Obstetric Fistula An Overview

Brad R. MacKinnon University of Vermont

Contents

What is obstetric fistula? Epidemiology Vesicovaginal Fistula Why do fistulas occur in young girls? The obstructed labor injury complex The obstetric fistula pathway Treatment Surgical management of urinary incontinence after obstetric fistula repair Campaign to end fistula References
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 My name is Telanish Shabera. I

am 14 years old. I was promised in marriage when I was 3, betrothed at 10, and pregnant at 12. After 3 days of labor, I was carried on a stretcher to a hospital, where my baby died 2 hours later. The obstructed labor left me incontinent. I smell, and I feel so ashamed.
Source: McKenna N. Fistula pilgrims. Federation International Gynecologists Obstetricians

dies in pregnancy or childbirth, and for every woman who dies, 20-30 others will survive but with morbidity, one of which is obstetric fistula
13

Source: G. Lewis, WHO Press.

What is obstetric fistula?

Injury of childbearing from prolonged obstructed labor w/o timely medical intervention typically a caesarean section to relieve the pressure. The baby usually dies. The women is left with chronic incontinence. Women often abandoned by husband and family, and ostracized by her community. Prospects for work and family life greatly diminished.
Source: Campaign to End Fistula Printed Materials 5

Epidemeology

18th Century obstetrical drawing of obstructed labor from absolute cephalopelvic disproportion. From William Smellies Sett of Anatomical Tables, 1752.
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Source: The Lancet 2006; 368: 1201-1209

How big a problem is this?

Estimates of 2-7 million women affected. Estimates of >75,000 new cases each year. Estimates of 3-5 cases per 1000 pregnancies. Limited indigenous surgical repair capability. Cultural and religious worldviews serve to perpetuate the status quo:

whatever will be, will be the will of God (Allah)

Women currently have neither the education, resources, nor rights to change the underlying causes of fistula. Note: the occurrence in the western world approaches 0.
Source: Aust N Z J Surg 2000; 70: 851854 7

Socioeconomic factors in obstetric fistula formation.

African women predisposed to dystocia due to narrow pelvic architecture. Marriage at early age, before pelvis growth is complete. Malnourishment retards maturation. Lack of access to emergency obstetric services. Poverty, illiteracy and limited educational opportunities. Note: Maternal mortality rates in Western Europe and the USA at the beginning of the 20th century were similar to those in the developing world todaydramatically reduced between 1935 and 1950 due to access to emergency obstetric services.
Source: Lancet 2006; 368: 12011209. 8

Vesicovaginal Fistula

Moderate-sized vesicovaginal fistula from obstructed labor. Metal catheter passed through the urethra is clearly visible through the bladder base, which is missing.

Source: Source: The Lancet 2006; 368: 1201-1209

Why do fistulas occur in young girls?

Increased incidence of cephalopelvic disproportion. Pelvic bone immaturity.

Reduced birth canal size before age 18. Reduced inlet, midplane, outlet dimensions. Late onset of puberty. Malnutrition. Chronological age age at menarche.

Net = Low gynecological age.

Younger age at marriage.

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The Typical Patient

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Small (44Kg) Short (<150 cm) Married Early (mean age = 15.5 years) Now Divorced 49% Separated 22% Uneducated 78% Poor/Rural (>95%) Developed fistula as primagavida 46%

824/899 fetal deaths 75/899 live births

14 died in first month

>50% of these women endured fistula for 1-9 years before seeking treatment. Avg. fistula 3.5 cm 92% repair success 71% fetuses were

Source: Am J Obstet Gynecol 2004; 190: 1011-1019

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Articles on Association of Age, Gynecologic Age, Cephalopelvic Disproportion, and Obstructed Labor15

Authors Chumlea et al., 2003 Moerman, 1982 Treffers, 2002

Description USA: Cross-sectional study of 2510 females age 820 USA: Longitudinal study of clinical, laboratory, and x-rays of 90 adolescent girls Global: Literature review

Key Findings Median age at menarche: 12.43 Pelvic inlet, midplane, and outlet clinically contracted during early adolescence (<17); growth of pelvis continues for 3 y after menarche Obstructed labor a major health problem for young adolescent girls, particularly in specific geographic regions

Zlatnik and Burmeister, 1977

USA: Records review of 1005 girls <17

Gynecologic age is the chronologic age minus age at menarche; Patients with low gynecologic age (<2 y) have an increased likelihood of delivering a low birth weight baby compared to those with gynecologic age >2 y; independent of chronologic age

Source: J Midwife Womans Health 2005; 50: 286-294.

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The obstructed labor injury complex10

Urological injury Vesicovaginal fistula Urethrovaginal fistula Ureterovaginal fistula Uterovaginal fistula Complex combined fistulas Urethral damage, including complete urethral destruction Bladder stones Stress incontinence Marked loss of bladder tissue from extensive pressure necrosis Secondary hydroureteronephrosis Chronic pyelonephritis Renal failure Gynecological injury Amenorrhoea Vaginal stenosis Cervical injury, including complete cervical destruction Secondary pelvic inflammatory disease Secondary infertility

Gastrointestinal injury Rectovaginal fistula formation Rectal stenosis or complete rectal atresia Anal sphincter incompetence Musculoskeletal injury Osteitis pubis Neurological injury Foot-drop from lumbosacral or common peroneal nerve injury Complex neuropathic bladder dysfunction Dermatological injury Chronic excoriation of the skin from maceration by urine or faeces Fetal injury Fetal case-fatality rate of about 95% Social injury Social isolation Divorce Worsening poverty Malnutrition Depression (sometimes with suicide) Premature death Source: The Lancet 2006; 368: 1201-1209 13

Complications of obstructed labor: pressure necrosis of neonatal scalp2

>90% of neonates stillborn, another 3% died the first week postpartum. Cause of death usually asphyxia or septicemia. After intrauterine fetal death, the head collapses, which facilitates vaginal birth
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Source: The Lancet 2006;368: 1210

The obstetric fistula pathway

Factors include:

Socio-economic Nutrition Education/literacy Early marriage Harmful traditional practices. Psychosocial damage Suffering ,illness, and premature death.
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Result:

Source: Source: The Lancet 2006; 368: 1201-1209

Common comorbitities associated with Fistula

Gynecologic

Amenorrhea PID Lower limb contracture 20 to nerve damage. Foot drop from sacral and perineal nerve compression Neurogenic bladder dysfunction Ammmonical dermatitis Vulvar excoriation

Musculo-Skeletal

Neurological

Dermatologic

Source: Campaign to End Fistula Printed Materials

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Psychosocial damage resulting from obstetric with fistula

More devastating than the physical injury. Divorce and abandonment. Cast out by their families. Social Pariahs. Many treated as having received a

punishment from God for sexual misbehavior. Depression, anxiety and other forms of mental health dysfunction common.
Source: Lancet 2006; 368: 12011209. 17

Early Detection and Treatment.

Catheterization

Viable treatment during first 90 days +/-. Avoid urine flowing through fistula. Promotes spontaneous closure of fistula. Foley for 6-8 weeks. For women in prolonged labor. Continuous catheterization. Administration of antibiotics postpartum.
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Prevention

Fistula Examination
.

Reprinted with permission from the WHO (H. Rochat)

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Simple vs. complicated vesicovaginal fistula.5

Source: Am J Obstet Gynecol 2006; 195: 1748-1752.

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Treatment

Surgery to repair the fistula.

At cost of $250+/- plus transport costs. Few hospitals with few trained surgeons. Stretching and mobilizing limbs. Physiotherapy of lower limbs, foot. Psychological and emotional counseling. Employment skill building. Crucial to recruiting women for treatment. Locate, educate, and transport. Treated women as role models.
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Rehabilitation

Outreach

Preoperative Care

Early detection/treatment of fistula is rare.

Fistulas in patients exist for months to years.

Malnutrition and Anemia Physical Therapy

Lower limb weakness. Muscular contractures. Fistula location with Foley and Dye. Rectovaginal fistula rule out. CBC and STD Labs.

Complete physical examination

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Urethrovaginal fistula before (A) and after (B) surgical repair.4

Surgery performed in the in dorsal lithtomy position. Careful vaginal examination essential to ensure no other fistulas present. 16-18F Foley placed in bladder. Success Rate >90% reported in multiple studies.
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Source: European Urology 2006; 50: 1000-1005.

Postoperative Care

Catheters left in place.

Urethral 1 week. Urinary 2 weeks. Clamped for short periods to accustom the bladder to distention. Bedsore preventative steps. Family planning education. Advise future deliveries be cesarean.
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Confined to bed rest for 2 weeks.

Abstain from intercourse for >3 month.

Surgical management of urinary incontinence after obstetric fistula repair12

>25% of women still incontinent after fistula repair. Most common in women who had a urethralvaginal fistula. Second operation can be done to repair using a combination of uretheralisation (urethral lengthening), plus fibromuscular sling of rectus fascia.
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Source: BJOG 2006; 113: 475478

Addis Ababa Fistula Hospital Fistula Ward.

Reprinted with permission from the WHO. (P. Virot)

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The forgotten fistula patients.

Helping women to reintegrate into society Education and training in work skills. Health education sessions and family counseling services Raising awareness of obstetric fistula locally and globally. Gaining agreement and resources for change.
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Source:Int J Gynecol Obstet 2006; 94: 254-261.

Obstetric fistula and stigma9

Womens Dignity Project (WDP) work on obstetric fistula in eastern Africa has two main themes:

Poverty, which precludes access to care, and Power of society to reject, banish and isolate Action-oriented research Partnerships of people and institutions committed to equitable treatment of women Challenging underlying policies that create and perpetuate stigmatizing conditions and poverty
Source: The Lancet 2006; 367: 535-536 28

Three types of engagement by WDP:

Campaign to end fistula

A part of the United Nations Population Fund (UNFPA), goals include:

Universal access to reproductive health services by 2015 Universal primary education and closing the gender gap in education by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing infant mortality Increasing life expectancy Reducing HIV infection rates Universal access to reproductive health services by 2015 Universal primary education and closing the gender gap in education by 2015 Reducing maternal mortality by 75 per cent by 2015 Reducing infant mortality Increasing life expectancy Reducing HIV infection rates

Campaign launched in 2003, and performing detailed needs assessment.

Source: Campaign to End Fistula Printed Materials

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Campaign to end fistula

Click on flash player link below or go to web address listed to start video

UNFPA

Video Player - Flash Player Installation.url

http://www.endfistula.org/movie/wm_english.htm
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Summary

A very real problem with an annual rate of new cases > indigenous repair capability.

The pool of affected women is growing faster then the ability to effect surgical repair, even if it was freely available to all who needed it.

The surgery repair is uncomplicated and inexpensive, but the real need is to avoid the occurrence of obstetric fistula in the first place. Under WHO leadership, an organized needs assessment and awareness campaign has startedto soon to evaluate results. Success will require fundamental changes:

in the availability of emergency obstetric treatment in tradition and cultural mores regarding early marriage, and an elevation in the respect for the human rights of women in general, and young girls in particular, in the developing world.

My take is that this is a monumental effort, and will only occur if piggybacked with other, broader programs related to human reproductive rights.
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References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Wall LL. Obstetric vesicovaginal fistula as an international public-health problem. Lancet 2006; 368: 1201-1209. Van Beekhuizen HJ, Unkels R, Mmuni NS, Kaiser M. Complications of obstructed labour: pressure necrosis on neonatal scalp and vesicovaginal fistula. Lancet 2006; 368: 1210. Norman AM, Breen M, Richter HE. Prevention of obstetric urogenital fistulae: some thoughts on a daunting task. Int Urogynecol J 2006; (Epub ahead of print). Pushkar DY, Dyakov VV, Kosko JW, Kasyan GR. Management of urethrovaginal fisyulas. European Urology 2006; 50: 1000-1005. Roenneburg ML, Genadry R, Wheeless CR. Repair of obstetric vesicovaginal fistulas in Africa. Am J Obstet Gynecol 2006; 195: 1748-1752. Mishra SK, Morris N, Uprety DK. Uterine rupture: preventable obstetric tragedies? Aus and NZ J of Obstet and Gynecol 2006; 46: 541-545. Jokhio AH, Kelly J. Obstetric fistulas in rural Pakistan. Int J Gynecol Obstet 2006; 95: 288289. Serour GI, (FIGO Committee Report). Ethical guidelines on obstetric fistula. Int J Gynecol Obstet 2006; 94: 174-175. Bangser M. Obstetric fistula and stigma. Lancet 2006; 367: 535-536. Donnay F, Ramsey K. Eliminating obstetric fistula: Progress in partnerships. Int J Gynecol Obstet 2006; 94: 254-261. Ramphal S, Moodley J. Vesicovaginal fistula: obstetric causes. Curr Opin Obstet Gynecol 2006; 18: 147-151. Browning A. A new technique for the surgical management of urinary incontinence after obstetric fistula repair. BJOG 2006; 113: 475-478 WHO. In: Lewis G, de Bernis L, editors. Obstetric fistula: guiding principles for clinical management and program development. Geneva: WHO Press; 2005. Wall LL, Karshima JA, Kirshner C, Arrowsmith SD. The Obstetric vesicovaginal fistula: characteristics of 899 patients from Jos, Nigeria. Am J Obstet Gynecol 2004; 190: 1011-1019. Miller S, Lester F, Webster M, and Cowan B. Obstetric fistula: A preventative tradegy. J Midwife Womans Health 2005; 50: 286-294. R.F. Zacharin, A history of obstetric vesicovaginal fistula, Aust N Z J Surg 2000; 70: 851854 32