. Methods Nutrition, sleep, and lifestyle patterns were assessed from onset of GDM until birth along with glycemic control and obstetrical outcomes. Data were collected by structured interview and from the medical files. Main outcome measures Maternal glycemic control and large for gestational age (LGA) neonate. Results Multivariate analyses on a cohort of 208 women revealed suboptimal glycemic control which was associated with a late breakfast (RR=2.26; 95% CI 1.09-4.67). Any 10-g increase in carbohydrate intake in the evening increased the risk 1.19 times for suboptimal glycemic control (RR=1.19; 95% CI 1.003-1.42), and 2.14 times for poor sleep quality (RR=2.14; 95% CI 1.04-4.41). The adjusted relative risk for birthweight above the 85th percentile was associated with excessive of 10-g increase of carbohydrate intake in the morning (RR=1.70; 95%CI 1.30-2.23) and in the evening (RR=1.39; 95% CI 1.16-1.67). Conclusions Chronobiological disorders are associated with suboptimal glycemic control and large-for-gestational-age newborn in women with GDM.

Objective: Internal contraction monitoring during the course of labor may identify elevated intrauterine resting tone. Our objective was to assess the association between elevated resting tone during labor and neonatal morbidity. Design: Secondary analysis of a prospective cohort study. Setting and Population: Term singleton patients with ruptured membranes and an intrauterine pressure catheter in place: Tertiary care hospital, United States of America Methods. Intrauterine resting tone was calculated as the average baseline pressure between contractions. The study group had elevated intrauterine resting tone, defined as intrauterine resting tone ≥75th percentile. Main Outcome Measures: Composite neonatal morbidity: hypoxic ischemic encephalopathy, hypothermia treatment, intubation, seizures, umbilical arterial pH ≥ 7.1, oxygen requirement, or death. Results: Of the 8580 patient in the cohort, 2210 (25.8%) were included. The median intrauterine resting tone was 9.7 mmHg (IQR 7.3-12.3 mmHg). Elevated resting tone was associated with shorter median duration of the first stage of labor (10.0 hrs vs 11.0 hrs, p <0.01) and lower rates of labor induction (p < 0.01). Neonatal composite morbidity was higher among patients with elevated intrauterine resting tone (5.1% vs 2.9%, p=0.01). After adjusting for chorioamnionitis and amnioinfusion, elevated intrauterine resting tone was associated with increased risk of neonatal morbidity (aOR 1.70, 95% CI 1.06-2.74). Compared to normal tone, elevated intrauterine resting tone was associated with mild acidemia and elevated lactate (aOR 1.81, 95% CI 1.38-2.37 and aOR 1.45, 95% CI 1.17-1.80, respectively). Conclusion: Elevated intrauterine resting tone is associated with increased risk of neonatal composite morbidity. Funding: None

Objective: To evaluate the performance of INTERGROWTH-21st and World Health Organization (WHO) fetal growth charts to identify small-for-gestational-age (SGA) and fetal growth restriction (FGR) neonates as well as their specific risks for adverse neonatal outcomes. Design: Multicenter cross-sectional study. Setting: Ten maternity units across four Latin American countries, 2016-2018. Population: 67,968 singleton live births. Methods: According to each standard, the neonates were classified as SGA and FGR (birthweight <10th and <3rd centiles, respectively). Main Outcomes Measures: The relative risk (RR) and diagnostic performance for the occurrence of a low Apgar score and low ponderal index were calculated for each standard. Results: The WHO charts identified more neonates as SGA than IG-21st (13.9% vs. 7%, respectively). 6.9% babies were considered SGA only by the WHO chart. Compared to normally grown babies, neonates classified as FGRs by both standards had the highest RR for a low Apgar (RR: 5.57; 95% CI: 3.99–7.78), followed by those SGA by both curves (RR: 3.27; 95% CI: 2.52–4.24), while SGAs identified by WHO alone did not have an additional risk (RR: 0.87; 95% CI: 0.55–1.39). Furthermore, the diagnostic odds ratio for a low Apgar was higher when INTERGROWTH-21st was used than when SGA and FGR were defined by WHO charts. Conclusions: In a large population of singleton deliveries from Latin America, the WHO fetal growth charts seem to identify significantly more SGA neonates than the INTERGROWTH-21st charts, but the diagnostic performance of the latter for low Apgar score and low ponderal index is better.

Objectives: To determine the impact of the diagnostic test method (clinical, diagnostic imaging, or diagnostic laparoscopy) of endometriosis on the individual’s sense of control over their disease and their perceived access to social supports. Design: Retrospective cohort study. Setting: International. Population: 1,634 people aged 18-55 who had received a diagnosis of endometriosis. Methods: This study reports on data collected by the validated Endometriosis Health Profile-30 (EHP-30) section of a larger survey conducted between May and July 2020. Participants were recruited by social media platforms. Scores on the dimensions of interest were analysed with diagnostic method as the variable of interest. Diagnostic method proportionality was also assessed as a secondary outcome by geographical region. Main Outcome Measures: Scores on the dimensions of control and powerlessness and social support on the EHP-30. Results: There was a difference between control and powerlessness scores for patients that received a diagnosis via imaging (ultrasound/magnetic resonance imaging) versus clinical diagnosis (P=0.049). However, this did not reach significance when co-variates were controlled for (P=0.054). No other comparisons between diagnostic method and EHP-30 scores demonstrated a difference. There was a statistically significant (P<0.0001) difference in the rate of utilization of the various diagnostic imaging techniques between geographical regions with diagnostic imaging being relatively uncommon and surgery being the most common method of diagnosis. Conclusions: The diagnostic method of endometriosis does not appear to have a clinically significant impact on an individual’s sense of control over their disease nor their access to social supports.

Background Fatigue is a burden for a substantial proportion of women in the postpartum period. A wide array of patient-reported outcome measures (PROMs) are used for assessment, which makes comparison of data difficult. Objective To identify the best PROM for postpartum fatigue using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. Search strategy We searched Web of Science, Embase, PubMed and CINAHL, with no date limiters, in July 2020 for validated PROMs used to assess fatigue in the postpartum period. Selection criteria Studies evaluating at least one author-defined domain of postpartum fatigue and one psychometric measurement property of a PROM. Data collection and analysis An overall rating was assigned based upon COSMIN criteria and the quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Main results We identified 49 validation studies using 18 PROMs in 21 209 women that evaluated postpartum fatigue. All three fatigue domains (Physical, Mental, Interference) were assessed by four PROMs: Fatigue Assessment Scale (FAS), Brief Fatigue Inventory (BFI), Checklist Individual Strength (CIS) and Fatigue Severity Scale (FSS). The FAS, which is freely available online, was the only PROM to demonstrate adequate content validity and at least a low level evidence of sufficient internal consistency, resulting in a Class A recommendation. Conclusion The FAS is the best available PROM to assess postpartum fatigue. However, it fails to assess important areas of postpartum recovery. Future studies should aim to develop a more specific PROM for postpartum fatigue.