The latest obstetric fistula research summarized for you in one place.
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July 2017


Fistula Research Update


Presented by Texas Children's Hospital® Global Women's Education, Research and Care Program

Fistula Patients at FfFF Fistula Care Center, Lilongwe, Malawi.
Photo credit: Dr. Jeffrey Wilkinson
Welcome back to the Fistula Research Update. This newsletter is created for researchers, fistula surgeons, medical providers, nurses, social activists and advocates. We hope that it is shared widely and that it will help us all to reach the collective goal of ending fistula.
-Editors Rachel Pope, MD, MPH & Jeffrey Wilkinson, MD  
Baylor College of Medicine 
Texas Children's Global WERC
New and groundbreaking...
Several articles have been published in the last few months on completely new aspects of fistula care that have never previously been explored. The following are some highlights /rp
In BJOG, Kopp et al. published: 
Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study. This is the first study to use a pad test in women after obstetric fistula repair to predict continence at follow-up.  Too often, fistula care providers have relied on subjective measures of urinary incontinence after repair which has lead to erroneously elevated estimates of success.  Important aspects of post-operative evaluation of the fistula patient include a dye test and an objective measure of ongoing incontinence.  In this study a negative pad test (<1.5 g after one hour) was a reasonable predictor for who would return dry and perhaps help better determine who requires more intensive follow-up after fistula repair.  As a note of caution, independent of the ability of any test to predict post-operative incontinence, follow-up visits are needed in order to assess patients’ other issues including psychosocial and reintegration issues. /jw

In February this year in the International Journal of Gynaecology and Obstetrics, Tang and colleagues analyzed FSH and anti-mullerian hormone (AMH) levels along with ovarian ultrasound in women with obstetric fistula who were potentially fertile.  About 1/3 of these patients had amenorrhea and these women had lower levels of AMH than those women with normal menstruation.  Given the trauma and associated morbidities that women experience with obstructed labor, it was a surprise to see that only one of the patients had hypogonadotrophic hypogonadism.  In 42% of the cases, amenorrhea was unexplained.  This is a preliminary attempt at quantifying the hormonal consequences of obstructed labor and fistula formation.  Future, larger studies are needed to help women with obstetric fistula and likely fertility to achieve their reproductive potential. /jw

Partnership between Johns Hopkins University, Harvard University, and medical institutes in Nepal led to the creation of a symptom-based fistula screening questionnaire as an aim to determine prevalence of OF in rural Nepal. Women who screened positive for an obstetric fistula underwent a confirmatory examination. A total of 16,893 women completed the questionnaire and only 68 screened positive for OF. 13 of those women were unable to be screened for various reasons. Therefore, 55 were examined. 53 of those individuals were found to be false positives, one was found to have a true VVF and one was found to have  a true VVF and RVF. The authors conclude that the tool is highly sensitive, however, based on these results, it is not reliable. Findings could potentially be different if this study were done in an area with higher prevalence of OF. /rp

Answering questions many of us have had:

An interesting study at the Hamlin Fistula Hospital in Addis Ababa, Ethiopia looks at urinary tract infections in women with obstetric fistula. Over half of all patients had a urinary tract infection and most of these infections were with E. Coli and infections were associated with prior catheterization and previous UTI.  Just over half of the patients with significant bacteriuria were symptomatic.  The authors concluded that amoxicillin-clavulanic acid is the drug of choice for coverage of these infections.  It would have been interesting to know some more details on how the urine specimens were collected in women with obstetric fistula as clean-catch, mid-stream collections and also how they were determined to be symptomatic.  The ability to generalize the antibiotic recommendations to other settings is limited given likely different resistance patterns between geographical regions and centers. /jw

In a paper on the quality of life after urinary diversion, Walker and colleagues found that 82% of women who underwent ileal conduit urinary diversion for irreparable obstetric fistula or bladder exstrophy felt that they were cured and all would recommend the procedure to someone in their situation.  This is reassuring news, albeit in a small case series of patients.  It is difficult to extrapolate these findings to development of urinary diversion programs in other settings.  The ethical and technical challenges with urinary diversion in low resource settings have been reviewed in BJOG in the recent past and there are two Mini-commentaries which will accompany this article.  The most important issues are to respect patient autonomy with comprehensive pre-operative counseling and to provide the expertise and resources to manage such complex patients before, during and after the procedure. /jw

Barriers to obstetric fistula treatment in low-income countries: A systematic review, is a literature reviewing looking to identify barriers to obtaining OF treatment as noted by other studies in the English-speaking literature. Using Thadeus and Maine’s three delays as a framework with which to view the articles, barriers were given themes. These themes included: (1) psychosocial, (2) cultural, (3) awareness, (4) social, (5) financial, (6) transportation, (7) facility shortages, (8) quality of care, and (9) political leadership. Not surprisingly, financial barriers were the most frequently mentioned barriers, mentioned by 65% of the reviewed articles. Next common were social and facility shortages, followed by transportation. All of these items likely pose barriers to access health care during the pregnancy that caused the fistula as well. As the article concludes, while barriers are easily identified, alleviating them is a greater challenge. /rp
The bigger picture of strengthening surgical care globally:
In 2015, the Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (the G4 Alliance) was launched to bring surgery and anesthesia to the forefront of health systems strategies. As a result the World Health Assembly resolved to recognize the role of surgery and anesthesia as part of universal health coverage. However consensus goals, targets, and indicators to guide policy are now needed for the implementation of such coverage. Therefore, the alliance has agreed on 15 consensus indicators in order to reach safe surgical and anesthesia care for 80% of the world by 2030. These indicators are within three domains: access, quality, and financial risk protection and include important goals such as access to timely essential surgery, cesarean section rate, and perioperative mortality. Some indicators may be easier to track than others, especially given the limitations often experienced in low-resource settings in collecting accurate data amidst coping with patient volume and acuity. This is nonetheless, an important step in reducing global inequity in access to surgical care. /rp

Special thanks to Freedom from Fistula Foundation  

and One By One
Presented by:
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