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D. Jack, M.B.A., M.D.

Assistant Professor, Des Moines University College of Osteopathic Medicine

However, the consequence of intravascular injection and excessive destruction of the vas by even a slight increase of instillation can be disastrous and the procedure irreversible. The fallopian tube is drawn up with dissecting forceps in a position where the broad ligament is relatively bloodless and curved clamps are placed in position on each side. Although the operation is simple, it gives excellent results and subsequent adhesions have been shown to cause no trouble. Interval sterilization is done when the woman is not pregnant or any time after 6 weeks of delivery. Indications Apart from multiparity and the need of permanent method of family planning, sterilization may be advisable in women with medical diseases. Laparotomy sterilization is performed when the abdominal incision extends well over 5 cm and is done during caesarean section and during gynaecological surgery. The fallopian tube is identified on each side, brought out through the incision, and the middle portion is formed into a loop which is tied at the base with catgut and excised. The operation is simple, requires short hospitalization, does not require sophisticated and expensive equipment like a laparoscope, and can be performed in primary health centre by a doctor trained in this procedure. Failure rate of 7% and occurrence of ectopic pregnancy are unacceptable, though it is a simple procedure to perform. The proximal end is buried in the myometrium and the distal end is buried in the broad the interval surgery should preferably be done in the preovulatory phase to avoid the potential risk of pregnancy in the postovulatory period. Laparotomy n Pomeroy method n Madlener method n Irving method n Aldridge method n Cornual resection Madlener Uchida Irving Pomeroy Fimbriectomy Figure 20. A hole is made in the anterior leaf of the broad ligament and the fimbrial end is buried into this. The high failure rate is due to the fimbrial end popping out and restoring the patency of the tube. The tubal serosa is stripped off the muscular layer in the midsegment of the tube, which is then excised. Excision of fimbria results in permanent sterilization and leaves no potential for reversibility. Vaginal tube ligation is not popular because of higher morbidity and mortality associated with infection, higher failure rate, and it is more difficult to perform. With the patient in the head low position, the trocar and cannula are inserted through the incision and an operating laparoscope introduced after removing the trocar. The uterus is manipulated from below by an assistant so that the fallopian tubes are moved to the centre of the operating field. The earlier cauterization technique has now been replaced by the silastic Falope ring, Hulka clip and Filshie clip, which are safer (Figure 20. Monopolar cauterization is liable to cause accidental intestinal burns and destroy a considerable part of the tubal structure, a disadvantage if recanalization is required at a later date. Laparoscopic sterilization is gaining popularity all over the world as it has a number of advantages: n n n Subumbilical scar is small and nearly invisible. Complications are uncommon but when they do occur, they are usually in the hands of inexperienced personnel: n n n n n n n n n Abdominal wall emphysema due to wrong placement of the needle. Previous abdominal surgery exposes the patient to the risk of intestinal trauma in case parietal adhesions are present. Pregnancy occurs either because of undiagnosed corpus luteal phase pregnancy, faulty technique or due to spontaneous recanalization. Partial spontaneous recanalization may result in ectopic pregnancy, and estimated rate is 0. Request for tuboplasty is made when a child dies or a change of partner occurs as in remarriage.

A small tear can be sutured immediately, but a large hole needs preliminary colostomy. Anal canal and rectal injuries are mostly obstetrical, inflicted during a difficult or operative vaginal delivery. Intestinal injuries are increasingly reported following laparoscopic surgery when cautery and laser are used. Hysteroscopic uterine perforation leading to intestinal burn and peritonitis are reported with transcervical endometrial resection and excision of the uterine septum. Treatment of intestinal injury is surgical suturing or resection and end-to-end anastomosis. The help of the general or gastrointestinal surgeon should be sought in major bowel injury. Immediate diagnosis and surgical repair can prevent or minimize the distressful symptom of faecal incontinence. Inadvertent instrumental perforation of the colon during laparoscopy: Non-surgical repair. Clinical Problems, Injuries and Complications of Gynecologic Surgery Baltimore, Williams & Wilkins, 1983. Gynaecological disorders and pelvic operations often contribute towards their occurrence or aggravation. On occasions, the underlying disease may be neurological and have no gynaecological bearing. Hence, it is important for the gynaecologist to identify urinary problems attributable to gynaecological causes in order to institute rational therapy. The establishment of a proper diagnosis will call for a detailed history, meticulous examination and often a full urological investigation including laboratory tests, cystoscopy, radiological evaluation, cystometry and ultrasound scanning. Because of the close association between the urinary and genital organs embryologically, malformation of one organ may also reveal malformation of the other and it should be searched for. Elderly women, smokers and those exposed to chemicals are vulnerable to bladder cancer; accompanying haematuria must raise the suspicion of cancer. Acute Retention of Urine Causes Several causes may contribute to the occurrence of retention of urine. Postoperative Retention Urinary retention is common after surgical operations on the vagina and perineum. Postoperative oedema may cause obstruction to the flow of urine, and pain from the pelvic region may lead to a reflex spasm of the bladder sphincter. The treatment of postoperative retention consists in timely, continuous catheterization until the residual urine comes down to less than 100 mL. Common Urinary Malfunctions Common urinary malfunctions include difficulty in micturition, retention and incontinence. An attempt must be made to exclude the neurological causes (especially in patients who experience inability to void urine, but experience no painful sensation). Most patients with disorders of bladder sensation Puerperal Retention After delivery, the patient is often unable to appreciate the filling of the bladder as a result of bruising of the vagina and painful perineal wound. Chronic Retention Chronic retention of urine in old women is due to bladder neck obstruction. Treatment of urinary retention: In the presence of an organic lesion, attend to the removal of the primary cause. Retention of urine due to a retroverted gravid uterus is encountered relatively frequently. This occurs between the 12th and 14th week of pregnancy, when the retroverted gravid uterus fails to grow out of the pelvis into the abdominal cavity. The anterior vaginal wall and the attached urethra get unduly stretched as the retroverted gravid uterus sinks low into the pelvic cavity. A soft rubber catheter can be usually passed into the bladder without difficulty suggesting that rather than occlusion of the urethra, it is the disturbance of the reflex mechanism of voiding which causes the retention.

Because of this tubular secretion of potassium, the urinary loss of potassium would continue and may even be greater than the intake, when daily intake of potassium is markedly restricted. Increased sodium intake increases the potassium loss because it makes more Na + available for exchange with K+ while low sodium intake reduces the urinary loss of K+. A part of this is secreted by, the colon in exchange for sodium which is reabsorbed. This potassium loss in stools continues even in subjects on very low potassium intake. This is in contrast to body sodium, which is conserved by achieving its complete reabsorption by the tubules and the intestines, when sodium intake is markedly reduced. Thus, proportionately more potassium is lost per unit volume of sweat than sodium, with respect to their plasma levels. Excessive sweating, as occurs during dry heat or during fevers, can cause significant potassium depletion. As per current estimate, nations which consume lots of processed foods ingest as much as 100-400 mmol of sodium and 50-70 mmol of potassium, with a dietary K+/Na+ ratio of less than 0. Hyperkalemia may occur in older patients with renal insufficiency Salt substitutes which may contain as much as 200 mmoles of potassium per. Part of the retained sodium shifts into the cells, thus displacing some of the potassium which is excreted. Conversely, in severe sodium depletion, as in diabetic coma, the serum potassium may be raised. If the plasma potassium level is high to begin with, acidosis will cause further rise in plasma potassium. However, acidosis, in the presence of marked potassium depletion, will cause severe cellular derangement as it will aggravate the fall of intracellular potassium. In the presence of potassium depletion, such a shift may cause marked hypokalemia. This phenomenon occurs in patients recovering from diabetic coma where, as the tissue glycogen is repleted following insulin and glucose, potassium shifts into the cells thus causing a fall in serum potassium level. Protein anabolism is also associated with increased potassium uptake by the cells while protein catabolism would cause cellular potassium loss. Aldosterone secretion is integral to potassium homeostasis, controlling its excretion in the urine, feces, sweat and saliva. The normal physiological regulators insulin and catecholamines are stimulated by the ingestion of foods containing glucose and potassium. They are essential in shifting potassium intracellularly mainly into the liver and the muscles. Potassium Depletion and Hypokalemia Hypokalemia is usually defined as plasma potassium < 3. However, body potassium depletion can exist in the presence of normal serum potassium. As much as 100 to 200 mMol of K+ loss is necessary in adults before the serum K+ falls below 3 mMol/L. In formed bulky stools, however, sodium loss may not be much but the loss of potassium could be considerable. Increase in plasma potassium level due to intracellular potassium loss in such conditions as sodium overload, starvation, acidosis or protein catabolism increases renal loss of potassium. In addition, renal loss of potassium also occurs in: (a) the presence of excessive aldosterone, hydrocortisone. Patients with glomerular diseases do not lose potassium; in fact, they generally retain potassium. It must also be borne in mind that potassium depletion, in itself, may cause renal tubular dysfunction. Many vague symptoms such as lethargy malaise, weakness of muscular activity anorexia and thirst have been attributed, to but not definitely proved to be due to mild potassium deficiency On average, a. Loss of potassium in amounts greater than 30% of the total body potassium causes widespread damage to cell function. If such a deficiency is not suspected, these symptoms may lead to the erroneous diagnosis of neurosis and may even result in death, if left untreated.

Aminophylline increases the cardiac output, reduces the pulmonary artery pressure and the cardiac preload, induces bronchodilatation, stimulates the respiratory centre and causes diuresis. Their central actions are similar to xanthines but peripherally they produce adrenaline-like actions (Chapter 18). Stimulants of the Brain Stem and Medullary Centres Most drugs belonging to this group (picrotoxin, pentylenetetrazole, nikethamide and camphor) are no longer used as respiratory stimulants (analeptics) because of lack of specificity toxicity and unproven efficacy In large doses these drugs produce clonic. Adverse reactions include vomiting, hypertension, tachycardia, arrhythmias, muscle twitchings, tremors and convulsions. It is effective orally It has been used with some success in patients with chronic ventilatory. Given orally or parenterally in animals, it produces convulsions characterised by tonic extension of the body and opisthotonus. Strychnine acts mainly on the spinal cord but it stimulates the entire neuraxis in large doses. It is a competitive antagonist of the inhibitory transmitter glycine at the post-synaptic inhibitory sites. Tracheal intubation and assisted ventilation are indicated if adequate ventilation is not restored. The universal antidote, if administered without delay would adsorb, the alkaloid and prevent its systemic absorption. Alternatively oxidising solutions like 1:, 1000 potassium permanganate or 2% tannic acid (as strong tea) may be employed. Reflex Stimulants of the Central Nervous System Lobeline: Lobeline is an alkaloid obtained from the leaves of Lobelia inflata. In addition it stimulates autonomic ganglia, and the axon reflex which induces sweating. Other reflex stimulants of the central nervous system such as nicotine, veratrum and apomorphine are discussed elsewhere. Liquor ammonia and smelling salts (ammonium carbonate) inhalation in syncope is a common household procedure which stimulates the respiratory and vasomotor centres reflexly. Regardless of terminology the objective of drug therapy in, psychiatry is to induce an improved mental state in mentally disturbed patients. Drugs which selectively modify the behavioural pattern are known as psychotropic or psychoactive drugs. Little is known about the neurophysiological and biochemical differences between normal individuals and mentally ill patients. The mind cannot be separated from the physical body Many physical illnesses cause associated. The etiology of psychic illnesses is complex, and includes both psychological and physiological/biochemical factors. In some of them, psychological problems predominate, whereas in others, disturbances of endogenous neurochemicals clearly exist. For pure psychological problems (affective disorders) psychotherapy is a good alternative to drugs, whereas drugs are most effective in treating biologically (neurochemically) based psychotic illnesses such as manic depressive psychosis. However, in all patients both psychotherapy and drugs are necessary for the best results. Evaluation of psychotropic drugs in animals: Models of psychic disturbances analogous to those seen in humans cannot be produced in animals. Further, the intellectual superiority of man over the highest primate is so great that it is difficult to predict usefulness of drugs in the treatment of human mental illnesses from the behavioural studies in animals. It is not surprising, therefore, that therapeutic application of many compounds in humans originated from accidental observations in patients getting such drugs for other purposes. Similarly, the modification of natural activities of various animals by drugs is helpful in evaluating their general stimulant or depressant properties.