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Monoamniotic twin pregnancy
This presents an unusual and interesting case. Very few cases of this tumor have been reported in t,hc literature, but as mentioned before, it is probable that many have not been diagnosed and have found their way under the classification of other tumors such as fibromas, lipomas, liposarcomas, and fibrosarcomas. Because of the rarity of the condition a correct preoperative diagnosis is difficult, and the more common conditions are usually considered. The most int,eresting feature of the case was the complete disappearance of the remnants of the tumor after the patient, had delivered. When the pat,ient was last
u. z. allg. Path. 30: I, 1901. E:vans, J. H., md 48: G75, 1940. Fe& E.: Zentralbl. f. Gyn&k, 57: R9, 1933. Ge+eZ: Ibid. 48: 1673, 1924. Kehrer, E.: Arch. f. Gyn;ik. 158: 582, 1934. Law, 4. Robertson: Rurg., Gynec. & Obst. 17: 3, 1913. Sipped, Pa&: Zentralbl. f. Gynlk. 47: 840, 1923. Stoeckel, JO.: Ibid. 47: 33, 1923. Strati: Zentralbl. f. ges. Chir. 39: 482, 1927. Sfra.ssman. P.: Berl. Dtsch. Ges. Gyngk. Halle 15, 2: 486, 1913. Twunm, .,I.: ,1(&t. obst. et g~ynec. &and&v. 20: 25, 1940. Prancona,
Beitr.
z. path.
Anat.
N. T. : Sm. J. Surg.
MONOAMNIOTIC WARREN (From
the
Departmen,f
11. JOSES, M.l)., of
Obstetrics
Medicnl
T
TWIN and
Sas
I’RE(:NANCY FRASCISCO,
Gynecology,
lhivemity
CAI~F. of C'difornict
School)
HE following case seemsof interest because twins so rarely develop in one amniotic sac. A white primipara, aged 2’i years, entered the private service of Dr. Frank W. Lynch in the University of California Hospital on Dec. 1, 1940, in premature labor. Her expected date or’ confinement was Feb. 15, 1941; her last menstrual period May 8, 1940. The prenatal course had been uneventful. The Wassermann test was negative and the pelvis was normal. Twins had been suspected in the early months of pregnancy because of the relatively large size of the uterus, but the rate of growth then slowed down and the possibility was discarded. The family history revealed that, the patient’s mat,ernal great aunt had twins but no other twins occurred in either the patient’s or her husband’s family. On entering the Hospital, the patient stated t.hat she had not felt any fetal movements for several days and that, four hours prior to entry, fleeting uterine contractions had begun, associated with suprapubic pain. These contractions had increased steadily in severity and at the time of examination were severe and occurred every one and onehalf to two minutes. An excessive bloody show occurred as t,he patient, entered the Hospital. Physical examination disclosed: a uterus two fingerbreadths above the umbilicus; no fetal heart could be heard. The uterus was not unusually hard or tender between contra&ions. On rectal examination, the cervix was dilated 4 cm. with the membranes intact and a footling presentation.
JONES
:
MONOAMNIOTIC
TWIN
PREGNANCY
131
Temperature, blood pressure, pulse, and respiration were normal. The hemoglobin was 83 per cent (12 Gm.). The blood type was IV (Moss). The patient was given nitrous oxide and oxygen with her pains, and because vaginal bleeding persisted, a vaginal examination was made which showed a cervix completely dilated with membranes bulging through the OS. These were ruptured artificially, when the lower edge of the placenta could be felt at the left posterior margin of the dilated cervix. Because vaginal bleeding still persisted, the feet were brought down rapidly and the fetus readily delivered as a breech presentation; the second, and much smaller, fetus, was expressed by pressure on the fundus. The first infant was a macerated premature fetus and weighed 1,300 Gm. The second infant was flat, almost papyrareus. It weighed
Fig.
1.
but, 185 Gm. and measured lSl/, cm. from crown to rump. Considerable bleeding occurred, both immediately after the delivery of the infants and of the placenta, the total blood loss being estimated at 1,200 CL Consequently, intravenous (10 per cent) glucose was administered to the patient immediately after the second stage, 1,000 CL in each antecubital vein followed shortly by a transfusion of 750 cc. of titrated blood. The patient’s condition was good throughout with no evidence of shock. The placenta measured 22 by 16 by 2 cm. in size and weighed 720 Gm. The membranes were intact, but there was only one amnion and one chorion. No evidence of a partition between the two cords could be found, and, in addition, Hood vessels from the larger of the two cords passed over the insertion of the smaller cord, entering the placenta in the one to the fetus t,his area. The cords were inserted marginally, papyraceus being 55 cm. long and but 0.5 cm. in diameter. The cord
132
AMERlC4N
,JOlUISAI.
01%‘ OBSTETRICS
ASI)
(:TSW:Ol
AX:\
to the larger fetus was 48 cm. in length and 1.5 cm. in diameter. At a distance of 30 cm. from the placenta, the two cords formed a complex true knot, while a separat,e true knot, was present in the narrow cord in the same area. It, seemed probable that the smaller fetus had died early in the pregnancy, possibly from a knot in its cord; and later had become entangled in the cord of the larger fetus, causing its death a day or two before the onset of the premature labor. The heart of the small fetus was grossly normal. The patient’s post-partum course was uneventful except for a rise in temperature t,o 38O C. on the third to sixth post-partum days, inclusive. Xulfanilamide was started on the fourth post-partum day, and coincided with a fall in temperature to normal within the next thirtysix hours. Blood counts on the first, fifth, and eighth post-partum days revealed the hemoglobin always above 80 per rent, and a maximum white blood count of 15,000. Urinalyses on the same days were within normal limits. The patient. was up and in good condition on her tenth post-partum day. A comprehensive review of t,hc cases on monoamniotic twins was made by Quigleyl in 1935. He stressed the rarity of the condition and states that from t,he time of the first case reports in the seventeenth century to 1935 he was able to find but 108 authentic cases to which he added one of his own. From t,he practical standpoint, the chief clinical interest is the danger of death of one or both fetuses from twisting or knotting the cords. This results in a high fetal mortality rate, but there is no more risk to the mother than in any other case of twin delivery. Quigley states that in 94 cases where it was possible to estimate mortality, the fetal death rate was 68 per cent. True knot formation was reported 58 times in the 109 cases, an incidence of 53 per cent. Eight monsters occurred in t,he series. Both twins survived in only 17 of the cases, a. 15 per cent, chance. (Since 1935, an additional ease olf survival of both infants has been reported by Parks.2) Quigley, in stjressing the rarity of this type of twins, states that he was able to find only eight cases reported in the American literature from 183% to 1935. In reviewing the case reports in the American literature, we find this group is even smaller, since one of the cases included in Quigley’s study- (Boyd,3 1883) is, in reality, a fetus papyraceus in a separate amnion. In fact, in describing the placenta of his specimen, Boyd states that “the fetal side shows the division in the amniotic sacs.” In the six years since Quigley’s study, we have found reports on three additional cases in the American and one in the British literature.*, 4-ti Taken with the case report above, five cases in the past six years would indicate that the extreme rarity of monoamniotic twins is due, in part, to a failure in reporting or recognizing the condition after the delivery. REFERENCES (1)
Q,uigZey,
Epstt%m, J. R. : 602, 1883. (4) Strauss, A. A.: 5. 1: 159, 1936.
Au. J. OBST. & GYNEC. 29: 354, 1935. (2) Parks, J., a& Ibid. 39: 140, 1940. (3) Boyd, G. M.: Ann. Gynee. & Pediat. 6: Rucker, X. P.: Am. J. Surg. 28: 175, 1935. (5) fiitt, S., and Ax J. OBST. & GYNEC. 30: 728, 1935. (rij Frewer, B.: Brit. M.
J.
K.:
u. z. allg. Path. 30: I, 1901. E:vans, J. H., md 48: G75, 1940. Fe& E.: Zentralbl. f. Gyn&k, 57: R9, 1933. Ge+eZ: Ibid. 48: 1673, 1924. Kehrer, E.: Arch. f. Gyn;ik. 158: 582, 1934. Law, 4. Robertson: Rurg., Gynec. & Obst. 17: 3, 1913. Sipped, Pa&: Zentralbl. f. Gynlk. 47: 840, 1923. Stoeckel, JO.: Ibid. 47: 33, 1923. Strati: Zentralbl. f. ges. Chir. 39: 482, 1927. Sfra.ssman. P.: Berl. Dtsch. Ges. Gyngk. Halle 15, 2: 486, 1913. Twunm, .,I.: ,1(&t. obst. et g~ynec. &and&v. 20: 25, 1940. Prancona,
Beitr.
z. path.
Anat.
N. T. : Sm. J. Surg.
MONOAMNIOTIC WARREN (From
the
Departmen,f
11. JOSES, M.l)., of
Obstetrics
Medicnl
T
TWIN and
Sas
I’RE(:NANCY FRASCISCO,
Gynecology,
lhivemity
CAI~F. of C'difornict
School)
HE following case seemsof interest because twins so rarely develop in one amniotic sac. A white primipara, aged 2’i years, entered the private service of Dr. Frank W. Lynch in the University of California Hospital on Dec. 1, 1940, in premature labor. Her expected date or’ confinement was Feb. 15, 1941; her last menstrual period May 8, 1940. The prenatal course had been uneventful. The Wassermann test was negative and the pelvis was normal. Twins had been suspected in the early months of pregnancy because of the relatively large size of the uterus, but the rate of growth then slowed down and the possibility was discarded. The family history revealed that, the patient’s mat,ernal great aunt had twins but no other twins occurred in either the patient’s or her husband’s family. On entering the Hospital, the patient stated t.hat she had not felt any fetal movements for several days and that, four hours prior to entry, fleeting uterine contractions had begun, associated with suprapubic pain. These contractions had increased steadily in severity and at the time of examination were severe and occurred every one and onehalf to two minutes. An excessive bloody show occurred as t,he patient, entered the Hospital. Physical examination disclosed: a uterus two fingerbreadths above the umbilicus; no fetal heart could be heard. The uterus was not unusually hard or tender between contra&ions. On rectal examination, the cervix was dilated 4 cm. with the membranes intact and a footling presentation.
JONES
:
MONOAMNIOTIC
TWIN
PREGNANCY
131
Temperature, blood pressure, pulse, and respiration were normal. The hemoglobin was 83 per cent (12 Gm.). The blood type was IV (Moss). The patient was given nitrous oxide and oxygen with her pains, and because vaginal bleeding persisted, a vaginal examination was made which showed a cervix completely dilated with membranes bulging through the OS. These were ruptured artificially, when the lower edge of the placenta could be felt at the left posterior margin of the dilated cervix. Because vaginal bleeding still persisted, the feet were brought down rapidly and the fetus readily delivered as a breech presentation; the second, and much smaller, fetus, was expressed by pressure on the fundus. The first infant was a macerated premature fetus and weighed 1,300 Gm. The second infant was flat, almost papyrareus. It weighed
Fig.
1.
but, 185 Gm. and measured lSl/, cm. from crown to rump. Considerable bleeding occurred, both immediately after the delivery of the infants and of the placenta, the total blood loss being estimated at 1,200 CL Consequently, intravenous (10 per cent) glucose was administered to the patient immediately after the second stage, 1,000 CL in each antecubital vein followed shortly by a transfusion of 750 cc. of titrated blood. The patient’s condition was good throughout with no evidence of shock. The placenta measured 22 by 16 by 2 cm. in size and weighed 720 Gm. The membranes were intact, but there was only one amnion and one chorion. No evidence of a partition between the two cords could be found, and, in addition, Hood vessels from the larger of the two cords passed over the insertion of the smaller cord, entering the placenta in the one to the fetus t,his area. The cords were inserted marginally, papyraceus being 55 cm. long and but 0.5 cm. in diameter. The cord
132
AMERlC4N
,JOlUISAI.
01%‘ OBSTETRICS
ASI)
(:TSW:Ol
AX:\
to the larger fetus was 48 cm. in length and 1.5 cm. in diameter. At a distance of 30 cm. from the placenta, the two cords formed a complex true knot, while a separat,e true knot, was present in the narrow cord in the same area. It, seemed probable that the smaller fetus had died early in the pregnancy, possibly from a knot in its cord; and later had become entangled in the cord of the larger fetus, causing its death a day or two before the onset of the premature labor. The heart of the small fetus was grossly normal. The patient’s post-partum course was uneventful except for a rise in temperature t,o 38O C. on the third to sixth post-partum days, inclusive. Xulfanilamide was started on the fourth post-partum day, and coincided with a fall in temperature to normal within the next thirtysix hours. Blood counts on the first, fifth, and eighth post-partum days revealed the hemoglobin always above 80 per rent, and a maximum white blood count of 15,000. Urinalyses on the same days were within normal limits. The patient. was up and in good condition on her tenth post-partum day. A comprehensive review of t,hc cases on monoamniotic twins was made by Quigleyl in 1935. He stressed the rarity of the condition and states that from t,he time of the first case reports in the seventeenth century to 1935 he was able to find but 108 authentic cases to which he added one of his own. From t,he practical standpoint, the chief clinical interest is the danger of death of one or both fetuses from twisting or knotting the cords. This results in a high fetal mortality rate, but there is no more risk to the mother than in any other case of twin delivery. Quigley states that in 94 cases where it was possible to estimate mortality, the fetal death rate was 68 per cent. True knot formation was reported 58 times in the 109 cases, an incidence of 53 per cent. Eight monsters occurred in t,he series. Both twins survived in only 17 of the cases, a. 15 per cent, chance. (Since 1935, an additional ease olf survival of both infants has been reported by Parks.2) Quigley, in stjressing the rarity of this type of twins, states that he was able to find only eight cases reported in the American literature from 183% to 1935. In reviewing the case reports in the American literature, we find this group is even smaller, since one of the cases included in Quigley’s study- (Boyd,3 1883) is, in reality, a fetus papyraceus in a separate amnion. In fact, in describing the placenta of his specimen, Boyd states that “the fetal side shows the division in the amniotic sacs.” In the six years since Quigley’s study, we have found reports on three additional cases in the American and one in the British literature.*, 4-ti Taken with the case report above, five cases in the past six years would indicate that the extreme rarity of monoamniotic twins is due, in part, to a failure in reporting or recognizing the condition after the delivery. REFERENCES (1)
Q,uigZey,
Epstt%m, J. R. : 602, 1883. (4) Strauss, A. A.: 5. 1: 159, 1936.
Au. J. OBST. & GYNEC. 29: 354, 1935. (2) Parks, J., a& Ibid. 39: 140, 1940. (3) Boyd, G. M.: Ann. Gynee. & Pediat. 6: Rucker, X. P.: Am. J. Surg. 28: 175, 1935. (5) fiitt, S., and Ax J. OBST. & GYNEC. 30: 728, 1935. (rij Frewer, B.: Brit. M.
J.
K.: