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Double survival of monoamniotic twins
MARTHA iFrom
EAGOOD, the
%.D.,
Departments
ANI) of
H.
!bYXOSD
Obstet~rics
ad
STOKES,
Pathology,
M.D., BIIIMISC~HAM, AA. Medical
College
of Ala3amu)
r-118 is a case report of monoamniotic twins with survival of the infants. It is of interest because there have been relatively few such reports in the literature. Quigleye quotes Rosenberg as stating that monoamniotic twins occur once in 60,000 pregnancies. In 1935 Quigleye reported 108 cases of monoamniotic twins which he had collected Out of this number 20 cases resulted from the literature and added one case of his own. i.n a single live birth, and another 17 resulted in double live births. He calculated the chance of double live births to be 15 per cent. Eight of Quigley’s cases were reported to be from the American literature. Jones5 .+cates that one which he included (a case reported by Boyd in 1883) was of a single fetus papyraceus in a single amnion. Of his 8, only one case resulted in a single live twin. In his review, Quigleyg presents a case of Podzahrodsky which is very similar to the one presented by us. He reports a case in which a midwife cut a cord which was tightly wound about the neck of the first twin. L ‘It proved to be the cord of the second twin and only by prompt delivery effected by Podzahrodsky were both twins saved. ’ ’ Coulton, Hertig, and Long3 in reviewing the literature in 1947 found 5 cases in the English. literature since Quigley’s report and added 2 of their own. These 7 cases are f,eviewed briefly. In 1935 Ruekerr reported a case of monoamniotic twins in which the first twin had both cords around his neck. The second twin in this case was macerated. There was a true knot uniting the cords which is not an uncommon finding in these cases. In 1935 Litt and Xtrausse reported a case of monoamniotic twins in which one was normal and the other anencephalic. There were muitiple true knots in the cords. Both infants were stillborn, having been delivered approximately five weeks prematurely. In ,1936 Frewer?reported a case in which the first child survived, and the second died 30 hours later. The first case of double survival in the American literature was that reported by Parks and Epstein8 in 1940. The twins were approximately one month premature. The :ords were united in a true knot. In 1942 Jones3 reported a case of monoamniotic twins delivered at seven and one-half months. One was a macerated premature infant and the other a flat papyraeeus. Their co-rds were joined in a true knot, and there ~-as also a true knot in each of the cords. In 1946 Acosta-Sison, Aragon, and de la Paz1 reported two cases of monoamniotic :wrns. The first ca.se was one in which the cords were knotted. The first child was born alive; but the second one, born thirty minutes later, was stillborn. The other case they i,eported was one of double survival of monoamniotic twins delivered by Cesarean section because of eclampeia. In May, 1947, Boyle and Riehterx reported a case of true knots in the umbilical cords ::aarsing the death of both twins in utero in the seventh month. In July, 1947, Coulton, Hertig, and Longa added two cases of double survival. Their cases were unique in that there was neither knotting nor tangling of the cords. Mendel-i in 2251 reported a case of monoamniotic twins in which the first baby was viable, and the second was macerated. 1152
Volume 65 Number 5
DOUBLE
SURVIVAL
OF
MONOAlMNIOTIC
1153
TWINS
In 1947 Coulton’sa review of the literature brought Quigley’s report up to that date. With the addition of the cases of Acosta-Sison, Boyle, and Mendel (which have appea,red in the literature since that review), there have been 11 cases of monoamniotic twins reported in the English literature since Quigley’s review in 1935. The addition of the following (case ,will bring the total to 12. Six of these cases have resulted in double live births. One 1of these resulted in a neonatal death so that there remain only 5 cases of double survival.
Case Report CASE A83542.-This 19-year-old white married woman, para i, gravida ii, was followed during the antepartum period by one of us in a Public Health Clinic. The last menstrual period was Aug. 7, 195,l. She had no complications other than slight edema of the ankles. On May 14, 1952, a twin pregnancy was diagnosed on abdominal examination, and this was confirmed by x-ray. Labor began at 7:30 A.M. on July 24, 1952. The membranes ruptured at 7:35 A.M. On admission the head was crowning. The patient was taken directly to the delivery room and anesthetized with nitrous oxide, oxygen, and ether. The first fetus presented in left occipitoanterior position and was delivered by low forceps with an episiotomy. The cord was found to be looped twice around the neck of the first baby. It could not be slipped over the hIsad or shoulders and was clamped and cut. Upon completi.on of the delivery it was found (to the surprise of the operator) that the cord which had been cut supplied the second twin, still in utero.
Fig.
1.
This cord was also knott.ed with the cord which latter could not be removed without untying the knot. cm. and 86.5 cm., respectively. A version and extraction from second twin, and a live baby resul.ted. first and second deliveries. The latter
left
supplied the first fetus, so that The umbilical cords measured
occipitoposterior position were then done Four minutes elapsed between the completion was finished at 8 :20 A.M.
the 71.5
on the of the
The babies were male infants weighing 5 pounds, 15 ounces, and 5 pounds, 4 ounces, respectively. They breathed and cried spontaneously. The second twin did not suckle as strong’ly during the second day as the first, but this was not noticed the third day. They were discharged on July 27, 1952, in good condition weighing 5 pounds, 9 ounces, and 4 p#ounds, 15 ounces. They are still living at this writing, Oct. 27, 1952. The placenta weighed 1,040 grams and was There were two umbilical cords, and the attachment the placenta. Their insertions were 7 em. apart.
roughly circular and 21 cm. in diameter. of each was 3.5 cm. from the edge of Careful inspection of the fetal side of
placenta rc~ealaii iimhilical cords and Iayers. The maternal
ttlr
no
in
httg:imms
of
amaiotic
orerdxxne
no place at the periphery side was not remarkable.
TV~H there
between
any
tlw
evidence
artat~imrants of
Iwo
of the amniotic
References ,\coata-Sison H ~wgon, ti, T., and de la Pxz, A.: J. Philippines 51. .i. 22: 13, ,LcJari. Boyle, J. B.1 a& Richter, C. I?.: ARI. J. OBST. & GYNEC. 54.: 119, 1947. Coulton, D., Hertig, A. T., and Long:, W. N.: ALL J. OBST. & GYNSC. 54: 119, 1947. Fremer, Edward: Brit. M. J. 1: log, 1936. Jones, Warren E.: Ax. J. OBST. & GYNEC. 43: 130, 1942. Litt, Sol, and Strauss, H.: Ax. J. OBST. & GYNEC. 30: 728, 1935. Mendel E. B.: J. Internat. Coll. Surgeons 15: 2, 1951. Parks, John, and Epstein, J. R.: AM. J. 05ST. & GYNW. 39: 149, 1940. Quigleg, J. K.: A&L J. 0~6~. & G~NJX. 29: 354, 1935. IZucker, M. I?.: Am. J. Surg. 28: 175, 1935.
EAGOOD, the
%.D.,
Departments
ANI) of
H.
!bYXOSD
Obstet~rics
ad
STOKES,
Pathology,
M.D., BIIIMISC~HAM, AA. Medical
College
of Ala3amu)
r-118 is a case report of monoamniotic twins with survival of the infants. It is of interest because there have been relatively few such reports in the literature. Quigleye quotes Rosenberg as stating that monoamniotic twins occur once in 60,000 pregnancies. In 1935 Quigleye reported 108 cases of monoamniotic twins which he had collected Out of this number 20 cases resulted from the literature and added one case of his own. i.n a single live birth, and another 17 resulted in double live births. He calculated the chance of double live births to be 15 per cent. Eight of Quigley’s cases were reported to be from the American literature. Jones5 .+cates that one which he included (a case reported by Boyd in 1883) was of a single fetus papyraceus in a single amnion. Of his 8, only one case resulted in a single live twin. In his review, Quigleyg presents a case of Podzahrodsky which is very similar to the one presented by us. He reports a case in which a midwife cut a cord which was tightly wound about the neck of the first twin. L ‘It proved to be the cord of the second twin and only by prompt delivery effected by Podzahrodsky were both twins saved. ’ ’ Coulton, Hertig, and Long3 in reviewing the literature in 1947 found 5 cases in the English. literature since Quigley’s report and added 2 of their own. These 7 cases are f,eviewed briefly. In 1935 Ruekerr reported a case of monoamniotic twins in which the first twin had both cords around his neck. The second twin in this case was macerated. There was a true knot uniting the cords which is not an uncommon finding in these cases. In 1935 Litt and Xtrausse reported a case of monoamniotic twins in which one was normal and the other anencephalic. There were muitiple true knots in the cords. Both infants were stillborn, having been delivered approximately five weeks prematurely. In ,1936 Frewer?reported a case in which the first child survived, and the second died 30 hours later. The first case of double survival in the American literature was that reported by Parks and Epstein8 in 1940. The twins were approximately one month premature. The :ords were united in a true knot. In 1942 Jones3 reported a case of monoamniotic twins delivered at seven and one-half months. One was a macerated premature infant and the other a flat papyraeeus. Their co-rds were joined in a true knot, and there ~-as also a true knot in each of the cords. In 1946 Acosta-Sison, Aragon, and de la Paz1 reported two cases of monoamniotic :wrns. The first ca.se was one in which the cords were knotted. The first child was born alive; but the second one, born thirty minutes later, was stillborn. The other case they i,eported was one of double survival of monoamniotic twins delivered by Cesarean section because of eclampeia. In May, 1947, Boyle and Riehterx reported a case of true knots in the umbilical cords ::aarsing the death of both twins in utero in the seventh month. In July, 1947, Coulton, Hertig, and Longa added two cases of double survival. Their cases were unique in that there was neither knotting nor tangling of the cords. Mendel-i in 2251 reported a case of monoamniotic twins in which the first baby was viable, and the second was macerated. 1152
Volume 65 Number 5
DOUBLE
SURVIVAL
OF
MONOAlMNIOTIC
1153
TWINS
In 1947 Coulton’sa review of the literature brought Quigley’s report up to that date. With the addition of the cases of Acosta-Sison, Boyle, and Mendel (which have appea,red in the literature since that review), there have been 11 cases of monoamniotic twins reported in the English literature since Quigley’s review in 1935. The addition of the following (case ,will bring the total to 12. Six of these cases have resulted in double live births. One 1of these resulted in a neonatal death so that there remain only 5 cases of double survival.
Case Report CASE A83542.-This 19-year-old white married woman, para i, gravida ii, was followed during the antepartum period by one of us in a Public Health Clinic. The last menstrual period was Aug. 7, 195,l. She had no complications other than slight edema of the ankles. On May 14, 1952, a twin pregnancy was diagnosed on abdominal examination, and this was confirmed by x-ray. Labor began at 7:30 A.M. on July 24, 1952. The membranes ruptured at 7:35 A.M. On admission the head was crowning. The patient was taken directly to the delivery room and anesthetized with nitrous oxide, oxygen, and ether. The first fetus presented in left occipitoanterior position and was delivered by low forceps with an episiotomy. The cord was found to be looped twice around the neck of the first baby. It could not be slipped over the hIsad or shoulders and was clamped and cut. Upon completi.on of the delivery it was found (to the surprise of the operator) that the cord which had been cut supplied the second twin, still in utero.
Fig.
1.
This cord was also knott.ed with the cord which latter could not be removed without untying the knot. cm. and 86.5 cm., respectively. A version and extraction from second twin, and a live baby resul.ted. first and second deliveries. The latter
left
supplied the first fetus, so that The umbilical cords measured
occipitoposterior position were then done Four minutes elapsed between the completion was finished at 8 :20 A.M.
the 71.5
on the of the
The babies were male infants weighing 5 pounds, 15 ounces, and 5 pounds, 4 ounces, respectively. They breathed and cried spontaneously. The second twin did not suckle as strong’ly during the second day as the first, but this was not noticed the third day. They were discharged on July 27, 1952, in good condition weighing 5 pounds, 9 ounces, and 4 p#ounds, 15 ounces. They are still living at this writing, Oct. 27, 1952. The placenta weighed 1,040 grams and was There were two umbilical cords, and the attachment the placenta. Their insertions were 7 em. apart.
roughly circular and 21 cm. in diameter. of each was 3.5 cm. from the edge of Careful inspection of the fetal side of
placenta rc~ealaii iimhilical cords and Iayers. The maternal
ttlr
no
in
httg:imms
of
amaiotic
orerdxxne
no place at the periphery side was not remarkable.
TV~H there
between
any
tlw
evidence
artat~imrants of
Iwo
of the amniotic
References ,\coata-Sison H ~wgon, ti, T., and de la Pxz, A.: J. Philippines 51. .i. 22: 13, ,LcJari. Boyle, J. B.1 a& Richter, C. I?.: ARI. J. OBST. & GYNEC. 54.: 119, 1947. Coulton, D., Hertig, A. T., and Long:, W. N.: ALL J. OBST. & GYNSC. 54: 119, 1947. Fremer, Edward: Brit. M. J. 1: log, 1936. Jones, Warren E.: Ax. J. OBST. & GYNEC. 43: 130, 1942. Litt, Sol, and Strauss, H.: Ax. J. OBST. & GYNEC. 30: 728, 1935. Mendel E. B.: J. Internat. Coll. Surgeons 15: 2, 1951. Parks, John, and Epstein, J. R.: AM. J. 05ST. & GYNW. 39: 149, 1940. Quigleg, J. K.: A&L J. 0~6~. & G~NJX. 29: 354, 1935. IZucker, M. I?.: Am. J. Surg. 28: 175, 1935.