SummaryDenial of pregnancy is an important condition that is more common than expected, with an incidence at 20 weeks gestation of approximately 1 in 475. The proportion of cases persisting until delivery is about 1 in 2500, a rate similar to that of eclampsia. Denial of pregnancy poses adverse consequences including psychological distress, unassisted delivery and neonaticide. It is difficult to predict which women will develop denial of pregnancy. There are a number of forms of denial of pregnancy, including psychotic and non-psychotic variants. Denial of pregnancy is a 'red flag' that should trigger referral for psychiatric assessment. A national registry may help to provide more information about this condition and implement appropriate care. This condition poses challenging legal and ethical issues including assessment of maternal capacity, evaluation of maternal (and possibly fetal) best interests and the possibility of detention in hospital.

We report two cases of Caesarean section in patients with Marfan's syndrome where continuous subarachnoid anaesthesia failed to provide an adequate surgical block. This was possibly because of dural ectasia, which was confirmed by a computed tomography scan in both cases.

P Pu ur rp po os se e: : Gestational diabetes insipidus (GDI) is a rare endocrinopathy complicating about 4:100,000 deliveries. We present the case of a preterm parturient with GDI and severe hypernatremia (serum sodium concentration = 174 mmol·L -1 ) presenting for an urgent Cesarean section.

P Pu ur rp po os se e: : The King-Denborough syndrome (KDS) is a rare disorder that is associated with myopathy, susceptibility to malignant hyperthermia (MH) as well as congenital skeletal and facial anomalies. We report the anesthetic management of a parturient with KDS.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : We describe the management of a 24-yr-old primiparous woman with a diagnosis of KDS and a history of previous MH reaction (age two). Her KDS resulted in chronic respiratory failure. She had a permanent tracheostomy and required overnight ventilatory support for the previous two years. She had three admissions during her pregnancy, one for pneumonia and two for preterm labour. Labour was induced at 37 weeks. Her labour was managed in the operating room where a "clean" anesthesia machine was ready. Cooling aids and a MH emergency kit were immediately available. Intravenous access, an arterial line and a lumbar epidural catheter were inserted before induction of labour.Ropivacaine 0.08% + fentanyl 2 µg·mL -1 were used for patientcontrolled epidural analgesia. After 6.5 hr of labour the patient required ventilation. An outlet forceps was performed for delivery. Postpartum, she was ventilated overnight in the intensive care unit.C Co on nc cl lu us si io on n: : The use of epidural analgesia, close monitoring and collaboration between the various disciplines were important in achieving a safe and uneventful labour in this high-risk parturient. King-Denborough (SKD) Objectif : Le syndrome de

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Background Disparity exists in anesthesia practices between high- and low-to-middle income countries, and awareness has been raised within the global health community to improve the standards of anesthesia care and patient safety. The establishment of international collaborations and appropriate practice guidelines may help address clinical care deficiencies. This report’s aim was to assess the impact of a multiyear collaboration on obstetric anesthesia practices in the Republic of Armenia. Methods An invited multinational team of physicians conducted six visits to Armenia between 2006 and 2015 to observe current practice and establish standards of obstetric anesthesia care. The Armenian Society of Anaesthesiologists and Intensive Care specialists collected data on the numbers of vaginal delivery, cesarean delivery, and neuraxial anesthesia use in maternity units during the period. Data were analyzed with the Fisher exact or chi-square test, as appropriate. Results Neuraxial anesthesia use for cesarean delivery increased significantly (P < 0.0001) in all 10 maternity hospitals within the capital city of Yerevan. For epidural labor analgesia, there was sustained or increased use in only two hospitals. For hospitals located outside the capital city, there was a similar increase in the use of neuraxial anesthesia for cesarean delivery that was greater in hospitals that were visited by an external team (P < 0.0001); however, use of epidural labor analgesia was not increased significantly. Over the course of the collaboration, guidelines for obstetric anesthesia were drafted and approved by the Armenian Ministry of Health. Conclusions Collaboration between Armenian anesthesiologists and dedicated visiting physicians to update and standardize obstetric anesthesia practices led to national practice guidelines and sustained improvements in clinical care in the Republic of Armenia.

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