Dilutional Hyponatremia During Intrauterine Adhesion

Dilutional Hyponatremia During Intrauterine Adhesion Severe dilutional hyponatremia in a patient during hysteroscopic of intrauterine  adhesion : A case report YE Yuzhu, LIN Lina Abstract Hysteroscopy is a minimally invasive procedure for the patients of intrauterin adhesion, but may result in potentially disastrous complication labeled transurethral resection of the prostate (TURP) syndrome. Excessive absorption of large scale of distension media under high inflow pressure by openings of venous channels in endometrium, the large volume of transfusion fluid that is beyond the modulation ability of body may produce the most dangerous situation of severe hyponatremia, hypervolemia and hypoosmolality. The consequence of hysteroscopy is mainly determined by the type of distension medium, irrigation pressure,condition of endometrium, preoperative catheterization, type of electrode system and duration of the surgery. A case of hysteroscopic resection of intrauterine adhesion in which severely symptomatic hyponatremia and hypervolemia happended with epidural anesthesia is presented. Key words: Hysteroscopy, hyponatremia, distension medium, infusion pressure, TURP (transurethral resection of the prostate ) syndrome. Introduction Hysteroscopy technique in the detection and treatment of intrauterine diseases plays an dominant role because of its unique feature of minimal invasion and remains the â€Å"gold standard† mean for the diagnosis of uterine disease, but may result in potentially disastrous complication known as TURP syndrome or hyponatremia and hypervolemia. A hysteroscopy precdure requires an intrauterin installation inserting into the uterine cavity accompanied by a suitable type of distention medium including dextrose 5% in water (D5W), 2.7% sorbitol, 0.54% mannitol and saline for the visualization of intrauterine situation. The most common fluid used clinically is D5W for its distinct features of low-viscosity, electrolyte-free, safety and lower cost. TURP syndrome appears when large scale of distension media (D5W) is overly absorbed including the following clinical signs: dyspnea, headache, nausea and vomiting, coma, and even can progress to cerebaral and pulmonary edema. Signs and syndrom es are nonspecific when the conditon is in its early stages and, as a result, it’s easy to be ignored. Vigilance and communication of the whole medical team is extremely required to avoid state of illness aggravating. Early management must be rendered as soon as possible for the critically ill patients by anesthetists. We report a case of a 36-year-old woman who developed TURP syndrome during hysteroscopic of intrauterine adhesion herein. 2. Case Report A 36-year-old, weight 62 kg , no medication or coexisting diseases, ASA physical status II , underwent hysteroscopy treatment because of her reiterative intrauterin adhesion during epidural anesthesia. Past surgical history revealed four times of previous hysteroscopies within the year, both of which were aimed to remedy for her secondary infertility but failed in acquiring satisfactory therapeutic efficacy. There were no positive fingds on the preoperative physical examination and normal values in laborarory results included blood routine test and plasmic electrolytes, and the concerntrations of sodium ion, potassium ion and blood glucose level were 139 mmol/L, 3.47 mmol/L and 4.0 mmol/L, respectively. A 12-lead electrocardiogram showed sinus rhythm. Upon arrival to surgical operating room, 500 ml lactated Ringers solution was dripped intravenously as maintenance fluid after standard monitors were placed. The heart rate was 76 beats per minute, respiratory rate was 18 breathes per minute and the oxygen saturation was 99%. Contiuous epidural anesthesia was performed successfully with 0.5% lidocaine and 0.375% ropivacaine 15ml totally within 15 minutes. Then the patient was placed in lithotomy position and no catheterization was offered because of the short operation period we had anticipated preoperatively although she expressed her micturition desire. The surgery initially proceeded unevenfully with very steady state of hemodynamics. 8,000 mL D5W as the irrigation fluid was delivered throught the hysteroscope by gravity pressure (60cm above the patient), and the irrigation pressure for uterine cavity distending was 150 mmHg. Monopolar electrode system was selected for endometrium resection, and controled the watts of electroresec tion and electrocoagulation within 40 60 watts and 60 80 watts, respectively. Simultaneous ultrasonographic monitoring was used to identify the sickness of uterus wall and uterine cavity size. A total of 1,000 mL of lactated Ringers solution was infused during the 70 minutes of surgery, with a total blood loss of 20 mL. Twenty minutes before the termination of surgery , the patient complainted of difficulty in breathing with simultaneous polypnea, shiver, and sensations of vertigo and nausea. Oxygen saturation dropped from 98% to 90% and recoverd soon after mask oxygen inhalation. Thereupon tramadol 50 mg was administered intravenously, and excellent effect obtained. Approximately 300 mL output of urine when the bladder was squeezed incautiously by ultrasound probe and the patient vomited once just the procedure completed. The patient appeared haziness of spirit-mind but responded appropriately to verbal stimulate. A dorsalis pedis artery blood sample was obtained from the patient , and electrolytes were reported using a blood-gas analyzing device. Results as follows: PH 7.31; Na+, 115 mmol/L; K+, 3.0mmol/L; ionized Ca2+, 0.93 mmol/L; Glucose, 27.8 mmol/L; HCO3—, 18.6 mmol/L. Based on the symptoms mentioned above, TURP syndrome was suspected. An indwelling urinary catheter was inserted immediately and 1,800 mL urine output was collected totlly at twice. A mixture of 50ml 10% saline and 100ml 0.9% saline was dripped to raise sodium concentration, meanwhile metoclopramide 10 mg was used for anti-nausea. But there were no diuretic and insulin used in case of aggravating of hypokalemia. Oxygen saturation maintained in 92% after oxygen mask was removed and with a progressive rise. Vital signs on permission to PACU were as follows: blood pressure, 126/79 mmHg; heart rate, 79 beats per minute; breathing rate, 20 breaths per minute; and oxygen saturation, 96%. The patient was transported to postanesthesia care unit (PACU) for continued treatments and review of blood gas analysis. On our arrival into PACU, arterial blood gas (ABG) analysis was performed when the venous transfusion of the hypertonic saline solution ended, revealing PH 7.36; Na+, 127 mmol/L; K+, 3.0mmol/L; ionized Ca2+, 1.0 mmol/L; glucose, 22.9 mmol/L; HCO3—, 21.5 mmol/L; BE, -3.6 mmol/L. The patient still had low sodium and potassium level from ABG, a mixture of 100ml 10% saline and 100ml 0.9% saline containing potassium chloride 0.5 g was supplemented in low-speed intravenously. Nurse anesthetist was asked to record vital signs every 15 minutes. 16:15~18:05, the patient got her vital signs stablized gradually and oxygen staturation could maintain over 95%. Review of her blood gas analysis showed: PH 7.36; Na+, 137 mmol/L; K+, 3.4mmol/L; ionized Ca2+, 1.0 mmol/L; glucose, 7.2 mmol/L; HCO3—, 23.2 mmol/L; BE, -3.6 mmol/L. The patient recieved 500 ml lactated Ringers solution totally in PACU, with a total urine output of 850 mL(data from PACU anesthetic chart), and sent back to the ordinary ward without any complaints and Alderete scores 10. 2. Discussion Hysteroscopy has gained widely used in diagnostic and therapeutic in gynecologic surgery for many special advantages, but is not devoid of risks especially when hysteroscopy is applied to resection of extensively endometrial lesion. Excessive absorption of irrigation fluid during hysteroscopic surgery from uterine cavity is the main cause of TURP syndrome or water intoxication, of which reported incidence is 0.2% [1]. The TURP syndrome mainly has clinical symptoms in cardiovascular system, respiratory system and nervous system including elevation of blood pressure, bradycardia, dyspnea, pulmonary edema, cerebral hemia and even death. The severity of consequence is associated with multiple factors, analysis of this case were as follows. The patient’s uterine cavity has low compliance and severe adhesion, so an intrauterine pressure (IUP) of 150 mmHg is required to obtain excellent visual conditions of bilateral tubal orifices. 8,000 mL D5W as the irrigation fluid is delivered i nto uterine for uterine distension in 70 minutes operation time. Based on clinical research, the absorptivity of distension media by body is within the range of 10 30 ml/min only when the irrigation pressure is less than 100 mmHg [2]. Therefore, we estimated 700 2,100 mL D5W is absorbed into circulatory system approximately, along with an infusion of 1,000 mL lactated Ringers solution. As a result, 1,700 3,100 mL is administered into blood intravenously at least, and even more. Hyperglycemia caused by excessive absorption of D5W produces hyperglycemic hyperosmolar status and then makes intracellular fluid transfers to outside the cell, which bings about exacerbating of hyponatremia status. The patient received high frequency hysteroscopy procedure in the short term leads to large-scale and severe damage of endometrium, allowing the distension fluid entering into blood circulation more easily, which contributes to hypervolemia in a more faster pace. As one of essential factors, ex cessive irrigation pressure plays a crucial role in distension fuild over absorption in the condition that endometrial venous sinus are widely open in hysteroscopic electric resection. In our case, we have to raise the pressure to 150 mmHg for a clear surgical vision of uterine cavity, therefore, rendering excellent chance for fluid entering into body. No catheterization was performed preoperatively, thus a large amount of fluid accumulates in bladder and circulation system. To sum up, in this case, fluid overload, hyperglycemic hyperosmolar status, high intrauterine pressure, disruption of endometrial vessles and lack of preoperative catheterization lead to a significant increasement of circulating volume and a sharply reduce of plasma colloid osmotic pressure. Extracellular free water in brain are transported from the outside to the inside of the cell, which results in cerebral edema and causes intracranial hypertension. A serious of neurological syndromes develop including dizzin ess, headache, nausea, vomiting, and haziness of spirit-mind. Likewise, as a consequence of irrigation fluid overload and dilution of the plasma protein concentration, pulmonary hydrostatic pressure elevated, leading to the accurrence of acute pulmonary edema and pulmonary interstitial edema. The ventilation/perfusion imbalance occurs, and then manifests in dyspnea, hypoxemia and a sustained downward trend of oxygen saturation, etc. Timely recognition and urgent corresponding treatment measures should be taken in the early course of water intoxication to prevent the condition deteriorated. In a general way, for every liter of hypotonic fluid absorbed, the serum sodium concentration will decrease by 10 mmol/L(10 mEq/L) [3]. 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¾Ã‚ Ãƒ £Ã¢â€š ¬Ã¢â‚¬Å¡Ãƒ ¦Ã¢â‚¬Å¡Ã‚ £Ãƒ ¨Ã¢â€š ¬Ã¢â‚¬ ¦Ãƒ ¦Ã…“ ¯Ãƒ ¤Ã‚ ¸Ã‚ ­Ãƒ ¥Ã¢â‚¬ ¡Ã‚ ºÃƒ §Ã… ½Ã‚ °Ãƒ ¤Ã‚ ¸Ã¢â€š ¬Ãƒ ¨Ã‚ ¿Ã¢â‚¬ ¡Ãƒ ¦Ã¢â€š ¬Ã‚ §Ãƒ ©Ã‚ «Ã‹Å"à ¨Ã‚ ¡Ã¢ ‚ ¬Ãƒ §Ã‚ ³-à ¨Ã‚ ¾Ã‚ ¾27.8 mmol/Là ¯Ã‚ ¼Ã…’à ¤Ã‚ ¸Ã‚ ´Ãƒ ¥Ã‚ ºÃ…  Ãƒ ¨Ã‚ ¯Ã¢â‚¬ ¢Ãƒ ©Ã‚ ªÃ…’à ¨Ã‚ ¯Ã‚ Ãƒ ¦Ã‹Å"Ã… ½Ãƒ ¨Ã‚ ¡Ã¢â€š ¬Ãƒ §Ã‚ ³-à ¤Ã‚ ¸Ã¢â€š ¬Ãƒ ¨Ã‚ ¿Ã¢â‚¬ ¡Ãƒ ¦Ã¢â€š ¬Ã‚ §Ãƒ ¥Ã‚ Ã¢â‚¬ ¡Ãƒ ©Ã‚ «Ã‹Å"à ¯Ã‚ ¼Ã…“20 mmol/L,à ¤Ã‚ ¸Ã‚ Ãƒ ¤Ã‚ ¼Ã… ¡Ãƒ ¥Ã¢â‚¬ ¡Ã‚ ºÃƒ §Ã… ½Ã‚ °Ãƒ ¦Ã‹Å"Ã… ½Ãƒ ¦Ã‹Å" ¾Ãƒ §Ã… ¡Ã¢â‚¬Å¾Ãƒ §-†¦Ãƒ §Ã¢â‚¬ Ã… ¸Ãƒ §Ã‚ Ã¢â‚¬  Ãƒ ¦Ã¢â‚¬ Ã‚ ¹Ãƒ ¥Ã‚ Ã‹Å"à ¯Ã‚ ¼Ã…’à ¨Ã‚ ¡Ã¢â€š ¬Ãƒ §Ã‚ ³-à ¥Ã…“ ¨Ãƒ ¦Ã…“ ¯Ãƒ ¥Ã‚ Ã… ½4à ¥Ã‚ °Ã‚ Ãƒ ¦- ¶Ãƒ ¥Ã‚ Ã… ½Ãƒ ¤Ã‚ ¼Ã… ¡Ãƒ ¦Ã‚ Ã‚ ¢Ãƒ ¥Ã‚ ¤Ã‚ Ãƒ ¨Ã¢â‚¬ ¡Ã‚ ³Ãƒ ¦Ã‚ ­Ã‚ £Ãƒ ¥Ã‚ ¸Ã‚ ¸Ãƒ ¦Ã‚ °Ã‚ ´Ãƒ ¥Ã‚ ¹Ã‚ ³Ãƒ ¯Ã‚ ¼Ã…’à ¦Ã¢â‚¬ ¢Ã¢â‚¬ ¦Ãƒ ¦Ã…“ ¯Ãƒ ¤Ã‚ ¸Ã‚ ­Ãƒ ¥Ã‚ ¯Ã‚ ¹Ãƒ ¤Ã‚ ºÃ… ½Ãƒ ¨Ã‚ ¡Ã¢â€š ¬Ãƒ §Ã‚ ³-à §Ã… ¡Ã¢â‚¬Å¾Ãƒ ¦Ã‚ £Ã¢â€š ¬Ãƒ ¦Ã‚ µÃ¢â‚¬ ¹Ãƒ ¦Ã‹Å" ¯Ãƒ ¦Ã…“â‚ ¬Ãƒ ©Ã¢â‚¬ ¡Ã‚ Ãƒ ¨Ã‚ ¦Ã‚ Ãƒ §Ã… ¡Ã¢â‚¬Å¾Ãƒ ©Ã‚ ¢Ã¢â‚¬Å¾Ãƒ ©Ã‹Å" ²Ãƒ ¦- ¹Ãƒ ¦Ã‚ ³Ã¢â‚¬ ¢Ãƒ 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Ã‚ ¸Ãƒ ¦Ã¢â‚¬ Ã‚ ¶Ãƒ ©Ã¢â‚¬ ¡Ã‚ Ãƒ ¨Ã‚ ¾Ã‚ ¾1000 à ¯Ã‚ ½Ã… ¾2000 ml à ¦- ¶Ãƒ ¥Ã‚ Ã‚ ³Ãƒ ¥Ã‚ ºÃ¢â‚¬ Ãƒ ¥Ã‚ Ã…“à ¦Ã‚ ­Ã‚ ¢Ãƒ ¦Ã¢â‚¬ °Ã¢â‚¬ ¹Ãƒ ¦Ã…“ ¯:Issacson KBà ¯Ã‚ ¼Ã… ½ Complications of hysteroscopyà ¯Ã‚ ¼Ã‚ »Jà ¯Ã‚ ¼Ã‚ ½Ãƒ ¯Ã‚ ¼Ã… ½ Obstet Gynecol Clin North Amà ¯Ã‚ ¼Ã…’1999à ¯Ã‚ ¼Ã…’26(1):39à ¯Ã‚ ¼Ã‚ 51à ¯Ã‚ ¼Ã… ½ )à ¯Ã‚ ¼Ã…’à ¦Ã‚ £Ã¢â€š ¬Ãƒ ¦Ã‚ µÃ¢â‚¬ ¹Ãƒ ¨Ã‚ ¡Ã¢â€š ¬Ãƒ ¦Ã‚ ¸Ã¢â‚¬ ¦Ãƒ ©Ã¢â‚¬â„¢Ã‚   à §Ã‚ ¦Ã‚ »Ãƒ ¥Ã‚ ­Ã‚ Ãƒ ¦Ã‚ µÃ¢â‚¬Å"à ¥Ã‚ ºÃ‚ ¦Ãƒ ¯Ã‚ ¼Ã…’à ¦Ã‚ £Ã¢â€š ¬Ãƒ ¦Ã‚ µÃ¢â‚¬ ¹Ãƒ §Ã¢â‚¬ Ã… ¸Ãƒ ¥Ã¢â‚¬ËœÃ‚ ½Ãƒ ¤Ã‚ ½Ã¢â‚¬Å"à ¥Ã‚ ¾Ã‚ Ãƒ £Ã¢â€š ¬Ã‚ Ãƒ ¨Ã‚ ¡Ã¢â€š ¬Ãƒ ¦Ã‚ °Ã‚ §Ãƒ ©Ã‚ ¥Ã‚ ±Ãƒ ¥Ã¢â‚¬â„¢Ã…’à ¥Ã‚ ºÃ‚ ¦Ãƒ ¥Ã¢â‚¬â„¢Ã…’à ¥Ã‚ °Ã‚ ¿Ãƒ ©Ã¢â‚¬ ¡Ã‚ Ãƒ £Ã¢â€š ¬Ã¢â‚¬Å¡Ãƒ ¯Ã‚ ¼Ã‹â€ 4à ¯Ã‚ ¼Ã¢â‚¬ °Ãƒ ©Ã… ¡Ã‚ Ãƒ ¦- ¶Ãƒ §Ã¢â‚¬ ºÃ¢â‚¬ËœÃƒ ¦Ã‚ µÃ¢â‚¬ ¹Ãƒ ¨Ã‚ ¡Ã¢â€š ¬Ãƒ §Ã¢â‚¬ Ã‚ µÃƒ ¨Ã‚ §Ã‚ £Ãƒ ¨Ã‚ ´Ã‚ ¨Ãƒ §Ã… ¡Ã¢â‚¬Å¾ à ¥Ã‚ Ã‹Å"à ¥Ã…’-à ¯Ã‚ ¼Ã…’à ¥Ã‚ Ã… ¡Ãƒ ¥Ã‹â€ Ã‚ °Ãƒ ¦- ©Ãƒ ¦Ã…“Å ¸Ãƒ ¥Ã‚ Ã¢â‚¬ËœÃƒ §Ã… ½Ã‚ °Ãƒ ¤Ã‚ ½Ã… ½Ãƒ ©Ã¢â‚¬â„¢Ã‚  Ãƒ ¨Ã‚ ¡Ã¢â€š ¬Ãƒ §-†¡Ãƒ ¯Ã‚ ¼Ã…’à ¦- ©Ãƒ ¥Ã‚ ¤Ã¢â‚¬Å¾Ãƒ §Ã‚ Ã¢â‚¬  Ãƒ ¦- ©Ãƒ ¦Ã‚ ²Ã‚ »Ãƒ §Ãƒ ¯Ã‚ ¼Ã…’à ©Ã‹Å" ²Ãƒ ¦Ã‚ ­Ã‚ ¢Ãƒ §-†¦Ãƒ ¦Ã†â€™Ã¢â‚¬ ¦Ãƒ ¦Ã‚ Ã‚ ¶Ãƒ ¥Ã…’-à £Ã¢â€š ¬Ã¢â‚¬Å¡Ãƒ ¯Ã‚ ¼Ã‹â€ 5à ¯Ã‚ ¼Ã¢â‚¬ °Ãƒ ¦Ã…“ ¯Ãƒ ¥Ã‚ Ã… ½ à ¥Ã‚ ¿Ã¢â‚¬ ¦Ãƒ ©Ã‚ ¡Ã‚ »Ãƒ §Ã‚ §Ã‚ ¯Ãƒ ¦Ã… ¾Ã‚ Ãƒ ¨Ã‚ ·Ã… ¸Ãƒ ¨Ã‚ ¸Ã‚ ªÃƒ §-†¦Ãƒ ¤Ã‚ ºÃ‚ ºÃƒ §Ã… ¡Ã¢â‚¬Å¾Ãƒ ¤Ã‚ ½Ã¢â‚¬Å"à ¥Ã‚ ¾Ã‚ Ãƒ ¥Ã‚ Ã‹Å"à ¥Ã…’-à £Ã¢â€š ¬Ã¢â‚¬Å¡ à ¦Ã‚ °Ã‚ ´Ãƒ ¤Ã‚ ¸Ã‚ ­Ãƒ ¦Ã‚ ¯Ã¢â‚¬â„¢Ãƒ ¥Ã…“ ¨Ãƒ ¥Ã‚ ¤-à §Ã‚ §Ã¢â‚¬ËœÃƒ ¦Ã¢â‚¬ °Ã¢â‚¬ ¹Ãƒ ¦Ã…“ ¯Ãƒ ¤Ã‚ ¸Ã‚ ­Ãƒ ¯Ã‚ ¼Ã…’à ¥Ã‚ °Ã‚ ¤Ãƒ ¥Ã¢â‚¬ ¦Ã‚ ¶Ãƒ ¨Ã¢â‚¬ ¦Ã¢â‚¬ Ãƒ ©Ã¢â‚¬ ¢Ã…“à ¦Ã¢â‚¬ °Ã¢â‚¬ ¹Ãƒ ¦Ã…“ ¯Ãƒ ¯Ã‚ ¼Ã…’à ¥Ã…’†¦Ãƒ ¦Ã¢â‚¬ ¹Ã‚ ¬Ãƒ ¥Ã‚ ®Ã‚ «Ãƒ ¨Ã¢â‚¬ ¦Ã¢â‚¬ Ãƒ ©Ã¢â‚¬ ¢Ã…“à £Ã¢â€š ¬Ã‚ TURPà §Ã‚ ­Ã¢â‚¬ °Ãƒ ¯Ã‚ ¼Ã…’à ¨Ã¢â‚¬ ¹Ã‚ ¥Ãƒ ¤Ã‚ ¸Ã‚  à ¤Ã‚ ºÃ‹â€ Ãƒ ¤Ã‚ »Ã‚ ¥Ãƒ ©Ã‚ «Ã‹Å"à ¥Ã‚ ºÃ‚ ¦Ãƒ ©Ã¢â‚¬ ¡Ã‚ Ãƒ ¨Ã‚ §Ã¢â‚¬  Ãƒ ¯Ã‚ ¼Ã…’à ¥Ã‚ °Ã¢â‚¬  Ãƒ ¥Ã‚ ¸Ã‚ ¦Ãƒ ¦Ã‚ Ã‚ ¥Ãƒ ¤Ã‚ ¸Ã‚ ¥Ãƒ ©Ã¢â‚¬ ¡Ã‚ Ãƒ §Ã… ¡Ã¢â‚¬Å¾Ãƒ ¥Ã‚ Ã… ½Ãƒ ¦Ã… ¾Ã…“à ¯Ã‚ ¼Ã…’à ¦Ã¢â‚¬ °Ã¢â€š ¬Ãƒ ¤Ã‚ »Ã‚ ¥Ãƒ ¥Ã…“ ¨Ãƒ ¤Ã‚ ¸Ã‚ ´Ãƒ ¥Ã‚ ºÃ…  Ãƒ ¤Ã‚ ¸Ã…  Ãƒ ¤Ã‚ ¸Ã¢â€š ¬Ãƒ ¦- ¦Ãƒ ¥Ã‚ Ã¢â‚¬ËœÃƒ §Ã… ½Ã‚ °Ãƒ ¦Ã‚ °Ã‚ ´Ãƒ ¤Ã‚ ¸Ã‚ ­Ãƒ ¦Ã‚ ¯Ã¢â‚¬â„¢Ãƒ ¥Ã‚ ¿Ã¢â‚¬ ¦Ãƒ ©Ã‚ ¡Ã‚ »Ãƒ ¥Ã‚ Ã…   à ¦- ¶Ãƒ ¥Ã‚ ¤Ã¢â‚¬Å¾Ãƒ §Ã‚ Ã¢â‚¬  Ãƒ ¯Ã‚ ¼Ã…’à ©Ã‹Å" ²Ãƒ ¦Ã‚ ­Ã‚ ¢Ãƒ ¦Ã‚ Ã‚ ¶Ãƒ ¥Ã…’-à ¨Ã¢â€š ¬Ã…’à ¥Ã‚ Ã‚ ±Ãƒ ¥Ã‚ Ã…  Ãƒ §-†¦Ãƒ ¤Ã‚ ºÃ‚ ºÃƒ §Ã¢â‚¬ Ã… ¸Ãƒ ¥Ã¢â‚¬ËœÃ‚ ½Ãƒ £Ã¢â€š ¬Ã¢â‚¬Å¡ Reference [1] Jansen FW, Verdevoogd CB, Ulzen KV, et al. Complications of hysteroscopy: aprospective multicenter study [J], Obstet Gynecol, 2000, 96 (2): 266 270. [2] Rhymer JS, Bell TS, Perry KC, et al. Hyponatremia following transurethral resection of the postate [J].Br Jurol, 1985, 57(4): 450à ¯Ã‚ ¼Ã‚ 452. [3] Prost AM, Liberman RF, Harlow BL, Ginsburg ES. Complication of hysteroscopic surgery: predincting patients at risk. Obster Gynccol. 2000; 96:517-520 [4] Cooper JM Brady RM. Intraoperative and early post-operative complications of operative hysteroscopy. Obstetric and Gynecology Clinics of North America 2000; 27: 347-365 [5]Romer T. Benefit of GnRH analogene treatment for hysteroscopic surgery in patients with bleeding disorders [J].Gynecol.Obstet Invest,2003,50:112-120. [6]Murdoch JA. Tong JG. Anesthesia for hysteroscopy. Anesthesiol Clin North Am. 2001;19:125-140 [ J ].à ¤Ã‚ ¸Ã‚ ­Ãƒ ¥Ã¢â‚¬ ºÃ‚ ½Ãƒ ¥Ã‚ ¾Ã‚ ®Ãƒ ¥Ã‹â€ Ã¢â‚¬ ºÃƒ ¥Ã‚ ¤-à §Ã‚ §Ã¢â‚¬ËœÃƒ ¦Ã‚ Ã¢â‚¬Å¡Ãƒ ¥Ã‚ ¿-,2009,9(12):1097-109 à ¨Ã¢â‚¬Å¾Ã‚ ±Ãƒ ©Ã‚ «Ã¢â‚¬Å"à ©Ã… ¾Ã‹Å"à ¯Ã‚ ¼Ã… ¡Witz CA, Silverberg KM, Burns WN, Schenken RS, Olive DL. Complications associated with the absorption of hysteroscopic fluid media. Fertil Steril 1993;60:745-56.

Assignment on Annual Report

Assignment On Mercantile Bank Limited Annual Report for the year ended 31st December, 2009 Topics are to be discussed here (Context) 01. Letter to Transmittal 02. Notice of 11th Annual General Meeting 03. Mission, Vision & Objectives 04. MBL Timeline 05. Credit Rating 06. Sponsors of the Bank 07. Board of Directors 08. Corporate Structure 09. Management Team 10. Head Office & Branch Network 11. Where We Locate 12. Financial Summary 13. Economic Impact Report 14. Message from the Chairman 15. From the Desk of Managing Directors and CEO 16. Directors’ Report 17. Managing Directors and CEO’s Report on Risk Management 18. Report on Corporate Governance 19. Compliance Report on SEC Notification 20. Report of Audit Committee 21. Report on Corporate Social Responsibility 22. Report on Customer Service 23. Report on Human Capital 24. Recognition 25. Signing of Financial Statements 26. Auditors’ Report 27. Financial Statements 28. Notes to the Financial Statements 29. Annexure A-G 30. Highlights of Mercantile Bank Limited 1. Letter to Transmittal: Here the Executive Vice President and Company Secretary wrote a letter to all shareholders informing the important items of the Annual Report. Such as Balance Sheet, Income Statement, Cash Flow Statement of the year. 2. Notice of 11th Annual General Meeting: In the notice the date, year, day, time and place of the AGM clearly (in bold letter) described. Important Agenda also represented in the notice. There are 5 Agenda are mentioned. In addition 6 footer Notes also published here. Important notes are record date of the share (March 07, 2010), amount of dividend (22%) etc. Executive Vice President and Company Secretary give his signature with date. 3. Vision, Mission & Objectives: The Vision of the back is make finest corporate institution. Mission is making the make profitable by caring, equitable growth by required and proper distribution of recourses. Strategic Objectives: to positive Economic Value Added, market leader in product innovation, achieve cost efficiency, be in the top five financial institution in Bangladesh. Financial Objectives: to achieve stable (? 20%) return on shareholders’ equity. Moreover Core value for Customers, Shareholders, Employees and Community 4. MBL Timeline: Here the development of Mercantile Bank Limited stated. It started incorporation in business and commercialization in 1999. Circulated Primary Share (IPO) in 2003. Got listed in both Bangladesh Stock Exchanges (Dhaka & Chittagong) in 2004 and end of year 2009 it has 50 braches all over the country. 5. Credit Rating: As per Credit Rating and information Services Limited (CRISL), Mercantile Bank Limited rated as â€Å"A† (Pronounced as Single A) in the long term and ST-2 rating in the short term on the basis of Financial Statements as on December 31, 2008. High certainty of timely payments, strong liquidity factors, good company fundamentals, easy excess to capital market and minimal risk factors are the key issues of the rating. 6. Sponsors of the Bank: Here the 27 sponsors’ names with photos are representing clearly. 7. Board of Directors: 22 Directors’ name and photo with their designation stated here. There are 1 Chairman, 2 Vice Chairmen and 18 Directors and 1 Managing Director and CEO in the Bank managing committee. 8. Corporate Structure: In Corporate Structure there are 8 different government body represented. Including Board of Directors (22 persons), Executive Committee (18 persons), Audit Committee (3 persons), Managing Director & CEO (1 person), Chief Financial Officer (1 person), Company Secretary (1 person), Auditors (2 persons) and Tax Advisor (1 person). . Management Team: Here the detail list of different managing committee separately represented with their designation. There are 10 categories of designation. Such as Managing Director & CEO, Additional Managing Director, principal, Deputy Managing Director, Senior Executive Vice Presidents, Executive Vice Presidents, Senior Vice Presidents, Vice Preside nts, First Vice Presidents and Assistant Vice Presidents. 10. Head Office & Branch Network: Under this title the details addresses of bank’s all 50 banking branches, SME braches and Brokerage House with Phone, Mobile and Fax number given. 1. Where We Locate: Here the map of Bangladesh given and all 53 (3 SME/Agro Branches) branches marked by company’s logo under district wise. 12. Financial Summary: Under Financial Summary Company’s last 5 years Net Interest Margin (NIM), Profit after Tax, Return on Assets (ROA), Cost Income Ratio, Return on Equity (ROE), Operating Efficiency Ratio and in the last 8 years comparable company’s Income Statement, Balance Sheet, Foreign Exchange Business, BIS Capital Measure, Credit Quality, Share Information, Operating Performance Ratio and Other Information represented. 3. Economic Impact Report: Here Economic Impact described in two ways; Direct Impact and Indirect Impact. Direct Impact are employment opportunities, paymen t of tax to the government, increase value to the Shareholders. Indirect Impact created by catering financial services, Bank generated wealth in the economy and profit for itself which is ultimately distributed amongst the shareholders and other participants in different form. In 2009, total value added by MBL was BDT 2,559. 96 (millions) and direct contribution to the economy was BDT 855. 26 (millions). There are two value added statements (Economic and Market) showed by column chart. A pie chart showed for distribution of Value Addition (maximum for government tax 33. 4%). Bank added BDT 129. 5 (million) under Economic Value Addition and BDT 4229. 48 (million) under Market Value Addition. 14. Message from the Chairman: At the first of the message the Chairman invited Shareholders to the 11th Annual General Meeting. There are some topics the Chairman discussed briefly. Those are: World Economy in 2009: here the impact of sub-prime mortgages landslip discussed. Bangladesh Economy in 2009: here the benefit of growth Bangladesh economy in the particular year stated. Performance of the Bank in 2009: here the actual amount of bank’s deposits collection, loan and advance, import business, export business and foreign remittance described. Diversified Business Activities of the Bank: under this section the details activity of bank represented here. Such as Deposits, Loan and Advances, Import & Export Business and Inward Foreign Remittance. SME: here bank’s SME structure described. Card Business: here bank’s different card business represented. Such as Credit card, Debit Card, VISA dual prepaid card, VISA Dual Hajj Card. Described it’s features and services. Corporate Governance Practice: here the responsibilities and activities of Board of Directors to the business operation represented. CSR Programs: here the guideline of management of the bank informs the board on CSR activities and is responsible to implement a specific line of approving authority, control and monitoring for financial support of such activities. Customer Service: here the Chairman describe how the bank server to the customer for achieve highest customer satisfaction. Human Resources Development: here the promotion and intensives to the employees represented for their superior performance. Recognition and Award: here the different achievements and rewards stated that in 2009 the bank gets thorough out the year. Future Outlook: here the challenges and opportunities for the bank in upcoming years described thoroughly. Challenges in 2010: here the economic effect on the bank in year 2010 is represented. Such as global downturn, slower growth of exports and workers’ remittance etc. Acknowledgement: here the Chairman gives his thank you notes and committed a stable growth of back where shareholder can rely on. 15. From the Desk of Managing Directors and CEO: Here the CEO describes the banks’ situation in the year 2009. He also represented Bank’s performance during the year 2009, its prospects and potential challenges in 2010. Such as Positive Growth: A Step Further: describing here the growth of the bank during the year. Prospects in 2010: he describe the opportunity, hope for the bank in upcoming year. Reviewing Our Business in 2009: here the business operation during the year stated clearly. Assets and Liabilities Position, International Business, MBL’s Products and Services, MBL’s Card Business, Agro-Based Financing, SME Financing, Our Priorities, Operation, Customer Relationship, Technology, Human Capital Development, Corporate Social Responsibilities (CSR), MBL Brokerage House, Mobile Banking, Commitment to Government, Base I-II Capital Accord, Anti Money Laundering, Network Expansion, Challenges in 2010, Our Preparation and Acknowledgement are the main topics he discussed. 6. Directors’ Report: The parts of the Director’s Report are World Economy, Bangladesh Economy (GDP, Inflation, Investment and Saving, Broad Money, Domestic Credit, Export, Import, Trade Balance, Remittance, Foreign Exchange Market, Prospect of Bangladesh Economy in 2010), Business Review (Deposit and Deposit Mix, Loan and Advance, Import Trade, Export Trade, Foreign Remittance, Treasury Operation and Fund Management, Earning Base in Assets, Asset Portfolio, Funding Structure, Capital, Statutory Reserve, Capital Adequacy, Number of Shareholders, Contribution to National Exchequer and Economy, Acquisition of IDLC Share, Purchase of Land, Branch Network, Board of Directors, Board and Committee Meeting, Corporate and Financial Reporting, External Auditors, Correspondence Relationship , R&D, Information Technology, Financial Products and Services, Different Deposit Products, Different Loan Products), Financial Review (Different Profit Incomes, Different Expenses, Different Tax, Dividend, EPS, O/E Ratio), Outlook 2010 and Acknowledgement are represented here. After that it repeated in Bengali Language. 17. Managing Directors and CEO’s Report on Risk Management: Here start with basic discussion on Risk Management. Such as Risk Management Realities, Approach, Oversight, Process etc. And later describe different types of Risk Management described with photo and tree table. Such as Credit Risk Management, Market Risk Management, Interest Rate Risk Management, Foreign Exchange Risk Management, Operational Risk Management, Internal Control and Compliance Risk Management, Equity Risk Management, Money Laundering Risk Management, Information Technology Risk Management, Liquidity Risk Management, Marketing Related Risk Management, Human Resource Related Risk Management etc. 18. Report on Corporate Governance: At first different names of Corporate Governance with responsibility and duty in the bank represented. Such as Board Of Directors, Board’s Supporting Committee, Management Committee, Control Environment Committee. Each of every committee are presented with meetings photo. 19. Compliance Report on SEC Notification: It is the notification issued by The Security and Exchange Commission for all listed companies in order to improve Corporate Governance on ‘Comply or Explain’ basis. There are three tables. First is Complied or Not Complied table. Only 3 rules are not complied by the bank among 43 rules which are under review. In second table the numbers with names of Directors attained Board Meeting during the year. And the last one is The Patter of Shareholding where shows the nos. and percentage of shares hold by Directors. 20. Report of Audit Committee: Here the name of Auditor with photo presented. And also some other topics such as composition of the Audit Committee, Role of the Audit Committee, Internal Control, Meetings, Financial Reporting, Internal Audit and Inspection, External Audit, Regulatory Compliance and Miscellaneous issues given here. 21. Report on Corporate Social Responsibility: Here the roles and responsibilities of the bank toward society described. In this section a table shows how much the bank contributed their profit to the society. The highest donation went to health sector. MBL has slogan to be the â€Å"Banglar Bank†. MBL has given different awards to different sectors. Photos and arenas are mentioned here. 22. Report on Customer Service: The importance of customer to the bank is presented here. Some core demands of customer are fulfilling by the back. Such as Bringing Mass and More people into the Banking net, Addressing Unique Needs of the Customers, Meeting Demand of Customers through Alternative Banking Channels, Response from the People etc. 23. Report on Human Capital: In this topic the process of giving service in effective manner the back took some steps such as Nursing the People with Utmost Care, Recruiting the Best People (bonus, promotion, recognition, training etc), Managing the people, Performance from the People etc. 24. Recognition: An award giving ceremony’s (ICAB Award-2008) photo given here. 25. Signing of Financial Statements: Here a photograph of Directors represented where they all present there for signing Financial Statements – 2009. 26. Auditors’ Report: At first Auditors declared those elements that they audited. Such as Balance Sheet, Profit and Loss account, Cash Flow Statement, Statement of Changes in Equity, Statements of Liquidity Analysis and Explanatory notes to Financial Statements. Also mention their responsibilities. In the auditor’s report they include Scope, Opinion (14 opinions), Auditors Firm Names, Auditor Signatures, Auditor Designation, Place and Date. 27. Financial Statements: In the Financial Statements there are 7 part of it. At first there is Balance Sheet (Classified Statement of all types of Assets and Liabilities), then Off-Balance Sheet Items (Contingent Liabilities and Other Commitments), Profit and Loss Account (Include all types of Incomes and Expenses, Provisions, Appropriations etc. , Cash Flow Statement (Net Cash Inflow and Outflow recorded here), Statement of Changes in Equity (Capital gain/reserve and losses/dividend), Liquidity Statement (assets and liabilities maturity analysis), Notes to the Financial Statements (details of financial statement such a s calculations, principals, disclosures etc). 28. Annexure A-G: In Annexure A all related asset’s depreciation charges calculated here, Annexure B described number of shares hold by Directors with their positions, Annexure C represented different Investment in Shares during the year. Annexure D stated market adjustment of approved Securities HTM and HFT shares. Annexure E mentioned maturity analysis of other assets (like as advanced deposits, stamps in hand etc. , Annexure F represented Compliance of BAS and BFRS (among 29 BAS 6 are not applied and among 4 BFRS none are applied), Annexure G provide Computation of Risk- Weighted Assets list. 29. Highlights of Mercantile Bank Limited: Here all necessary information towards the investors are presented here, such as paid-up capital, total assets, total deposits, ROA, ROI, EPS, NI per share, P/E Ratio etc. 30. Proxy Form: It is the application printed and provided by the firm to shareholders incase of his absence, shareholder can give voting power to his nominated person. Need to fill up the gaps and attach revenue stamps and send to the authority before particular date. It has two parts, one for office and other for shareholder. ————-END————–

The Breakdown Of The Basic Nature Of Chinese Poetry

The breakdown of the basic nature of Chinese and English lyrical relations shows that they can be distinguished from one another through the use of metaphor to evoke the relationship between scene and feeling and vehicle and tenor respectively. The Western poetry’s use of metaphor celebrates the use of human deception through a made-up connection between that which is being talked about (tenor) and the one who talks about it (vehicle). On the other hand, the Chinese poetry’s relies on the metaphor to come up with the context of scene and feeling which involves the appreciation of the dynamic lyrical resonance between nature and the human being. Moreover, while the Western practice engages in purposeful process of conveyance to formulate such explicit correspondence between tenor and vehicle, the Chinese tradition is set apart by the spontaneous encounter that evokes the implicit correspondence between scene and feeling. This paper therefore looks into the use of scene a nd feeling in Chinese poetry and tenor and vehicle in Western poetry in relation to the metaphor with an effort to highlight their differences and application. â€Å"Scene† and â€Å"Feeling† relationship The term scene basically portrays the physical context that is described in the poem. This physical context usually entails descriptions of rivers, mountains, vegetation, and animal life among others (Yanfang 186). When it comes to Chinese poetry, the portrayal of nature is a key element. 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For any conclusion, the premises used directly to support it are called its basic premises. In a more complicated argument, there may be reasons for the reasons, and so on. But these reasons for the reasons are not part of the core. The core of the argument is the conclusion plus its basic premises. Every argument has to start somewhere, so it is not a good criticism of an argument to complain that all its premises have not been

The Ways We Lie - 982 Words

Lying has is a part of our culture, and it seems as if not a day goes by where you do not lie at all. Our world could not exist as it does, if we lived in a society in which lying did not exist. However as humans, we are prone to lying, because of our need to protect ourselves, or the ones close to us, that we turn to lying in order to either make our lives easier or to avoid problems. Humans have adapted over time into societies where lying is an evolutionary advantage, which has made it a part of our DNA. Even children, as soon as they can talk, are using deception as a way to get what they want, and these children have not even had a chance to learn to lie. Lying also continues throughout our entire lives, because it is not something that we can help, it is a part of who we are. When evaluating the argument Stephanie Ericsson makes in â€Å"The Ways We Lie†, regarding the reasons we chose to lie, however it is also important to consider extending the argument to include the idea that lying is not only a daily occurrence, it has also become imbedded into human nature. A professional deception detector, and author, Pamela Meyer points out the fact that, â€Å" Lying is complex. It s woven into the fabric of our daily and our business lives. We re deeply ambivalent about the truth†¦. It s as old as breathing. It s part of our culture, it s part of our history. Think Dante, Shakespeare, the Bible, News of the World†, in a TED Talk in which she details certain clues about how toShow MoreRelatedThe Way We Lie1467 Words   |  6 PagesThe Ways We Lie In the essay, The Ways We Lie,† the author, Stephanie Ericsson, tells about the many ways people lie and explains the reasons for doing so. In her essay, she talks about ten specific ways of lying that she believes are prevalent in today’s society. First is â€Å"the white lie,† which is basically telling a harmless lie instead of the truth, if the truth is destructive. She writes, â€Å"Telling a friend he looks great when he looks like hell can be based in a decision that the friends needsRead MoreThe Way We Lie641 Words   |  3 PagesIt is very true that we lie. We lie everyday conscious or unconsciously, anywhere and to anyone. It has become a way of life to many people, when one lies it feels completely normal, actually they don’t feel anything at all. One can be couth lying in any place like work, home and to different person’s friends, family, clients, teachers and even authority. In the preface of the story the author had describe how in a day she had lied a minimum of four times to various people. In spite of this the authorsRead MoreThe s The Way We Lie1557 Words   |  7 Pagesscandalous lie, are self-serving and can cause a great degree of harm to others or even to oneself. In Stephanie Eric sson’s â€Å"The Way We Lie,† Ericsson categorizes the various types of lies and their ramifications, whereas in Anton Chekhov’s â€Å"The Lady with the Dog,† the writing touches on the selfish lies that both Dmitri Gurov and Anna Sergeyevna tell to sustain their adulterous relationship. Although the extent to which lying is selfish depends on the motives and circumstances of the lie, I claimRead MoreThe s The Way We Lie1464 Words   |  6 PagesIn Stephanie Ericsson’s â€Å"The Way We Lie,† Ericsson categorizes the various types of lies and their ramifications, whereas in Anton Chekhov’s â€Å"The Lady with the Dog,† the writing touches on the selfish lies that both Dmitri Gurov and Anna Sergeyevna tell to sustain their adulterous relationship. Although the extent to which lying is selfish depends on the motives and circumstances for the lie, and whose interest it benefits, I claim that not only are most lies selfish, but the y are also morally wrongRead MoreThe Ways We Lie Argument Essay674 Words   |  3 PagesLies have been around for as long as people have been. We all lie, whether it is to protect someone we love of to cover up something we don’t want others to know about, it is still lying, and we all do it everyday. Lying has become the new normal for our modern society, so much so, that some of us have lost our morals completely. It is just so much easier and quicker to just lie to someone than to tell the truth, and now you can never tell who is lying to you or who is telling the truth. People useRead MoreThe Ways We Lie By Stephanie Ericsson1146 Words   |  5 PagesIn today’s American society, lying has become something that we are accustomed to using almost every day without even realizing it. In â€Å"The Ways We Lie†, Stephanie Ericsson, screenwriter, advertising copywriter, and writer, elaborates on the act of lying and how it is used by everyone on a daily basis. Sh e comes up with a list of the common, different kinds of lies that we all have told. Furthermore, the text goes in depth about the significance of lying and how it is an essential part of every human’sRead MoreThe Ways We Lie By Stephanie Ericsson1148 Words   |  5 PagesIn the essay The Ways We Lie, author Stephanie Ericsson writes in depth about the different types of lies used by most people everyday. While listing examples of them, Ericsson questions her own experiences with lying and whether or not it was appropriate. By using hypothetical situations, true accounts, and personal occurrences, she highlights the moral conflicts and consequences that are a result of harmless fibs or impactful deceptions. 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The author argues that some lies aren’t very severe, and often times are necessary, whereas others can prove to be harmful in the long run and can exact harsh consequences. ( 315 ) Ericsson uses examples in which these lies are presented such as with business acquaintances, politicians or friends and evenRead MoreThe Ways We Lie By Stephanie Ericsson1355 Words   |  6 PagesShould we stop lying and should stop letting people lie to us? In â€Å"The Ways We Lie†, Stephanie Ericsson describes lying as â€Å"a cultural cancer that†¦ reorders reality until moral garbage becomes as invisible to us as water is to a fish† (Ericsson 186). Ericsson believes that we have accepted lies to the point where do not recognize it anymore. Ericsson has a point when she says that lying shoul d not be tolerated, but it should be the unnecessary lies that should not be tolerated. There are lies that