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Objectives: To compare the effectiveness and complications of Burch colposuspension and Mid Urethral Slings (MUS) for the treatment of Stress Urinary Incontinence (SUI). Methods: We conducted a cross-sectional study of 162 patients who underwent surgery for SUI with Burch colposuspension (n=40), tension free vaginal tape (TVT) (n= 59) or transobturator tape (TOT) (n=63), from 2006 to 2014 at the Aga Khan University Hospital- Karachi. All three groups were assessed in terms of demographics, cure rates, intraoperative and postoperative complications at one and five years using incontinence impact questionnaire-short form-7 (IIQ-7) and urogenital distress inventory -short form-6 (UDI-6). Results: Mean age of the participants in Burch, TVT and TOT group was 44.1 ± 7.4, 48.3 ± 8.9, 53.0 ± 9.4 respectively. Majority of patients in TVT group were premenopausal (59.3%) and postmenopausal in TOT group (53.9%). Most abdominal hysterectomies were done in Burch group (40) while vaginal hysterectomies and anterior and posterior colporrhaphy in TOT group (55). All the procedures had both subjective and objective cure rate of more than 82% at one year, with TVT having the highest success rate of 96.61%. The objective cure rate in Burch, TVT and TOT group at five years was 74.19%, 90.30% and 81.25% respectively. Intraoperative complications included hemorrhage in one patient during Burch procedure and bladder perforation in two cases of TVT, with no significant difference in short or long-term complications with either procedure. Conclusions: All the three procedures have equal efficacy and complication rates. Even though TVT is the new gold standard but in view of current debate regarding mesh related complications, there is a need to readdress Burch colposuspension for treatment of SUI. doi: https://doi.org/10.12669/pjms.37.5.4017 How to cite this:Abrar S, Razzak L, Mohsin R. The practice of Burch Colposuspension versus Mid Urethral Slings for the treatment of Stress Urinary Incontinence in developing country. Pak J Med Sci. 2021;37(5):1359-1364. doi: https://doi.org/10.12669/pjms.37.5.4017 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A 25-year-old female patient visited our clinic with complaint of cyclic haematuria. She had previous two Caesarean Sections at a secondary care hospital. Her complete urinalysis showed abundant red blood cells. Through computed tomography a fistula tract between the posterior wall of the bladder and the anterior wall of the lower uterine segment was diagnosed. The Cystoscopy revealed a fistulous opening with a diameter of nearly 1.5 cm localized between the bladder and uterine cavity. Fistulae was repaired by abdominal approach without transection of bladder. Surgery was performed by mobilization of bladder and wide anterior uterine dissection. A 2cm defect in the lower uterine segment was identified and was closed with 0 polyglycolic acid suture. Bladder defect was repaired in two layers. Then omental tissue flap was placed between the two surfaces. At 6 months follow the up patient was asymptomatic. Keywords: cyclic menouria; vesicouterine fistulas; Youssef’s syndrome. Continuous..

Objectives: This study asseses the association of overactive bladder symptoms and pelvic organ prolapse severity and evaluates the effect of pelvic reconstructive surgery on overactive bladder (OAB) symptoms in women with pelvic organ prolapse (POP). It also looks into any pre and post-operative factors responsible for persistent postoperative OAB symptoms. Methods: This was a retrospective cross-sectional study conducted at the Aga Khan University Hospital, Karachi between 1st January 2014 and 31st December 2018. In this study women presenting with POP and concommitent OAB who underwent surgery for site specific defects, measured using Pelvic Organ Prolapse Quantification (POP-Q) staging system. OAB was defined as presence of urinary frequency, urinary urgency incontinence (UUI) and an affirmative response to item #15 and/or item #16 of the Pelvic Floor Distress Inventory (PFDI), which was used both pre and postoperatively. Primary outcome of the study was to find complete resolution or improvement of urinary frequency and UUI on the PFDI, 24 months after surgery. The secondary outcome was to see persistent OAB postoperatively and the factors associated with it. Results: Overactive bladder (OAB) symptoms improved significantly regardless of the severity of prolapse at 24 months postoperative period. Body mass index (BMI) and postoperative constipation were the only statistically significant variables associated with persistent OAB symptoms postoperatively. Conclusions: Surgical correction of POP results in significant improvement in symptoms of OAB, in all stages of POP and co-existing OAB. However women with high BMI and post-operative constipation may be prone to persistent frequency and/or UUI. doi: https://doi.org/10.12669/pjms.37.3.3312 How to cite this:Abrar S, Rizvi RM, Zahid N. The association of symptoms of overactive bladder with pelvic organ prolapse and its improvement after pelvic reconstructive surgery. Pak J Med Sci. 2021;37(3):897-902. doi: https://doi.org/10.12669/pjms.37.3.3312 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To perform a clinical audit of the practices of third and fourth degree preineal tears management in our institution. Methods: A review of medical records was performed, of women having singleton term vaginal delivery sustaining obstetric anal sphincter injuries (OASIS) at Aga Khan University Hospital (AKUH), Karachi from January 2008 to December 2018. We compared the change in practices regarding management of OASIS with the results of our previous study done at AKUH in 2008. Results: The frequency of OASIS in our department is 0.56% (142/25370). The documentation of OASIS improved compared to previous study ( 20.7% to 87%). There was also a significant increase in documentation of the method of repair, use of delayed absorbable suture material for the repair of external anal sphincter and follow-up at 06 weeks to see the success of repair and plan next delivery. The use of vaccum vaginal delivery increased to 27(19%) from 5(4%) but there was decrease in the OASIS complicated by instrumental vaginal deliveries, which may be due to the decrease in the use of forceps from 64% to 26%. Conclusions: Despite of increase in the number of deliveries , frequency of OASIS remained similar to the previous study. There was a significant increase in the vaccum vaginal delivery, documentation of degree of tears, use of delayed absorbable suture material and long-term follow-up and decrease in the use of forceps. The compliance to international guideline increased as compared to our previous paper. Continuous...

Objective: The purpose of our study was to see the efficacy of 3 different modes of treatment for overactive bladder (OAB) in symptoms reduction and quality of life improvement. Methods: We conducted a 12-week single-blinded randomized controlled trial of women aged 22–65 years with clinical diagnosis of OAB. Arm A (n = 47) received bladder training, arm B (n = 50) received pelvic floor muscle training (PFMT), and arm C (n = 50) received PFMT with biofeedback. Bladder diary was used to assess the difference in urinary frequency, urgency, and leak accidents before and after treatment. Initial and final assessment was made using ­validated urogenital distress inventory short form 6 (UDI-SF6) and incontinence impact questionnaire short form 7 (IIQ-SF7). Results: UDI-SF6 scores showed significant improvement in all arms. There was a reduction in UDI-6 scores from 8.38 ± 4.3 to 4.77 ± 5.5 with a mean difference of 3.61 ± 7.4 in patients in arm A (p = 0.002), arm B (p = 0.01), and arm C (p = 0.016). All patients in arms A, B, and C reported significant improvement in quality of life as assessed by IIQ-SF7 scores with significant p values of 0.009, 0.051, and 0.001, respectively. Bladder diary results using paired t test showed the significant difference in day time urinary frequency in arm A after treatment, as well as the reduction in both leak accidents and urgency score in all 3 arms. Conclusions: All 3 arms of study showed significant results and can be used as the first line of management.

Additional file 1: Appendix. Study questionnaire

Background Pelvic organ prolapse (POP) is a gynecological condition resulting from pelvic floor dysfunction in women. The objective of this study is to estimate “the prevalence of pelvic organ prolapse” associated factors, duration and impact on women’s quality of life in rural Pakistan. Methods A cross-sectional study was conducted with a three stage random sampling strategy. Three health centers were selected and selected Lady Health Workers from each health center interviewed a random sample of women in their households. The interview used a structured questionnaire to collect symptom data. Female gynaecologists then conducted a clinical examination at the local health center on women who reported symptoms of prolapse to verify and grade pelvic organ prolapse using Baden-Walker classification system. Results Among the 5064 women interviewed (95.8% response rate), 521 women had clinically confirmed POP, a prevalence of 10.3% (95% CI 9–11%). Among women with POP 37.8% had grade III or IV prolapse. Women with four or more children had the highest proportion of pelvic organ prolapse (75%) followed by women aged 36–40 years (25%).Among women with POP, 60.8% reported their quality of life as greatly or moderately affected; 44.3% had it for more than 5 years; and 78.7% never consulted a doctor. Conclusions Pelvic organ prolapse is highly prevalent in rural Pakistan, impacts on women’s everyday lives and remains mainly untreated. Measures should be taken to provide health care services to reduce this burden of disease among women.

Case: A female aged 22 years, suffering from cyclical menouria since age of 12years presented to our clinic with concerns for future sexuality and fertility. Clinical examination revealed the absence of a vagina, although labia minora and majora were adequately developed. Secondary sexual growth such as axillary and pubic hair, breast development was normal. Micturating cystogram shows abnormal fistulous communication between the posterior urethra and upper vagina with contrast outlining the uterine cavity. Magnetic resonance imaging revealed functioning left kidney along with vaginal agenesis and an abnormal communication between uterus and urethra. The surgical treatment included urethrovaginal fistula repair and pull through vaginoplasty. The patient was asymptomatic till her last visitConclusions: In this case, the diagnosis of congenital urethrovaginal fistula was delayed until adulthood despite menouria. This is a rare case report and to our best of literature search .we could not find any such case report.Key words: congenital, menouria, urethrovaginal fistula, vaginal agenesis

ObjectivesThere is conflicting evidence regarding the indications of urodynamic studies (UDS) and various guidelines. American urogynecologic Society (AUGS), National Instititute of Health and Care Excellence (NICE), and WHO provide variant indications for UDS testing. For developing countries, there are no data to support the usefulness of UDS. Considering the cost, invasiveness, and expertise required for UDS, we planned to review UDS performed at Aga Khan University and Hospital (AKUH) from 2007 to 2014. Our purpose of study was to derive important conclusive messages as a guideline for future practices.Study designThis is a cross-sectional retrospective review of 500 patients undergoing UDS from 2007 to 2014.ResultsComparison between clinical diagnoses and urodynamic diagnoses was done and frequencies were computed. The mean age of the patients was 61.1 years, the mean body mass index was 25 and mean parity was 4.1. There was a matching between clinical and urodynamic findings of stress urinary incontinence (SUI) and overactive bladder (OAB), but disparity was observed in cases of mixed urinary incontinence (MUI) and lower urinary tract symptoms (LUTS). Occult SUI was found in 33% of patients with POP.ConclusionKey messages were derived for future practice stating that for cases of SUI and OAB, UDS are not required, but patients with complex MUI, chronic LUTS, and neurogenic bladder warrant UDS.How to cite this articleChughtai NG, Rizvi RM, Kashif U. Key Messages of Urodynamic Studies in Cases of Urinary Incontinence and Pelvic Organ Prolapse: A Retrospective Review. J South Asian Feder Obst Gynae 2016;8(4):299-303.

Pelvic organ prolapse and urinary incontinence are among the most common chronic disorders in women. These are common problems whose pathogenesis remains unclear. As life expectancy increases, significantly greater number of women now present with pelvic organ prolapse and urinary incontinence requiring surgical intervention. Currently, the lifetime risk of undergoing prolapse or continence surgery is one in 11, and up to 30% of patients will require repeat reconstructive surgery and repeat surgery for incontinence in 10%. In an attempt to improve surgical outcomes and to preserve vaginal capacity and coital function, a number of synthetic and biological prostheses have been developed. This review aims to look at the role of graft and mesh in vaginal surgery. We conducted a search for English-language articles published during 1997 to 2016, using MEDLINE, PubMed and United States' National Library of Medicine databases. We reviewed around 50 papers but referenced only 30 for this article. The literature review provided us a new insight regarding safety of mesh. Polypropylene mesh is safe for vaginal surgery if used by experienced surgeons. The safety of mesh becomes compromised in the hands of commercial surgical kit providers. All the new mesh tailored kits should undergo evidence-based trials and then can be safely used worldwide.

Objective To estimate the prevalence of obstetric fistula, its duration and impact on women's daily life using robust data collection methods in a population-based sample in rural Pakistan. Design A population-based, cross-sectional study. Setting A rural community in Sindh Province, Pakistan. Population Randomly selected women aged 15 years or older. Methods A multistage random sampling strategy was used to recruit the women. Lady Health Workers interviewed women in their own homes using a structured questionnaire to obtain symptom data. Women with symptoms of incontinence were then examined by female gynaecologists in their local health facilities to confirm obstetric fistula. Main outcome measure Obstetric fistula confirmed by gynaecological examination. Results Among the 5064 women interviewed (96% response rate), 20 women with obstetric fistula were identified, showing a prevalence of 0.39% of all women (95% confidence interval [95% CI] 0.22–0.57%) and 0.45% of parous women (95% CI 0.25–0.65%). Significantly more of the women with obstetric fistula compared with parous women without fistula were primiparae and aged 5 years and 90% reported a major impact on their lives, yet only four had consulted a doctor, three of whom had failed repairs. Conclusions The prevalence of obstetric fistula is high in rural Pakistan. Appropriate provision is needed for fistula repair to reduce the burden of the condition. Alongside this, the improvement of maternity care services is urgently needed to prevent its continued occurrence.

There is a large body of literature investigating the mechanism, risk factors, and pathophysiology of postpartum urinary retention; it is usually a temporary condition where early diagnosis and appropriate management can avoid long term complication. This article reviews the etiology, prevention, management and long-term implications of retention for bladder functions.

The Multiparous Goat Pelvic Model was used to train obstetricians and residents for perineal and anal sphincter anatomy and techniques of repair of Obstetric Anal Sphincter Injuries (OASIs). The purpose of this study was to assess the similarity of this model with human anatomy and the usefulness of goat model for training obstetricians for perineal tears. Six workshops were conducted between June 2009 and December 2010. A total of 90 participants, including 64(70.3%) residents and 26(28.5%) consultants in Obstetrics and Gynaecology, attended hands-on training workshops using experimental goat pelvic model for the repair of perineal tears. Among the consultants, 23 (88.5%), and 60 (93.7%) residents could easily identify the goat anal sphincter. With reference to the similarity to human vaginal dimensions, 20 (76.9%) consultants and 43(67.1%) residents found it to be similar with human anatomy. Evaluating the anal canal anatomy, 22 (84.6%) consultants and 34(53.1%) residents reported it to be similar to the human anal canal. The perineal body anatomy was reported as very different by both consultants and residents (80% and 67.9% respectively). All the consultants and 49(76.5%) of the residents strongly recommended the use of this model for future hands-on workshops.

This article was migrated. The article was not marked as recommended. Background: Internship is a phase of training wherein a graduate learns in the context of practice, acquiring skills under supervision so that he/she may become capable of functioning independently. We are reporting the process of curriculum restructuring for strengthening the Internship Program at this university hospital.Methodology:We used Kerns' six-step model to evaluate and restructure the internship curriculum. Step 01: Problem Identification & General need assessment- Thorough literature review revealed Internship as the crucial year of training that needs to be fashioned around the competencies required to make good doctors. Step 02: Targeted Need Assessment- Focused group discussions and questionnaire based survey were done in order to identify the gaps in the existing internship program. Step 03: Goals & Objectives- The aims and objectives were made to make the Internship Program a qualitative learning experience and a transition year from medical college to specialty training for Interns. Step 04: Educational Strategies- Strategies were developed to fill in the gaps which were identified in the need assessment survey including the educational sessions, orientation and objectives of program. Step 05: Implementation- The restructured curriculum was shared and was then implemented with full support from all stakeholders. Step 06: Evaluation and Feedback- The program will be evaluated after 1 year of implementation.Conclusion:Kern's six‑step approach to curriculum development is an effective method for revamping the curriculum for interns and thereby enhancing the quality of the Internship program in our setup.

Objective To estimate the prevalence of urinary incontinence (UI) and its subtypes in women in rural Pakistan, associated factors, severity and impact on daily life. Design Population-based, cross-sectional study. Setting A rural community in Sindh Province, Pakistan. Population Randomly selected women aged 15 years or older. Methods A three-level random sampling strategy was used to select women: a random sample of health centres; a random sample of Lady Health Workers (LHWs) from each health centre; and a random sample of women in the LHW catchment areas. The LHWs used an interview-based structured questionnaire to collect data from women. Main outcome measure Urinary incontinence reported by women. Results Among the 5064 participants (response rate 95.8%) the prevalence of any UI was 11.5% (581/5064; 95% CI 10.6–12.3). The most common subtype was stress incontinence, with a prevalence of 4.7% (95% CI 4.1–5.3), followed by urge incontinence, with a prevalence of 3.2% (95% CI 2.7–3.7), mixed incontinence, with a prevalence of 2.8% (95% CI 2.3–3.2), other incontinence, with a prevalence of 0.4% (95% CI 0.2–0.5) and continuous incontinence, with a prevalence of 0.5% (95% CI 0.3–0.6). Older age, higher parity and marriage at an early age were independently associated with UI. We found that 52% of women with UI reported leakage at least daily, and 45% reported a great or moderate impact on their daily life. Only 15.7% of women with UI had consulted a doctor. Conclusions The prevalence of UI reported in rural Pakistan was lower than is generally found in studies from the developed world, but among the women affected it commonly occurred on a daily basis and impacted on their everyday lives, yet few had obtained medical advice.

Background: Urodynamic testing is often regarded as essential to the proper diagnosis of bladder storage and emptying disorders but urodynamic testing is an invasive and expensive procedure. Pakistan is a developing country with limited provision of urogynecological services, and therefore few urodynamic studies. Study Design: This cross-sectional study was conducted from January 2009 to January 2010 at the Aga Khan University Hospital to assess the frequency of agreement between clinical findings and urodynamic studies in accurately diagnosing urinary incontinence. Methods: We included 157 women and their symptoms of urge urinary incontinence (UUI), stress urinary incontinence (SUI) or mixed urinary incontinence were matched with urodynamic study findings. Results: Out of 157 women 47 (29.9%) presented with SUI and 33 (21%) with UUI but urodynamic stress incontinence (USI) was found in 59 (37.6%) and detrusor overactivity in 38 (24.2%). This shows a reliability level of ĸ = 0.41 for SUI and ĸ = 0.7 for UUI. There was a weak agreement (ĸ = 0.33) between clinical findings of urinary incontinence and urodynamic studies; in 78 cases (49.7%) the urodynamic findings matched the clinical findings. Conclusions: The poor level of agreement between clinical findings and urodynamic study interpretations re-emphasizes the fact that the bladder is not a reliable source of identifying urinary symptoms in women.

To assess subjective success rates, complications and impact on quality of life (QoL) in women treated by Tension Free Vaginal Tape for urinary incontinence.A retrospective cohort analysis was made on 30 consecutive women undergoing TVT procedure alone or as concomitant to other pelvic surgical procedures, from June 2004 to October 2007. All the Patients were evaluated by history, clinical examination with POP-Q (pelvic organ prolapse-quantification) scoring for uterovaginal prolapse and urodynamic testing. Improvement of health-related QoL (quality of life) was assessed by incontinence impact questionnaire-short form (IIQ-7) and urogenital distress inventory-short form (UDI-6). The success of surgery was evaluated by asking whether the incontinence was cured, improved or had no change after the operation. Data was computed and analyzed by using SPSS version 13.Concomitant surgery was performed in 14 (46.6%) cases. Median age was 47 years and duration of follow up was 14 months (range 4-37 months). Eight (26.6%) women had mixed Urinary Incontinence with Detrusor Overactivity. Previous pelvic surgery like MMK (Marshall-Marchetti-Krantz along with TAH (total abdominal hysterectomy) was found in 5 (16.6%) cases. Complications were listed as per-operative, short-term and long-term. Among the short-term complications Bladder perforation was seen in 2 cases (6.7%) and overt urinary retention in 2 cases (6.7%). Long-term complications as voiding dysfunction occurred in only 1(3.3%) case. Symptoms were labeled as completely cured in 27 (90%) patients, significantly improved in 2(6.6%) and one with mixed incontinence regarded as having worsening of urge symptoms and dysuria.A median follow up of 14 months showed that our surgical results of TVT alone or with concomitant surgery were similar to internationally published results and TVT can be safely performed with concomitant procedures.

To review our practice of diagnosing and managing third and fourth degree perineal tears.Retrospective case series conducted by reviewing medical records of all women having singleton, full term vaginal delivery at Aga Khan University Hospital, Karachi from November 1990 to October 2005.The frequency of obstetric anal sphincter injury (OASI) in our department was 0.5% (135) out of a total of 26,844 vaginal deliveries. Seventy five percent were nulliparous (102). Forceps delivery was performed in 86 patients out of 135 (63.7%). In only 28 patients (20.7%), the diagnostic criterion for classification of third degree tears was used. For the repair of third degree tear end-to-end method was performed on 97 (71.9%) patients. Twenty nine women had subsequent uncomplicated vaginal deliveries. None of these patients were subjected to endo-anal ultrasonography and/or anal manometry. The documented evidence regarding planning of future delivery was found in only 4 cases.The frequency of distribution of third and fourth degree perineal tear in our study was 0.5% which is significantly lower than clinically suspected or recognized. Our study shows that 75.5% patients were nulliparous and the use of forceps for delivery was 63.7% among more than 50% of these patients. This indicates that forceps delivery if possible should be avoided or substituted with vacuum delivery which has a lower incidence of OASI. Most of the management was according to international accepted standards except that 72.3% were stitched under local analgesia.

Congenital obstructing lesions of vagina, hydrometrocolpos, and hematocolpos, present at a variable time during early childhood and adolescence to different medical and surgical specialties. Twenty-six cases presenting over an 18-years period (1987–2005) were divided into three groups; Group A: neonates (6), Group B: adolescents (18), and Group C: adults (2). Common presentations in neonates (Group A) were abdominal mass (5), neonatal sepsis (3), and respiratory distress (2); whereas abdominal pain (18), voiding dysfunctions (13), and backache (7) were prevalent in adolescents (Group B). Adults (Group C) presented with inability to consummate and infertility (2). Four patients received erroneous treatment; exploratory laparotomy (1) and appendectomy (3). Urinary symptoms and associated urinary abnormalities were present in more than 50% of cases, especially those with complex anomalies. Management included excision of imperforate hymen (16) and transverse vaginal septum (8) through perineal (20) and abdominoperineal approach (4). Patients with urogenital sinus (1) and cloacal malformation (1) had staged reconstruction at 2.5 years of age following preliminary vesicostomy and colostomy at birth. On follow up (range 1–15 years; mean 7) more than 60% patients have menstrual irregularity (11), endometriosis (5), and infertility (4). In conclusion, rarity and variable presentation of congenital vaginal obstructions can lead to delayed diagnosis and erroneous management. A high index of suspicion and cross-sectional imaging help in early diagnosis and associated renal anomalies. A comprehensive management is imperative to preserve the reproductive potentials, as significant proportion of patients may experience sexual difficulties, menstrual irregularity, and infertility.

To determine the frequency of urinary symptoms in women attending Gynecology clinics at Aga Khan University Hospital, Karachi.A total of 186 women attending the gynaecology clinics for symptoms of menstrual disorders, vaginal discharge or uterovaginal prolapse were asked to fill the survey questionnaire which included all the details about lower urinary tract symptoms (LUTS).Of the 180 women, 82.8% were aged between 15-44 years with BMIor = 25. Culture confirmed recurrent urinary tract infection (at least 3 episodes of urinary tract infections evidenced by positive urine culture or treated by repeated use of antibiotics) was reported by 32 (17.2%) women. The frequency of urinary incontinence was 44.4% with 17.2% cases having stress urinary incontinence (SUI). Symptoms of urinary tract infection were not significantly affected by age, parity and mode of delivery. Parity was strongly associated with prevalence of SUI (F=10.48, P0.001). Both urge and mixed incontinence were significantly related to age (F=20.57, P, 0.001 and F=13.88, P0.001) but were not affected by parity and mode of delivery.The high frequency of urinary symptoms in our community demands a need for more extensive epidemiological study and a specialized unit to provide awareness, treatment and training in this area.

Postpartum urinary retention (PPUR) has been variably defined as part or all of the following: sudden onset of painful or painless inability to void the bladder over 12 h with urine volume greater than bladder capacity requiring catheterization. In 2002 the International Continence Society revised the definition of acute urinary retention as “a painful palpable or percussable bladder when the patient is unable to pass any urine.” In its covert form urinary retention consists of increased post-void residual volume (RV); in its overt postpartum form it refers to the inability to void the bladder spontaneously after delivery. Medical records of 28940 women who were delivered at Aga Khan University Hospital (AKUH) from January 1993 to December 2003 were reviewed using code numbers from the 2003 edition of the International Classification of Diseases Ninth Revision (ICD-9). A manual compilation of the medical records was also performed to validate the ICD code search. (excerpt)