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Monoamniotic twin Pregnancy
MONOAMNIOTIO TWIN PUGNANOY DONALD WALTERS, M.D., AND DONALD WHITEHEAD,
M.D.,
WASHINGTON, D.
C.
(From the Department of Obstetrics and Gynecology, the George Washington University and Hospital)
occurrence of monamniotic twinning is relatively rare. In a review of T HE 332 twins at the Chicago Lying-in Hospital from 1931 to 1941, Potter and Crunden1 found no case of monoamniotic twins. King/ however, reported 5 cases in an 18 month period in New Orleans. This seems to indicate that the incidence of monoamniotic twins is greater than is generally believed and that many cases are not recognized as such and are therefore not reported. The clinical diagnosis of monoamniotic twin pregnancy is impossible until the time of delivery. After delivery of the first twin, if there is prolapse of a twisted or knotted umbilical cord or if there is absence of the second amniotic sac, mono amniotic twins should be suspected. Immediate delivery of the second twin should be accomplished to prevent the effects of hypoxia resulting from tightening of the knotted cords.
Fig. 11l:!9
1130
WAL'l'ERS AND \\"lIl'l'EHEAlJ
,\fl1.
J. Ohst.
&. Grllce. May, 19;7
CASE I.-Mrs, H, P., a 32-year-old gravida iii, para ii, went into labOl' on Sept. 12, 1955, six weeks prematurely. The diagnosis of twins lYas made in labor. Caudal anesthesia was used. When the cervix was fully dilated a compound left bregma anterior and arm presentation of the first twin was found. The second fetal head was impacted in the pelvis close beside the first head. The second fetal head and arm were dislodged with considerable difficulty. The first fetus was then delivered by midforceps. It was a viable bahy girl who weighed 3 pounds, 12 ounces. The second fetus was then delivered spontaneously and immediately from a left mentum anterior position. The second twin weighed 3 pounds, 8 ounces. Both umbilical cords were found to be arising from the placenta 4 cm. apart with no evidence of a partition between them. They were tightly entwined and a true knot was present (Fig. 1). The babies responded well to mild oxygen resuscitation, and were sent to the premature nursery in good condition, They have continued to progress well up to the present time (Fig. 2).
Fig. 2.
Fig. 3.
CASE 2.-Mrs. E. G., a 24-year-old gravida i, para 0, was admitted to the hospital on March 15, 1955, eight weeks prematurely, with a history of irregular uterine contractions, The patient had felt no fetal movement for the three weeks prior to admission. Examination showed a normal temperature and pulse. The blood pressure was 122/80. The ahdomen
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was gravid, the size of a 6 months' gestation, and was soft and nontender. No fetal heart tones were heard. The fetal membranes ruptured spontaneously during a pelvic examination two hours after admission, and the amniotic fluid was thick and dark brown. The first fetus was delivered almost immediately after rupture of the membranes from the left occiput posterior position. This fetus was a stillborn baby girl weighing 1 pound, 4 ounces. The second fetus was delivered as a breech, left sacrum anterior, six minutes later. This fetus was a stillborn baby girl weighing 1 pound, 14 ounces. The placenta was delivered spontaneously and immediately with the birth of the second twin. The placenta showed intertwining of the cords and contained five true knots. Both cords arose from the placenta 3 cm. apart and no partition was seen between them (Fig. 3). Both fetuses were macerated, indicating that they had been dead in utero for considerable time. The mother w~s diHcharged on March 18, 1955, in good condition after an uneventful postpartum course.
Conclusions
1. Two cases of mono amniotic twin pregnancy arc presented. 2. Both monoamniotic twins survived in one case. 3. Only 11 cases have been reported in the American literature (including the case reported here) of a double survival of monoamniotic twins. 4. After delivery of the first twin, prolapse of twisted or knotted umbilical cords or the absence of a second sac should suggest monoamniotic twins. Immediate delivery of the second twin should be accomplished. 5. Thorough examination of the placenta and umbilical cords of twin pregnancies should reveal a higher incidence of monoamniotic twins. References 1. Potter, E. L., and Crunden, A. B.: AM. J. OBST. & GYNEC. 42: 870,1941. 2. King, J. A., et al.: AM. J. OBST. & GYNEC. 63: 691, 1952. 3. Quigley, J. K: AM. J. OBST. & GYNEC. 29: 354,1935. 4. Parks, J. L., and Epstein, J. R.: AM. J. OBST. & GYNEC. 39: 140, 1940.
5. 6. 7. 8.
McCormick, C. 0.: J. Indiana M. A. 22: 245,1929. Conybeare, R. C.: Obst. & Gynec. 4: 444,1954. Hanes, M. V.: Obst. & Gynec. 4: 448, 1954. Hagood, M., and Stokes, R. H.: AM. J. OBST. & GYNEC. 65: 1152, 1951.
M.D.,
WASHINGTON, D.
C.
(From the Department of Obstetrics and Gynecology, the George Washington University and Hospital)
occurrence of monamniotic twinning is relatively rare. In a review of T HE 332 twins at the Chicago Lying-in Hospital from 1931 to 1941, Potter and Crunden1 found no case of monoamniotic twins. King/ however, reported 5 cases in an 18 month period in New Orleans. This seems to indicate that the incidence of monoamniotic twins is greater than is generally believed and that many cases are not recognized as such and are therefore not reported. The clinical diagnosis of monoamniotic twin pregnancy is impossible until the time of delivery. After delivery of the first twin, if there is prolapse of a twisted or knotted umbilical cord or if there is absence of the second amniotic sac, mono amniotic twins should be suspected. Immediate delivery of the second twin should be accomplished to prevent the effects of hypoxia resulting from tightening of the knotted cords.
Fig. 11l:!9
1130
WAL'l'ERS AND \\"lIl'l'EHEAlJ
,\fl1.
J. Ohst.
&. Grllce. May, 19;7
CASE I.-Mrs, H, P., a 32-year-old gravida iii, para ii, went into labOl' on Sept. 12, 1955, six weeks prematurely. The diagnosis of twins lYas made in labor. Caudal anesthesia was used. When the cervix was fully dilated a compound left bregma anterior and arm presentation of the first twin was found. The second fetal head was impacted in the pelvis close beside the first head. The second fetal head and arm were dislodged with considerable difficulty. The first fetus was then delivered by midforceps. It was a viable bahy girl who weighed 3 pounds, 12 ounces. The second fetus was then delivered spontaneously and immediately from a left mentum anterior position. The second twin weighed 3 pounds, 8 ounces. Both umbilical cords were found to be arising from the placenta 4 cm. apart with no evidence of a partition between them. They were tightly entwined and a true knot was present (Fig. 1). The babies responded well to mild oxygen resuscitation, and were sent to the premature nursery in good condition, They have continued to progress well up to the present time (Fig. 2).
Fig. 2.
Fig. 3.
CASE 2.-Mrs. E. G., a 24-year-old gravida i, para 0, was admitted to the hospital on March 15, 1955, eight weeks prematurely, with a history of irregular uterine contractions, The patient had felt no fetal movement for the three weeks prior to admission. Examination showed a normal temperature and pulse. The blood pressure was 122/80. The ahdomen
Volume 73
Number 5
MONOAMNIOTIC T\VIN PREGNANCY
1131
was gravid, the size of a 6 months' gestation, and was soft and nontender. No fetal heart tones were heard. The fetal membranes ruptured spontaneously during a pelvic examination two hours after admission, and the amniotic fluid was thick and dark brown. The first fetus was delivered almost immediately after rupture of the membranes from the left occiput posterior position. This fetus was a stillborn baby girl weighing 1 pound, 4 ounces. The second fetus was delivered as a breech, left sacrum anterior, six minutes later. This fetus was a stillborn baby girl weighing 1 pound, 14 ounces. The placenta was delivered spontaneously and immediately with the birth of the second twin. The placenta showed intertwining of the cords and contained five true knots. Both cords arose from the placenta 3 cm. apart and no partition was seen between them (Fig. 3). Both fetuses were macerated, indicating that they had been dead in utero for considerable time. The mother w~s diHcharged on March 18, 1955, in good condition after an uneventful postpartum course.
Conclusions
1. Two cases of mono amniotic twin pregnancy arc presented. 2. Both monoamniotic twins survived in one case. 3. Only 11 cases have been reported in the American literature (including the case reported here) of a double survival of monoamniotic twins. 4. After delivery of the first twin, prolapse of twisted or knotted umbilical cords or the absence of a second sac should suggest monoamniotic twins. Immediate delivery of the second twin should be accomplished. 5. Thorough examination of the placenta and umbilical cords of twin pregnancies should reveal a higher incidence of monoamniotic twins. References 1. Potter, E. L., and Crunden, A. B.: AM. J. OBST. & GYNEC. 42: 870,1941. 2. King, J. A., et al.: AM. J. OBST. & GYNEC. 63: 691, 1952. 3. Quigley, J. K: AM. J. OBST. & GYNEC. 29: 354,1935. 4. Parks, J. L., and Epstein, J. R.: AM. J. OBST. & GYNEC. 39: 140, 1940.
5. 6. 7. 8.
McCormick, C. 0.: J. Indiana M. A. 22: 245,1929. Conybeare, R. C.: Obst. & Gynec. 4: 444,1954. Hanes, M. V.: Obst. & Gynec. 4: 448, 1954. Hagood, M., and Stokes, R. H.: AM. J. OBST. & GYNEC. 65: 1152, 1951.