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Patients who failed to conceive after gonadotropin stimulation in in vitro fertilization treatment were classified into normal, high, or poor responders. They were routinely offered another cycle with a combination of a gonadotropin releasing hormone agonist and gonadotropin therapy (in order to evaluate whether this combined therapy could improve their response). The gonadotropin-induced cycle was compared with the combined therapy cycle. With the combination treatment, in the normal responders the phase of ovarian stimulation was significantly (P less than 0.001) prolonged, and the number of follicles and oocytes collected (5.7 +/- 0.7 vs 3.1 +/- 0.4) was increased, without any change in serum estradiol level compared to the control cycle. In high responders the number of oocytes was not modified by the combined treatment compared with the control cycle. However, serum estradiol level was significantly (P less than 0.005) decreased. The combined therapy did not modify any parameter of response in poor responders. We conclude that the response to combined agonist/gonadotropin therapy is dependent on the patient's own basal response. No improvement in response was expected in poor responders.

The perfect analgesic regimen is constantly sought, no matter how labor is conducted. The quest for an effective drug that will afford maximum relaxation and pain relief with minimum interruption of any natural homeostatic mechanism is a foremost subject in present obstetric analgesics research. Synthetic alternatives are being offered, promising perfect compatibility with the clinician’s demands. Nalbuphine, a semisynthetic narcotic agonist-antagonist analgesic of the penanthren series, is supposed not to be liable to cause respiratory depression and is expected to have fewer side effects. A double-blind, randomised prospective study of 137 patients who received lOmg nalbuphine or 50 mg pethidine i.v. during the active phase of labor in term was carried out. Maternal cardiovascular variables, pain intensity, progress of labor and fetal heart rate during labor were related to side effect and neonatal outcome (1- and 5-min Apgar scores and umbilical venous pH). Neither regimen showed an advantage over the other. Data analysis points to a possible transient depressive effect induced by nalbuphine on the fetal or neonatal central nervous system.

Spigelian hernia is a rare spontaneous ventral hernia through the linea semilunaris.1,2 The incidence of Spigelian hernias, especially in pregnancy, is unknown.Diagnosis of Spigelian hernia is often difficult because the symptoms simulate those of lower quadrant abdominal disease.' Therefore, the clinician must have some additional tools in helping to diagnose this difficult problem, particularly in pregnancy.We describe here a case of strangulated Spigelian hernia diagnosed by ultrasonography at 9 weeks, menstrual age. CASE REPORTA 39-year-old woman, gravida 5, para 4, healthy, with no medical, surgical, or drug history, was admitted to the gynecological ward on the 9th week of her pregnancy due to vomiting and loss of bowel movements for a few days. There were no other complaints including abdominal pains.The physical examination on admission revealed a dehydrated patient. The abdomen was tender without any signs of peritonitis. There was a suspected lump in the left lower abdominal quadrant. The gynecological examination showed a 9-week enlarged uterus. The rest of the examination was normal. The striking laboratory findings were urea 179 mg%, creatinine 4.4 mg%, Na 125 mEq/L, and K 3.0 mEq/L. The differential diagnosis at that stage included intestinal obstruction, ovarian torsion, and acute renal failure. The signs of severe dehydration, loss of bowel movement, and the lump in the left lower

Cordocentesis has been practiced as a diagnostical tool for prenatal diagnosis of intrauterine infections, hematological disorders, metabolic status of the fetus and rapid cytogenetic analysis. The performance of 198 cordocentesis is presented over 3 years of experience. A 21 gauge spinal needle is inserted via the optimal point on the maternal abdomen under real-time ultrasonic guidance into the insertion of the umbilical cord in the placenta. Successful cordocentesis were achieved in 98.5% of the cases. Termination of pregnancy was directly related to the procedure in only 1%. Hematoma surrounding the puncturing site was demonstrated in one case, but without damage to the fetus. In our series the main indication for performing cordocentesis was the need for rapid karyotyping. The use of fetal lymphocytes for chromosomal analysis offers a rapid and a reliable method for routine clinical demands. The availability of a rapid chromosomal analysis offers a considerable advantage in pregnancies of advanced gestational age. In those pregnancies it appears to be most important to have a rapid diagnosis where anatomical structural anomalies are associated with chromosomal malformations in up to 30%. The metabolic status of the fetus is considered in either acute distress or in cases of suspected sub-optimal metabolic hemostasis, where IUGR or oligohydramnios are demonstrated. Cordocentesis, even though is a new technique, turns to play a major role in modern perinatology. The possibility of a direct rout to fetal blood vessels early during the pregnancy bears the tremendous potential of early diagnosis and treatment.