Maternal and fetal expectations with multiple pregnancy

lVIATER~AL

AND FETAL EXPECTA'l'IONS WI'l'H MULTIPLE PREGNANCY*

JOHN

C.

HIRST,

A.B., .M.D., F.A.C.S.,

PHILADELPHIA, PA.

(From the Department of Obstetrics, University of l'ermsyll'£!nUt Medical and Graduate "lfeilical Schools)

HIS study is offered for three reasons: first, as response to aroused

T

public interest in plural births due to survival of several recent Americant and two Britisht quadruplets, and of course the Canadian Dionne quintuplets, to indicate what may reasonably be expected from the occurrence of multiple pregnancy; second, to show that the accident of more than one birth at a od11gle confinement should be anything but a matter of the usual amazement and chagrin to the physician, astonishment and dismay to the parents and amusement to everybody else; and third, to offer personal r:onnnents on toxernia of pregnancy as seen in t·wins and triplets. The material presented is a brief sumrnar.\· of the literature coneerned with unusual complications seen in plural births, as well as leading articles bearing upon our statistics, which are derived from 223,394 total births beyond sixteen weeks' gestation in the City of Philadelphia in the seven years from 1931 to 1937 inclusive, as obtained from the Municipal Bureau of Vital Rtatistics. From these an: obtained through the Philadelphia Maternal Mortality Committee (Philip F. WilliamR. M.D., Chairman) the plural births among 1,469 puerperal deaths from all causes aR well as 835 deaths excluding those associated with abortiou, miscarriage and ectopi(' g·estation. To these g·roups are added detailed progress of 3 setR of tdplets and 219 pairs of t·wins out of 19,463 total birtl1s beyond hnmty weeks' gestation in the Philadelphia IJying·-in Hospital from ,Jnl~- 1, 1929, to June 30, 1938; 1 set of triplets and 60 pail's of twins ont of 5,483 births in the :\Iaternity Department of tlw Hospital of the TTnivt>rsity of Pennsylvania from 1931 to 19R7 inclusive, and a recent "experimental" group eomprising ont> set of tripl~t;;; a]J(] 26 pairs of twins from the last 2,000 birtl1s in the Preston RC'trt>at, Pl1iladelpbia. The scope of the stud~- does not inrlude speeulation on the cause or mechanism of twinning or em the ~weurac;v of reported habitual litters as evaluated by Greulich ;1 or on differentiation and biologic differences and relative frequenC.'' of single and double ovum twins, race, reeurrence and age. so well described by Guttmacher, 2 but is conrerned rhiefl,\· with re>mlts SN'll in plnral births. *React. by invitation. at the Fifty-Fir>"t Annual Meeting: of the American Association of Obstetrlcilms. Gynecologists :md Abilominal Surgeons, \:Vhlte Sulphur Springs. W. Va .. September 22 to 2·1, 19~8. tMullins. mi.:'erl. a~·ed 1 year. Porter, Okla.; Kasper. mixed. aged 21·2 yrs., Passaic. New Jersey; Schense. mixed. ar:ed 7 yr.. Aberileen. S. D. ; Morlok, females, aged 8 yr.. Lansing, Mich.; Perricone. males. aged 9 yr.. Beaumont, Texas; Keyes, females, aged 23 yr.• Hollis. Okla. · :!:Taylor, mixed, aged 3 months; Mites, aged 3 years.

634

HIRS'l':

635

Ml'L'l'IPLE PREGNANCY

CITY OF PHIL..t\DELPHIA STATISTICS

Maternal Res·ultii.-In this large ~erie::;, in addition to giving the maternal death tate from all puerperal causes, we added an additional rate obtained by deducting
-

ALL PER

PUERPERAL DEATHS 1000 BIRTHS

PUERPERAL DEATHS EXCLUDING THOSE ASSOCIATED WITH ABORTION Alie ECTOPIC GEST~TION PUERPERAL llEATHS ASSOCIATE!) WITH TWIN BIRTHS OVER 20 WEEKS GESTATION

AUTHOR'S

TWifol

BIRTHS

PHILADELPHIA

Fig. 1.-Maternal mortality rates showing an average of 1.21 per cent
In Philadelphia iluring the last for twin births, 0.50 per cent for abortions and ectopic gestations, the Lving-in and University of ·

seven years. all puerperal compared to Pennsylvania

Fig. 1 that the average maternal death rate ( 1.21 per cent) associated with plural births over sixteen weeks' gestation, during the last seven years, was three times the average rate (0.50 per cent) for the total puerperal deaths and over four times as great as the average rate (0.33 per cent) for maternal deaths excluding abortion, miscarriage, and ectopic gestation. At this point, it may be stated that Phila•lelphia experienced no quadruplets over 16 weeks' development, but from the three years 1934 to 1936, inclusive, there were seven known triplet birthsn (1 :13,253) and in the remaining four years, 16 calculated (1 :8,000) additional, but there were no maternal deaths associated with these 23 triplet birthe.

Splitting up the twin dea.ths according to Fig. ~ ~~ tl!HlN I :HII (I: 100+ in our Philailelphi:t ~erieR), the frequency was doubled in thl:' septi<~ antl eanliac death~. quadrup!Nl in the late gestational toxemic, and iner<'Ro<:'d to thE' :tmazing frequen<•y of 1:] ~ in th<• pofltpartum hemorrhage fataliti<'s. It i;; obviono therefore tlmt in RpitP of till• faet that in Philadelphia 80 per t•ent of all patient~ to ht> t•onfint•tl al'e llospitalizPd. each woman with multiple pregnant:y a.s~ume" rick Kuftiriently grt>Ht a" to requin~ extraordinary precautionR 8uggeRted later. Infant Results.-Only the g!'neral ~till birth ( OV('l' ](i to 20 wpekB) rates awl tlte neonatal death (over 2:-l weeb or 1,500 gr11.) rate~ for the year~ Hl:n to 19:":7 in" dusive (Fig. :!) rmn be pre~enteu for the l'ntire dty of Philadelphia, ~hH•e the Htill-

90

BIRTHS

-

STILL

c=J

NEONATA~

DEATH$

PER 1000 BIRTHS

80

70

60

AUTHOR'S

PHILADELPHIA

TWIN

BIRTHS

HOSPITALS

Fig. 2.-Comparison of gross stillbirths and neonatal deaths over sixteen weeks in Philadelphia with rates among 558 twins in the Lying-in and University of Pennsylvania Hospitals.

birth Committee of the Philadelphia Obstetrical Society ( ehttirman, 'l'haudeus Montgomery, M.D.) and the Neonatal Death Committee of the Department of Health (chairman, Ralph Tyson, M.D.) are of recent origin and have not yet reported causes of their respective deaths. The above rates, like the general maternal ratrcS, show a gradual decline with a seven-year average of 3.8 per cent for stillbirths, and 2.75 per cent for neonatal deaths (total 6.55 per cent), which is roughly one-half the respective rates (gross 7.0 per cent and 13.62 per cent; corrected 6.27 per cent and 6.1 per cent) among 558 twins in the author's hospital series. The latter, totaling 12.37 per cent (corrected), show a reversal of the two types, indicating that pre· maturity is of greater importanee in the postnatal than in the natal period of the infant's existence.

HIRH'f:

.MUL'l'IPLE PREHKANUY

637

THE LYING-IN, UNIVER8l'l'Y 01<' PEKKSYLVANIA AND PRES'l'ON RETREAT

HOSPITAL SERIES

Hince there were but five instances of triplets, these may he disposed of briefly at this point according to a recent report: 10 toxemia in one mother, post-partum hemorrhage in another, and severe endometritis in a third, but all labors and de· liveries easy, due to marked prematurity in each case. One infant was stillborn, four died within a short time and probably the sixth. Since that report, one additional set of syphilitic triplets in the twenty-sixth week of gestation has been confined as an emergency undiagnosed case in the Lying-in Hospital without dystocia or other complications, delivering spontaneously with only twenty-five minutes be· tween infants which were all females and weig·hed 1 pound 4% ounce~; 1 pound 4%, ounces, and 1 pound 4 ounces, all of whom died in a few hour~, and combined with the above triplets yield an infant mortality of over 50 per cent.

Progress of twin pregnancy and infants from the first two hospital services, representing 95 per cent registered confinements, are combined and will be described under five headings, namely: pregnancy, labor, delivery, puerperium, and infant. :1. Pregnaney.-Among 279 double pregnancies of twenty weeks' gestation or over, there were but 40 primigravidas, the average being gravida 3.8. The duration of pregnancy averaged 35.4 weeks from the first day of the last period, which partly account~< for the faet that only 99 duplic•ations were diagnosed before labor, 20 in labor and 160 or the majority as late as birth. The earliest diagnosed case was that of twins in one horn of a double uterus at thirteen weeks by the author by means of double ballottement and relatively inereased urinary anterior pituitarylike excretion. Roentgenography confirmed the diagnosis in 58 cases, proved the only means of diagnosis in 24, was not utilized at all in the great majority or 195, and was erroneous in 2 of the pregnancies, which were classified a~: private :\4; registered ward 219; registered student out-service 10; aml emergency or unregi~tered 15 ( 5.4 per cent). Complications.-Exeess weight was frequent, the greatest amounting to 70 pounds ( 200 to 270 pounds), which according to Matthewsu when over 200 pounds predisposes to exeess kidney, liver, and heart ~>tress, prolonged labor in the majority, !'orne type of complieation in 75 per cent, and malposition in 26 per cent of all such eases. Toxemia appeared 37 times as pre-eclampsia (14 quite "mild," and 2 superirnpos~:ii on nephritis), 3 times as eclampsia, and only 7 times as hyperemesis. If to the mild pre·eclamptics may be added 12 instances of considerable edema only, we obtain a picture simulating low reserve kidney (Stander's1 2 tempo· rary disorder distinrt from all nephritides, not distinguishable from ''mild preedampsia,'' featured by :;:light hypertension and albuminuria and orca~ional slight e
638

AMERICAN JOURNAL OF OBSTE'l'RICS AND GYNECOLOHY

rary bilateral hydronephrosis and relatively normal estrogen and anterior pituitary" like excretion26 in a triple pregnancy complicated by very mild late gestational toxPmia at thirty-eight weeks,9 we continue in this belief, discounting thP infrequenc•y of ureteral symptom~ in tlw prt'sent twin ~prieR on thE' basis o:f lar~k of present •·ystoscopic faeilities maintained in and by the two matE·rnity •lrpartments roneE'rned. A final eomment on thl" common edema of latt' twin prPgnancy iR the Rignificance of change of blood volume whieh iR in•~reased 2(1 p<'r eent in normal single late pregnancyH and greate~t of all in twin pregnancy,H all of the aforementioned icleas being apparently oppo~ed to but not incompatible with the generally accepted general-arteriolar-Rpasm mechanii'm in late gestational toxemia.16 Syphilis played its usual part, affecting J 7 or 6.1 per cent of the mothers; severe cardiac deficiency affected 14, while plaeenta previa and partial abruptio placentae endangered, respectively, G and :J pregnancie~, yet there were no prenatal deaths. 2. Labor.-Labor began and ·~ontinned spontaneously towards the second birth~ in 193 of the raseR; medical induction was utilized 24 times, and :failed only 9 time~. Excluding podalic: version, the membrane" of the :first sac were artificially ruptured 14 times, of the serond 45 times; anrl Rurgkal induc:tion was required only 4 times. Only 27 instanc:eH of dystocia were JJoted, with an average duration of 23.4 hours in such easeR. In spite of frequent polyhydramnios and malposition, prolapsed umbilical cord was noted only once before birth of the first twin. Analgesia in the form of morphine sulphate was given 4() times, the maximum dose was l!t. gr., twice; as pentobarbitol sodium 48 times, maximum dose 9 gr., average 6 gr.; and as miscellaneous sedatives 4 times, the heaviest being alurate 10 gr., so that narcosis cannot be responsible for the high fetal death rates. 3. Delitoery.-Both infants were delivered spontaneously 51 times, the first 67 times and the second only 13 times, making 182 spontaneous births out of 558 deliveries (31.1 per cent), and by contrast cesarean section was performed 12 times ( 4,3 per cent). Forceps assistance wns utilized 85 times for the first child and 12 times for the second; version, li times for the first and 125 times for the second; and breech extraction 54 times for the first and 70 times for the second, this high frequency (68.9 per cent) of interference accounting for a low average time-interval between births of 13.1 minutes, including a maximum wait in one case of eight and one-half hours. Hemorrhag·e during birth waF not fatal but severe in 12 (4.3 per cent) women, once due to plac.enta previa, 3 times due to abruptio placentae between infants, and 8 times before delivery of the placenta. 'l'he very nature of twin births and both of our groups of statistics indicate frequent hemorrhage from low placental implantation or premature separation, yet several recent case reports in the literatureH-19 would suggest rarity of such bleeding. Prolapse of the umbilical cord between births occurred 4 times, whereas one cord was so short as to require high forceps for delivery. 4. Puerperium.-Post-partum hemorrhage was serious in 15 cases (5 per cent), for whom 21 transfusions were essential and for as many more might well have been TABLE I.

IN(!IDENCE 0~' TWIN BIRTHS IN 'l'HE FOUR MOST COMMON CAUSES 0~' M.\TERNAI. DEATH IN THE CITY OF PHILADELPHIA

CAUSE OE' DEATH

NUMBER AND RATIO OE' TWIN BIRTHS

156 'roxemia and eclampsia Hemorrhage: 6 129 A. All types (+) (74) B. Post-partum 1 49 Heart disease 9 246 Other canBes (Excluding abortion~ and ectopic gestations) 27 835 'l'otals ~~-----·~----

(1:21.5) (1:18)

(1:49) (1 :27.3) (1:31)

------

..

HIRST:

639

MULTIPLE PREGNANCY

used, making a total incidence of hemorrhage in pregnancy, labor, delivery, and puerperium of 36 .or 13 per cent. The nonfatal and fatal morbidities are listed in 'l'ables II and III and are much higher than for single pregnancy. 5. lnfants.-The average weights of each pair of babies were 5 pounds 6 ounces for the larger and 4 pounds 9%, ounces for the smaller, the largest pair weighing x pounds 11¥..! ounces and 8 pounds 1% ounces. One hundred eleven were breast fely, aml 17<1 lmlntion to the 39 stillbirths, little relation to the 22 neonatal complications (Table IV) but may or may not have had relation to the 76 total neonatal deaths involving 40 pairs, plus 14 of the larger and 21 of the smaller of pairs according to Table V. TABLE

!I.

CAUSES OF NONFATAL PUERPERAL COMPLICATIONS IN 27tl TWIN BIRTHS OVER TWENTY \VEEKS' GESTATIO:'\. HIGH l.!XCIDENCE OF EKDOMETRI'riS ATTRIBlJTABLE TO l<'REQUENT INTERFERENCE (68.9 PER CENT)

2 22

Parametritis Pyelocystitis Pneumonia Breast engorgement Postoperative Perineal Upper respirator.'" infection Septic splenitis Total 'r .\BLE III.

2

62 (22.3%)

--·-·········-····--~~-~-~-----'---'-'-.:.__-

CA\'SE'> OJ<' DEA'l'H FROM 279 Twn;; BIRTHS OVER TWENTY \VEEKS' GESTATION

1. Septicemia, peritonitis 2. Post-partum hemorrhage. (Bilateral hydronephrogis, ascites, pleural effusion) .•. Hemolytic streptococcic septicemia 4. Acute dilatation of heart 5. Abscess of broad ligament, bilateral eelluliti;,;, acute splenic tumor, bilateral pleurisy 5 Total T.\JlT,E

IV.

NONFATAl. COMPLICATIONS AMONG 443 Sl"RVIVAL TWINS LISTED BY 'rHE PEDIATRIC SERVWE

foot Fractured humerus Rickets Convulsions Anemia Pneumonia Pulmonary atelectasis Facial growth Pylorospasm Abscess of anus Congenital heart disease and undt>scended testicle Hypospadias Microcephaly Hemorrhagic disease Total

1 1

2 1

3 1 3 1 1 1 1

1 1 1

22

,UU:RIC,\1\ .JOURNM, fH' OBRTI~'l'RIUS .\:\D HYl\ECOLO
ti40

.From lu5 ~et' of twin~ in tlw PhilatlPlphia Lying·in Hospital, T,vson2o found nearly :3 time:< a~ many twin" hom in Augu~t as in otlH'r months of th<> year, there· fore sin0e hi-ovular twins arP three times a~ frequPnt as uniovular, and since most December twin "oneeptions would dPliV('r in Augu~t ratlwr than SPptembt•r, tliP queRtion of possible ~easonal double ovulation Hhoulnoarnnion,24 Pte. TABl.E

Y.

CAITSEB Ol' ill NEOSATAI, DEATllll FRO~! 558 TWJJ'
H

'l'rauma Hemorrhagk disease

~ •>

I~rvthroblastosis

•)

Ryphilis Asphyxia Prolapsed cord Cardiac deficiency Atresia of esophagus and anus Pneumonia Doubtful

•)

Total Deductible Prematurity Under 28 weeks ·under 1500 gm. Defects Corrected neonatal deaths TABI,E

VT.

•>

I

1

lH

iii ( 13.62%) 31)

3

34

P!tOBABI,E CAUSES OF' PHEMATURITY A:MOKG 41)~ BIRTHS IN ~'fib~

LYING-IN HosPITAI, (TYsoN) NUMBER OF

PER ('EN'I'

])JgJ)

LIVED

41

19

:!4 21

26

n

:3

1(1

12.0 10.0 ii.O 2.0

!I

Ul

7

1 2

CASES

Multiple pregnancy Premature separation Injury to mother Placenta previa Cardiac Polyhydramnios Pneumonia Nephritis Myoma Abortion Tuberculosis Pyelitis Acute cold Asthma Unknown

60

;j()

2-J.

9

I

1.9 0.8 0.6 0.6 0.6 0.6 0.2 0.4 0.2 0.2

196

41.8

4

3 :l

3 :l l 2

1

6

.., •)

1 3

3

'·'" 1 2 0

0

il

n

2

0

0 0 0 70

1

1 1

126

HIRST:

MULTIPLE PREGNANCY

641

Having become "twin-conscious," the author personally observed over 2,000 practically consecutive recent pregnancies in the Preston Retreat for the special purpose of twin management, but even by particular attention to all gravida v and over, and to those who had delivered previous fraternal twins, was able to diagnose manually one set of triplets and only 19 out of 26 pairs of twins before birth, not including one positive false diagnosis in a case of polyhydramnios. \Vhen diag·nosed, these twin pregnancies were supplied with extra milk and beef, vitamins A, B, D, and G and ferrous sulfate capsules and 8 out of the 14 that were diagnosed in pregnancy were admitted to the ·ward as "waiting women" at thirty-six weeks. To this simple plan we ascribe a slightly increased average gestation to over thirtysix weeks, avoidance of cesarean section, and protection of the mother by particular care to prevent post-partum hemorrhage as by not too heavy sedation and avoidance of ether. This was, however, offset by bleeding from one lateral placenta previa, one abruptio placentae and one instance of intrapartum hemorrhage due to an acardiacus acephalus attached almost directly to the placenta, causing abruptio placentae. There were five instances of mild and one of severe late gestational toxemia, and no deaths. In this small series under special attention, 2 out of the 55 infants were stillborn (including the acardiacus, plus one that died from placental necrosis due to toxemia) and five died after birth, one of which was delivered at twenty-six weeks and two at twenty-seven weeks, yielding a corrected total infant mortality of 3 out of 55 infants (5.4 per cent). SUMMARY AND CO)l"CLUSIONS

1. Maternal, fetal, and neonatal deaths associated with twin and triplet pregnancy have been analyzed from 223,394 total births over sixteen weeks' gestation in Philadelphia from 1931 to 1937 inclusive; and detailed maternal and infant progress from 5 sets of triplets and 305 pairs of twins from the Lying-in, University and Preston Retreat Hospitals has been analyzed. 2. Maternal, stillbirth, and neonatal death rates from twin pregnancies have been shown to be increased roughly about three times over those for single births. 3. The author suggests abdominal tension resulting in renal ischemia or ureteral obstruction as a common factor in both nulliparous ''low reserve kidney" and "mild pre-eclampsia" in multiple pregnancy. 4. Quantitative serum and twenty-four-hour urinary excretion of estrogen and prolan should determine whether ''low reserve kidney'' and many cases of multiple pregnancy toxemia. are similar, and distinct from pre-eclampsia. 5. By becoming twin conscious, three-fourths of all multiple pregnancies may be diagnosed manually, and 90 per cent of suspected cases should be diagnosed by x-ray in time to provide dietetic, tonic, and physical support; avoidance of unnecessary cesarean section, and ex-

642

AMERICAN JOURN.U, OF OBSTETRICS AND GYNECOLOGY

cess sedation and ether in labor; and hospitalization including preparation for immediate transfusion in all cases, thereby reducing both maternal and fetal accidents by at least one-half. 6. More time up to one hour, and fewer versions are inJicated for the seeond birth, to allow opportunity for the uterus to readjust itself, thereby minimizing the risk of infection aud post-partum hemorrhage. 7. Scrupulous manag·ement of the third stage of labor, and uterine packing for eight hours in all cases of lwmorrhage b-efore or aftee delivery will prevent many deaths from twin births. 8. Prematurity is the greatest infant hazard, prejudicing the neonatal period more than the natal. 9. Meticulous care. including microscopic examination. in examining the se<•undines from multiple pregnam\V slJOnld be obli~ator;'\-. REI<'ER.leNCES

(1) G-reulieh, William W.: .T. A . .YI. A. 110: 559, ] 938. (2) Guttmacher, Alan F.: AM .•r. OBST. & GYNEc. 34: 71\, 1937. (:1) Falk, H. C., and Blinick, Georgi:': Ibid. 35: 1058, 1938. ( 4) Le~·inl:', William: Ibid. 33: t179, 1937. (5) Pudney, W. K.: Ibid. 33: 161, 1937. (6) Fer,quson, .John A., anrl Otis, Isra.el 8.: Ibid. 30: 139, 1935. (7) Siegler, Samuel L.: Ibid. 29: 122. 1935. (8) L~~ll, Clifford B.: Ibid. 28: J 26, 1934. (9) Strome. Frank P.: Direetor, Bureau of Vital Statistie~. Commonwealth of Pennsylvania, Department of Health. (10) Hirst, John C.: AM • .r. 0BST. & GYNEC. 35: 868, 10311. ( 11) Matthews, Har~•ey B., a11il Der Brucke, Maurice G.: .I. A. M. A. 110: 5fi4, 1938. (12) Stander, H. J., and Kuder, K.: AM. J. 0BST. & GYNEt'. 35: 1. 191\8. (l!'l) HirNt, John C.: Ibid. 18: 528, 1929. (14) Eastman, Nicholas .J.: Ibid. 34: 549, J9il7. (15) Thomson, .Jeffer,qon, Hirsheimer, A.., Gibson, John G., and EPan,•, W. A.: I hid. 36: 58, 1938. (HI) lruilng, Frederick C.: Ibid. 31: 466, 1936. (17) Haws, ill. W.: Ibid. 29: 895, 1935. (18) Balasquiile, L. A.: Ibid. 29: 008, 1935. (Hl) Gallaghe1·, .Joseph: Ibid. 28: 270, 1934. (20) Tyson, Ralph M.: Unpublished data. (21) Idem: New York State M. J. 34: 18, 1934. (22) Edmund,Y, P. K.: A~r. J. 0BST. & GYNEC'. 29: 600, 1935. (23) Colli'r&.~, R. M.: Thiel. 33: 503, Hl37. (2+) Quigley, .James: Ibid. 29: 354, 193:i. (25) Peters, John P., Laviete.~, Paul H., and Zimrnm-mann, Ha,rry: Ibid. 32: 911. 1936. (26) Smith, 0. Watkin.~. and Srnith, Georg"' Van R., with .Joslin, Elliott P., and White, PriRci!la: Ibid. 33: 365, Hli\7. 500 NoRTH Twt:NTIE'rH STR};ET

DISCUSSION DR. BAYARD CARTER, Dt;RHAM, N. C.-The figureH for North Carolina concerning twin pregnancies bear out Reveral features of Dr. Hirst's paper. We find that approximately 40 per cent terminate prematurely. The incidence of toxemia gives roughly a figure of 45 per cent as contrasted with the incidence of about 26 per cent in the ordinary country type of patient who comes to the clinic. The incidence of abruptio placentae and the bleeding Ryndromes has also been great
HIRST:

MULTIPLE PREGNANCY

643

DR. THADDEUS L. MONTGOMERY, PHILAm~LPHIA, PA.--It is of consluerable importance to differentiate between tl1e pathology associated with uniovular twins and that encountered in binovular pregnaney. 'I' here are certain forms of dis· turbance which are inseparabl~· associated with the one or the other form of multiple prngnancy; for instance, it is possible for one of binovular twins to die in utero without influencing the vitality of the other twin, while it is impossible for one of uniovular twins to be deatl for any length of time \Vithout cauRing the death of the other twin. Therefore, in binovular pregnancy one ma~· l?nrounter in one placenta aggressive conditions of the chorionic epithelium, such ~ts hydatidiform mole, or extreme regression of thP pl:1eenta and ner,ro~is, without either lesion being present in the other placenta. On the other hanart waves which are easily diagnosed on account of their different rhythm, size and direetion, the latter corresponding to the position of the fetu~. \Yhile taking the te~ts in the eleetrocanliographic labomtory, for I did not exam· ine the patients otherwise, a case was sent which I did not know to be twin pregnancy. In the tracings we found two typeH of fetal waves in addition to the maternal deflections, one being upFide down, as we see in vertex presentations, the other upwards, as we see in hreeeh presentation~. \Ve were, therefore, in the position to tell on account of the electrocardiogram that there were twins present, that both twins were- alive, that one \Vf\1' in a vertex, tht> other in a hrt'ech position. These findings were ve-rified hy x-m;v pieture later. DR. HIRST (closing).-\Ve should look with suspicion upon every large abdomen in pregnancy, x·ray and possibly electrocardiograph every one, and we should warn small maternity de.partmeuts to be prepared for any emergeney, especially hemorrhage, in these twin case$. In the larger institutions we should have a. member of the major Htaff present at every twin birth if only to restrain the resident obstetrician from doing internal podalic version of the second baby until indicated.