Diabetes insipidus with an ACTH-secreting carcinoma of the bronchus.

287 LAPAROTOMY The abdomen was opened through a paramedian incision alongside the previous scar. On reaching the peritoneum it was found only in the uppermost third of the incision. The lower two-thirds was extraperitoneal and occupied by a grossly distended bladder, which was drawn up towards the umbilicus. The peritoneal cavity was opened and the incision extended upwards. The lower segment showed pronounced oedema and bruising. The uterovesical peri-toneum was opened, bringing into direct view a fetal limb through a concomitant rupture of the previous caesarean scar and the urinary bladder. The entire fetal head was located within the bladder, which stretched over it like a bathing cap. The remainder of the fetus was in the uterine cavity. The ruptured transverse scar was widened under vision with a pair of scissors and the baby delivered as far as the neck by breech extraction. The head, which was in the occipitoposterior position, was then extracted from the bladder. This resulted in the birth of a healthy male infant with an Apgar score of 6/10 at one minute. All layers of the bladder were involved in a laceration from the trigone for a distance of about 8 cm measured in the partly contracted state after delivery. In addition to the ruptured scar a vertical laceration extended from it to beyond the cervix into the vagina for a few centimetres. The edges of the ruptured bladder were firmly adhered to the lower segment, from which it could be separated only by sharp dissection. The ureteric orifices were visible on each edge of the laceration. Both ureters were catheterized. The bladder was dissected free with some difficulty because of its adherence. Total hysterectomy was performed with conservation of the Fallopian tubes and ovaries. Suprapubic cystotomy was carried out with a Malecot catheter. The bladder was repaired in two layers and extraperitonealized, the ureteric catheters being removed at the end of the operation. The vaginal vault was incompletely closed to allow drainage. One litre of blood was transfused and a course of ampicillin prescribed. Except for pyrexia on the first and second days the postoperative period was uneventful. The suprapubic catheter was removed on the ninth day and both mother and baby were discharged on the 14th day. Four weeks later the mother was found to be asymptomatic and the baby thriving. An intravenous pyelogram showed no abnormality. Comment Extensive laceration of the lower uterine …