Objective: To analyze trends in iatrogenic urogenital fistula among patients admitted for fistula repair at the Pakistan Institute of Medical Sciences, Islamabad.Methods: In this longitudinal study, all patients who presented for fistula repair between 2006 and 2018 were included in the study. Patient data were collected on age, parity, and type and etiology of fistula, which was classified as ischemic or iatrogenic. Results:Of 634 fistula patients, 371 (58.5%) had iatrogenic fistula, while 263 (41.5%) patients developed ischemic fistula due to obstructed labor. Mean age of patients was 31.6 years. Yearly trends showed an increase in iatrogenic fistula from 43.2% in 2006-2008 to 71.4% in 2017-2018. The major etiological contributor to iatrogenic fistula was hysterectomy (52.5%), followed by cesarean hysterectomy (26.4%), and cesarean delivery (19.9%). Conclusion:A rising trend in iatrogenic fistula was observed. This emphasizes the need for optimization of surgical approaches and surgical skills. Moreover, gynecologic surgeries should be restricted to authorized gynecologic surgeons. K E Y W O R D S Iatrogenic fistula; Obstetric fistula; Pakistan; Trends quality of health care and training systems. Although surgical training offers a possible solution, health personnel may not have gained adequate practical experience to deal with complicated deliveriesand surgical procedures. Therefore, there is a need for advanced training for improved decision-making and surgical skills in both obstetric and gynecologic management, especially for safe cesarean delivery and hysterectomy. Furthermore, despite the declining trend in obstetric fistula, measures must also be taken to further improve health services in access-restricted areas. These measures will ultimately lead to a better healthcare system and decrease the rate of fistula development.In conclusion, the present study observed a rising trend in iatrogenic fistula over almost 12 years at a single center in Islamabad, Pakistan. These recent increasing trends in iatrogenic urogenital fistula emphasize the importance of improving safety standards for surgical techniques, both obstetric and gynecologic. AUTHOR CONTRIBUTIONSNT designed and directed the project and drafted the manuscript. KB directed the project and carried out data collection. OA performed data analysis and interpretation and drafted and critically revised the manuscript. SL and HH conducted data collection.

Objective The aim of this study was to assess long-term effects for women following the use of magnesium sulphate for pre-eclampsia.Design Assessment at 2-3 years after delivery for women recruited to the Magpie Trial (recruitment in 1998(recruitment in -2001, which compared magnesium sulphate with placebo for pre-eclampsia.Setting Follow up after discharge from hospital at 125 centres in 19 countries across five continents.Population A total of 7927 women were randomised at the followup centres. Of these women, 2544 were not included for logistic reasons and 601 excluded (109 at a centre where <20% of women were contacted, 466 discharged without a surviving child and 26 opted out). Therefore, 4782 women were selected for follow-up, of whom 3375 (71%) were traced.Methods Questionnaire assessment was administered largely by post or in a dedicated clinic. Interview assessment of selected women was performed.Main outcome measures Death or serious morbidity potentially related to pre-eclampsia at follow up, other morbidity and use of health service resources.Results Median time from delivery to follow up was 26 months (interquartile range 19-36). Fifty-eight of 1650 (3.5%) women allocated magnesium sulphate died or had serious morbidity potentially related to pre-eclampsia compared with 72 of 1725 (4.2%) women allocated placebo (relative risk 0.84, 95% CI 0.60-1.18). ConclusionsThe reduction in the risk of eclampsia following prophylaxis with magnesium sulphate was not associated with an excess of death or disability for the women after 2 years.

Aims:  The aim was to determine the incidence and association of urinary problems post successful fistula repair. Methods: The retrospective analysis was conducted at Maternal Child Health Pakistan Institute of Medical Sciences, Islamabad, and comprised data related to patients having undergone vesicovaginal fistula repair from January 2008 to June 2018. Various modalities were used to determine the underlying cause of these symptoms including patient’s history, examination, ultrasound, urine examination and urodynamic studies. Statistical analysis of the record was done using SPSS 21 software. Results:  Among total 318 successful fistulas repair patients, 78 (24.5%) had urinary problems post operatively. Out of these 78, 56.4% had stress incontinence, 41% infection and 2.6% urge incontinence.13.6% of the stress incontinence was due to sphincter weakness. Urge incontinence was found to be due to detrusor instability. These post-operative urinary complaints were significantly associated with the repair of vesicovaginal (31.3%), urethral (23.1%) and vesicouterine (15.7%) fistula compared to those involving ureter(p 0.04). No significant association was found between the incidence of post-operative urinary complaints and previous history of surgical repair, parity, fistula size and duration of fistula. Conclusions: Urinary incontinence after fistula repair requires careful evaluation as the successful repair of a urogenital fistula can correct the fistula defect, but it might not make the patient dry. Moreover, performing further continence surgery may exacerbate the condition in some cases.

Aims:  To determine the frequency of iatrogenic urogenital fistula in patients admitted for the repair of fistula in MCH, Pakistan Institute of Medical Sciences, Islamabad. Methods: The retrospective analysis was conducted at MCH PIMS, Islamabad. It comprised data related to patients having undergone urogenital fistula repair. Statistical analysis of the record was done using SPSS 21 software. Results:  Total 98 patients were analyzed. Themean age of patients was 31.6. Out of these, 67.3% of fistulas were attributed to iatrogenic causes while 32.7% were due to obstructed labour. The iatrogenic fistula included post instrumental delivery (5.1%), caesarian section (8.2%), caesarean hysterectomy (17.3%), hysterectomy (36.7%). The fistula caused by obstructed labour included post caesarian section (23.5%) and post normal delivery (9.2%). Conclusions: Our study data showed rising trend of iatrogenic fistula as compared to obstructed labour. This emphasizes the need of optimization of the surgical approach training along with improved obstetric skills, especially in the periphery. Keywords: iatrogenic fistula, obstetric skills, delivery

Objective: Despite the successful fistula repair many patients may continue to complaint of persistence of symptoms in terms of frequency, urgency, urge incontinence and stress incontinence. To evaluate the association of various predictive factors with the outcome of surgical repair of urogenital fistula and todetermine the incidence and association of urinary problems post successful fistula repair. Methods: The retrospective analysis was conducted at Maternal Child Health, PIMS, Islamabad. It comprised data related to vesicovaginal fistula repair of patients from January 2008-June 2018. Various modalities were used to determine the underlying cause of these symptoms including patient’s history, examination, ultrasound, urine examination and urodynamic studies. Results: A total of 364 patients of urogenital fistula repair were reviewed, with an overall success in 318 (87.4%) cases.Primary surgical repair of vesicovaginal (90.0%), vesicouterine (86%), ureteric (100%) & ureterovaginal (98%) were more successful. Success rate was further decreased with the history of >1repair attempt of vesicovaginal (71.4%) & vesicouterine (66.5%) fistula. Among 318 successful fistulas repair patients, 78 (24.5%) had urinary problems post operatively. Out of these 78, 56.4% had stress incontinence, 41% infection and 2.6% urge incontinence. Conclusions: Urinary incontinence after fistula repair requires careful evaluation as the successful repair of a urogenital fistula can correct the fistula defect, but it might not make the patient dry.