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This chapter addresses the role of health professionals in providing abortions and examines the dynamic technology of this field. Once the decision to perform an abortion is made, the proper procedure must be selected. Gestational age is the fundamental determinant but the experience and capability of the practitioner are also crucial. Suction curettage is the safest and most effective procedure available for abortions performed within 10 weeks of conception. Evaluation of the abortion patient should include, at a minimum, tests for hemoglobin, presence of gonococci, and Rh type. One of the most important parts of preparation for an abortion is sensitive and searching counseling. A potentially serious complication of suction curettage is perforation of the uterus. Dilatation and evacuation (D and E), is similar to the suction curettage procedure. This method may be used for gestations of 20 or more weeks after conception and requires greater operator expertise and experience. The complications of D and E are similar to those of suction curettage but are more frequent. Amnioinfusion is currently the most widely used method of pregnancy termination after 14 weeks in the US. The abortifacient agent that has had the greatest use is hypertonic saline. Morbidity associated with saline amnioinfusion includes hemorrhage requiring transfusion, retained tissue requiring manual or surgical removal infection, coagulopathy, and hypernatremia. Prostaglandins are alternative abortifacient agents. A disadvantage of using prostaglandins to induce abortion is that they frequently require repeat doses to be effective. Other disadvantages include nausea, vomiting, diarhea, and bronchospasm. Urea is anther effective abortifacient agent.
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PMID:Abortion. 38 51

We report the case of a young man who became adipsic following a subarachnoid hemorrhage and subsequently had two episodes of life-threatening hypernatremia. Investigations demonstrated that he had defective osmoregulated thirst and AVP release, but normal AVP responses to hypotension and nausea. There is also evidence that he had intact baroregulated thirst. We discuss the results of our investigations in the context of current models of hypothalamic-neurohypophysial function.
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PMID:Chronic hypernatremia due to impaired osmoregulated thirst and vasopressin secretion. 189 37

Pituitary apoplexy is characterized by a wide spectrum of clinical features. A quite rare case of painless thyroiditis, hypopituitarism and central diabetes insipidus (DI) followed by pituitary apoplexy was presented. A 61-year-old woman was admitted to our hospital in May, 1986 because of marked general malaise, polydipsia and weight loss which became progressively worse. Four months earlier she had experienced episodes of abrupt onset of severe headache associated with nausea and blurring vision. Physical examinations revealed a fine tremor, dry skin and nervousness. The thyroid gland was not palpable. Visual fields were intact. Her blood pressure was 105/64 mmHg with variable tachycardia. The routine laboratory studies were normal or negative except for hypoalbuminemia, hypocholesterolemia and hypernatremia. Erythrocyte sedimentation rate was 12 mm/hr. An impairment in corticotropin secretion was suspected from the low plasma cortisol and the low urinary excretion of 17-OHCS and the sufficient response to ACTH. Basal levels of GH and gonadotropin were also low, and responses to the stimulation tests (Insulin-stress, L-DOPA, and LH-RH) were all blunted. Brain computed tomographic scan and magnetic resonance imaging demonstrated a suprasellar mass that, after infusion, developed peripheral ring-like enhancement and large hyperintense pituitary mass, respectively. A diagnosis of pituitary apoplexy with anterior pituitary failure was made. However, the initial levels of thyroid hormones showed elevated as follows: Free T3 7.6 pg/ml, Free T4 3.3 ng/dl and T3-resin uptake 41.1%. TSH responses to TRH were all suppressed. TSH receptor antibody (TBII) was negative. Both antithyroglobulin and antimicrosomal antibodies were repeatedly positive. A thyroid scan with 99mTc revealed no uptake in the thyroid area. These findings led us to the diagnosis of "painless autoimmune thyroiditis". She had become hypothyroid without any medication. At that time radioactive 99mTc and 123I uptakes increased significantly. When hydrocortisone was substituted, daily urine output abruptly increased to about 10 liters with low osmolality, and the presence of DI was suspected. This diagnosis was confirmed by water deprivation and hypertonic saline infusion tests and subsequent pitressin test. She is currently quite well on L-thyroxine, hydrocortisone and desmopressin (1988). This association with pituitary apoplexy must be a rare occurrence, as a literature search has failed to find a similar case. The pathogenetic trigger of "painless thyroiditis" in this case may be responsible for some immunological change due to secondary adrenal insufficiency after pituitary apoplexy.
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PMID:[An unusual association of transient resolving thyrotoxicosis due to painless thyroiditis, hypopituitarism and central diabetes insipidus associated with spontaneous pituitary apoplexy]. 230 57

Literature data on current methods of induced abortion during the 2nd trimester are reviewed with special emphasis on the use of intraamniotic administration of hypertonic saline solution. A 20% saline is injected during amniocentesis either intra-abdominally or through the vagina; the optimum time period for pregnancy termination is 21-23 weeks of gestation. In the majority of patients, miscarriage occurs within 24-36 hours. The incidence of complications after administration of 20% saline ranges from 1.7-2.18%. Complications include hypernatremia, hemolysis, anuria, coma, seizures, incomplete abortion, hemorrhage, and inflammatory pelvic disease. Contraindications for pregnancy termination using hypertonic saline include cardiovascular diseases, central nervous system diseases, kidney diseases, late pregnancy toxemias, presence of postoperative cicatrix on the uterus, and placenta previa. The mechanism of abortifacient action of hypertonic saline may be associated with stimulation of the synthesis of endogenous prostaglandins (PG). The findings that PG can stimulate uterine contractions prompted clinical trials of PG as abortifacient agents. Longterm iv administration of PGF2 alpha and PGE during 2nd trimester was found to be associated with serious complications (nausea, vomiting, diarrhea, phlebitis at the site of vein puncture). For this reason, the method of iv administration of PG was abandoned. Intra-amniotic administration of PGF2 alpha (40-50 mg) was shown to induce abortion in 82-91% of the patients within 48 hours after injection. The incidence of hemorrhage and rupture of the cervix uteri after PG administration was significantly greater than that after saline injection. The intramuscular and vaginal administration of synthetic PG alone or in combination with Laminaria was shown to provide the most effective and safe method of induced abortion during the 2nd trimester.
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PMID:[Artificial termination of pregnancy in late periods]. 332 84

In outlining the pathology of various electrolyte metabolism abnormalities in cancer patients we considered the main clinical points between pathologies and emergency treatment. In regard to sodium (Na+) metabolism, one pathologic state that requires our attention is hypernatremia. Hypernatremia is accompanied with dehydration and is due to water loss, vomiting, diarrhea and renal insufficiency. One of the major causes of this condition is lack of the antidiuretic hormone due to intracranial metastasis of the tumor. When hypernatremia becomes severe, it is accompanied with circulatory failure, muscular asthenia, disorientation, convulsions, coma and other cerebral symptoms. Treatment consists of replenishing the water content by infusion of electrolyte solutions which should be carefully conducted after complete diagnose of the severity of the patient's pathological condition. Hyponatremia, like sick cell syndrome, is observed relatively frequently in cancer patients. When the serum Na level falls markedly, it induces cerebral edema and causes disorders of consciousness. The major treatment consists of providing both water and sodium supplements. Hyperkalemia is observed at the time of renal insufficiency, tissue lesions, vomiting, and diarrhea. When serum potassium level rises, it causes bradycardia, ventricular fibrillation, or cardiac arrest. It is important to diagnostically apprehend the severity of this condition using EKG and determining the serum K1+ level. For emergency treatment injection of calcium gluconate is very effective. Hypokalemia is often manifested by the loss of intestinal fluids due to diarrhea or during administration of diuretic agents. Clinical symptoms include neural paralysis but emergencies occur relatively infrequently. K C1 injections are used in treating this condition. Hypercalcemia is manifested in cancer patients during hyperparathyroidism. Its clinical symptoms include lassitude, tachycardia, nausea, vomiting, and renal dys-function, leading to neural symptoms in severe cases. The main treatment consists of injection of physiological saline solution and administration of calcitonin, mithramycin. Hypocalemia is manifested during renal insufficiency, lack of vitamin D, and hypothyroidism. In classic cases it causes tetanic spasms. Injection of calcium is an effective treatment but since during tetanic spasms alcalosis may easily occur, treatment should only be provided after obtaining a complete understanding of the patient's condition. The pathological conditions described above can not be said to specific to cancer but it should be kept in mind that one of their main causative factors is the involvement of mechanism which produces ectopic hormones from cancerous tissues.
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PMID:[Electrolyte metabolism and emergency]. 688 72

The osmolality of body fluids is normally maintained within a narrow range. This constancy is achieved largely via hypothalamic osmo-receptors that regulate thirst and arginine vasopressin, the antidiuretic hormone (ADH). Anything that interferes with the full expression of either osmoregulatory function exposes the patient to the hazards of abnormal increases or decreases in plasma osmolality. Hyposmolality is almost always due to a defect in water excretion. Increased intake may contribute to the problem but is rarely, if ever, a sufficient cause. Impaired water excretion can be due to a primary defect in the osmoregulation of ADH (inappropriate antidiuresis) or secondary to nonosmotic stimuli like hypovolemia or nausea. The two types differ in clinical presentation and treatment. Resetting of the ADH osmostat is commonly associated with resetting of the thirst osmostat. Hyperosmolarity is almost always due to deficient water intake. Excessive excretion may contribute to the problem but is never a sufficient cause. Impaired water intake can result from a defect in either the osmoregulation of thirst of the necessary motor responses. Thirst may be deficient because of primary osmoreceptor damage as in the syndrome of adipsic hypernatremia or secondary to nonosmotic influences on the set of the system. They are distinguishable by the clinical presentation as well as the type of ADH defects with which they are associated. So-called essential hypernatremia due to primary resetting of the osmostat has been postulated, but unambiguous evidence for such an entity has not yet been reported.
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PMID:Neurogenic disorders of osmoregulation. 703 30

Symptoms can markedly influence the hemodialysis patients well-being and quality of life. The aim of this paper is to study the frequency of symptoms at home and how these relate to biochemical and treatment variables. Seventy-three hemodialysis patients were questioned on the absence, occasional presence or daily recurrence (score = 0, 1, 2) of 14 symptoms and a record was made of their biochemical parameters, age, time on treatment and KtIV as a function of each symptom. The following relationships were detected: thirst with high Osm and BUN; asthenia with old age and hypoalbuminemia; insomnia with hypercalcemia; hypersomnia with hypoxemia and hypernatremia; anorexia with hypokalemia; dyspnea with old age, hypernatremia and hypokalemia; dysgeusia with hypoxemia; nausea with alkalemia, hypoxemia and low BUN; vomiting with alkalemia. Pruritus, arthralgia, restless legs syndrome, cramp and tremor showed no relationships. Monitoring acid-base balance and plasma electrolytes could help to alleviate symptoms and ameliorate quality of life of hemodialysis patients.
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PMID:Symptoms in hemodialysis patients and their relationship with biochemical and demographic parameters. 998 55

We present here a case of prominent hypercalcemia accompanied by hypothalamic tumor and Graves' disease. A 24-year-old man with hypothalamic tumor showed hypopituitarism, central diabetes inspidus (DI) and hyperthyroidism. Nausea, loss of thirst and appetite, and general fatigue were found with the unveiling of hypercalcemia and hypernatremia. Parathyroid hormone (PTH) and 1alpha-dihydroxyvitamin D levels were suppressed with a normal range of PTH-related protein values. One-desamino-(8-D-arginine)-vasopressin (DDAVP) and half-saline administration normalized hypernatremia, while hypercalcemia was still sustained. Administration of cortisone acetate and thiamazole reduced the elevated serum Ca level. In the present case, concurrent hyperthyroidism was assumed to accelerate skeletal mobilization of calcium into the circulation. Hypocortisolism and central DI was also considered to contribute, to some extent, to the hypercalcemia through renal handling of Ca.
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PMID:Hypercalcemia accompanied by hypothalamic hypopituitarism, central diabetes inspidus and hyperthyroidism. 1041 54

A 42-year-old man came to our emergency room hyperthermic (oral temperature, 42.4 degrees C), diaphoretic, and delirious. Other findings included labile blood pressure, sinus tachycardia (heart rate, 138/min), tachypnea (respiratory rate 34/min), muscle rigidity, and incontinence. Two days earlier, he had gone to a local clinic with complaints of abdominal pain, nausea, and vomiting. Promethazine was prescribed, and this was the patient's only medication on admission. Laboratory studies showed leukocytosis, hypernatremia, metabolic acidosis, elevated creatinine phosphokinase level, elevated transaminase levels, azotemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and myoglobulinuria. The clinical and laboratory findings were characteristic of the neuroleptic malignant syndrome, with promethazine as the offending agent.
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PMID:Neuroleptic malignant syndrome due to promethazine. 1054 78

A 30-year-old white man with schizophrenia developed anorexia and nausea, and was admitted to hospital for confusion and delirium. He was on olanzapine, 10 days prior to admission. On admission, typical neuroleptic malignant syndrome (NMS) developed with elevated body temperature (39.7 degrees C), obtundation, tremor, rigidity, diaphoresis, fluctuating pupillary diameter, tachycardia, labile hypertension, elevated serum creatine kinase and severe hypernatremia (190 meq/l). Olanzepine was stopped few days after admission to the hospital and the NMS manifestations resolved by hospital day 12. The patient had all of the major manifestations of NMS. There was no other likely explanation for his illness. This is the first case reported in which NMS was associated with olanzapine and extremely elevated levels of serum sodium. Copyright 2001 John Wiley & Sons, Ltd.
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PMID:Neuroleptic malignant syndrome with olanzapine associated with severe hypernatremia. 1240 81


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