Resistance to local anaesthetics administered via epidural, intrathecal and pudendal injections.

A primigravida presented to our institution in established labour. Her past medical history included joint hypermobility, postural orthostatic tachycardia syndrome, Raynaud's syndrome, fibromyalgia and gastroparesis. Two technically uneventful lumbar epidurals with bupivacaine and fentanyl provided no analgesia. The spinal element of a planned combined spinal and epidural was also ineffective, so alternative analgesia was offered. While this was being prepared, the obstetric team recommended an instrumental delivery. An attempted pudendal nerve block with lidocaine had no effect, and general anaesthesia was therefore provided for a lower segment caesarean delivery. We believe this is the first report of local anaesthetic resistance via three distinct routes of administration in a single patient. Resistance to local anaesthetics is unusual and is more common in patients with hypermobility spectrum disorders. This case demonstrates the unique experience of a patient with a hypermobility condition who had failed epidural, spinal and pudendal local anaesthetic. We suggest that patients with a hypermobility condition should be specifically assessed for local anaesthetic resistance as part of anaesthetic pre-assessment, to enable early planning.

The outcome of intracytoplasmic sperm injection in patients with retrograde ejaculation.

The objective of this retrospective clinical study was to assess the benefit of assisted fertilization in cases of anejaculatory infertility due to retrograde ejaculation. We report the outcome of intracytoplasmic sperm injection (ICSI) treatment. In 16 couples in which the men suffered from retrograde ejaculation. We performed 35 cycles of ICSI with spermatozoa retrieved from post-ejaculatory urine. The patients had been instructed to alkalinize the urine by ingesting sodium bicarbonate before the procedure. The fertilization rate averaged 51.2%. Seven clinical pregnancies were achieved. Three spontaneous first trimester abortions occurred, but three live offspring were delivered and one pregnancy is ongoing. In conclusion, the use of ICSI may be feasible for patients with retrograde ejaculation who are resistant to medical treatment and whose sperm quality is so low or unpredictable that intrauterine insemination or conventional methods of in-vitro fertilization are not possible.

Human sequelae of severe carbamate poisoning.

Carbofuran is a carbamate that functions as a cholinesterase inhibitor. Accidental or intentional ingestion can produce a life-threatening syndrome that requires prompt diagnosis and treatment. We describe a case of intentional carbofuran ingestion that resulted in coma, respiratory failure from acute respiratory distress syndrome (ARDS), and cortical blindness.

Wilson's disease.

We describe a patient who had severe neurologic symptoms, psychiatric abnormalities, and secondary amenorrhea superimposed on a history of hemolytic anemia and micronodular cirrhosis attributed to hemochromatosis. The correct diagnosis of Wilson's disease was delayed until the appearance of Kayser-Fleischer rings and a low serum ceruloplasmin level. Appropriate treatment ameliorated symptoms, and maintenance therapy has been effective in retarding progression. It is essential to consider Wilson's disease in patients with unexplained hepatic, neurologic, and psychiatric dysfunction, because appropriate early medical treatment can prevent further organ damage and reduce the risk of permanent damage to the liver and brain.

Persistent urticarial eruption in an asthmatic patient.

This case demonstrates the importance of recognizing urticarial vasculitis in patients with chronic urticarial eruptions. The salient points in history that point towards the diagnosis of urticarial vasculitis include the presence of painful urticarial lesions that last longer than 24 hours and that heal leaving residual pigmentation. In some cases the urticaria may evolve into palpable purpura. An associated systemic illness that may resemble systemic lupus erythematosus should also suggest the diagnosis, which is established by skin biopsy. Histopathology reveals a leukocytoclastic vasculitis involving postcapillary venules. When associated with systemic vasculitis, the urticaria is likely to be of the hypocomplementemic variety, with immunoglobulin and complement deposition on biopsies, and with serum complement studies demonstrating classical pathway activation, low C1q levels, and anti-C1q precipitins. A variety of agents have been used in the management of urticarial vasculitis, including aspirin, nonsteroidal anti-inflammatory agents, corticosteroids, colchicine, dapsone, hydroxychloroquine, and cytotoxic agents such as cyclophosphamide and azathioprine.

[Ovarian pregnancy after gamete transfer (gift). A case report]. / Ovargravidität nach Gametentransfer (GIFT) Ein Fallbericht.

A case of ovarian pregnancy after gamete transfer (GIFT) is reported in a 33-year old women who, after intensive stimulation therapy, experienced a right tubal pregnancy in one cycle and an ovarian pregnancy on the left side in the next. The incidence of ovarian pregnancies seems to have been increasing during the past years, comprising 3.3% of all extrauterine pregnancies. This may be influenced by the possibilities of sterility therapy today. Clinical presentation, possible pathogenesis, diagnostic steps and preferred management are described. The use of transvaginal sonography has improved the diagnosis of ectopic pregnancies and should be routinely used leading to an early diagnosis and organ-preserving therapy. This case report is intended to assist and promote the sensitivity towards an early diagnosis of this rare form of ectopic pregnancy.

Ovarian stimulation for in-vitro fertilization: clomiphene and HMG.

Details of the problems and successes obtained after various forms of hormonal stimulation in an IVF programme are presented. The endocrine conditions normally existing in the natural menstrual cycle are discussed first, followed by analyses of the types of responses to clomiphene, clomiphene and HMG, HMG alone and LHRH agonists. Clomiphene produces fewer embryos than other treatments but gives a good control of follicle growth and ovulation. Clomiphene and HMG increases the number of available oocytes, and this raises the chance of pregnancy, but there is a greater heterogeneity in the follicular population. HMG alone is suitable for most conditions except for those with PCO syndrome and gives an average of six oocytes per treatment cycle. The problems associated with premature rises in levels of LH are overcome by using LHRH agonists with HMG, and this results in satisfactory numbers of oocytes but requires endocrine support in the luteal phase. The need for luteal phase support after various therapies remains unclear, and a calculation of the ratios between various steroids may help to clarify the need for it.