TRUE INTERLOCKING TWINS:THE LESS0NS LEARNT Dr. Tripti Sinha*

Received 22February 2077/ Received in revised form 10 November 2oL7/ Accepred 25 Novem ber 2oL7

: An extelsMe lite rle rgview revgqls thq! though exremety r:are,twinint.AsLr"nt ri a .o.pfi."tioniOi rritipt6 pregnahiies cannot be ignored. With more being achieved by assisted reproducfive technoiogy more cases'are'like"ly to be encountered unless strategiesto anticipate and prlvent its occurrence are put in place. f n tf',. *orrtr.enario, perina,.f or,.or" can be improved by ma ndatory institutional ad mission in late pregna n.y or. labour with vigilance especialiv during second stage to detect slow rrested progress "arty /a du ring delivery of the first twin. This case highlightr t'.lo*1ni, may not 4lways ne"possible

Keywords: Multiple ; Twin entanglement/locking; lnter-locked twins; Perinatal outcome; Vaginatdetivery; Caesarean

l.ntroduction She had routine antenatal checkups at the hospital a few ti mes. Locked twins is a rare complication of multiple pregnancies Her last menstrual period was on 27/1,1,12014 and the where two foetuses become interlocked during delivery. lt expected date of delivery was 319/2015. Her investigations occurs in roughly 1 in 140 to 1,000 twin deliveries and 1 in were within normal limits. The ultrasound report was not 90,000 deliveries overall.' With the growing incidence of available at admission but her attendant informed that it was a multiple pregnancies due to assisted reproductive techniques, twin pregnancy. (The report was shown later on7 /7 l15,which there is a strong likelihood of a commensurate increase in the showed two live twin foetuses; the presenting twin was in incidence of locked twins also. breech presentation and the second twin was in transverse lie; the expected A case of locked twins in which neither twin could be salvaged date of delivery was 2O/8115; the placenta was due to late presentation is discussed to highlight the anterior and liquorwas adequate). importance of patient counseling regarding regular antenatal The patient on admission was in great distress with strong care and institutional admission in iate pregnancy or early labour pains but vitals were stable. She was moderately pale labour to optimize the outcome of this rare but serious and afebrile. was 32-34 weeks size with contracted complication of multiple pregna ncies. feel. Presentati-on of second twin and heart sounds could not be ascertained ciearly, The trunk, upper and Iower limbs of the first twin was hanging at Case report the vulva together with a loop of cord without pulsation. The cervix was fully dilated and the A 23-year-old-primigravida from a rural area was admitted at chin of the first twin was impacted in the against the 1.10 pm on 1"5/7 115 to the labour ward of Sri Krishna Medical head of the second twin (Figure 2). There was significant College, Muzaffarpur, advanced in labour with arrest of the bleeding pervaginum. after-coming head of a baby delivering by breech (Figure 1). She was about 34 weeks pregnant. Her labour pains had started the previous night but due to transport delays she reached the health facility in the advanced stage of labour,

Figure 2. Chin-to chin locking

Figure 1. Arrestof after-coming head of firsttwin

Corresponding address *DrTripti Sinho, Assistant Professor, Department af and Gynecology, Sri Krishna Medical College, Muzoffarpur, Bihar. postal address: 705 North, Udaigiri Bhowan, Budh Morg, opposite Pstno Museum, Potna-800001, Bihar, tndia. E-mai!: [email protected], ph: Og4g10 60s1s/0995s2 40482

Volume I No.4, Oct-Dec, 2017 G n Obstetrics & GYnaecologY

and Giventhefactthatthisisanextremelyrareconditionandits diagnosis of locked twins was made'.The'patient to A occurs when the leading twin has been subiected counseled about the prognosis' Jirgnori, attendants were foetal loss of the first twin is almost the rule was done under facioru causing asphyxia Emergency lower segment (conservatively in morethan 60% reported cases)' The lower uterine segment was distended ,pinriun"t,f',esia. in which the second twin was delivered abdominally by A review of literature lncludes cases and thinned. The second,t{iq recent salvaged by a number of interventjons ln 3.47 pm o1 tilt l)!; An assistant tl9nj. d-.9llYej:d has been vertex at for liberal use of ultrasonogr:'ap''hy no cardiac puliation in it' The years there has been a trend tire flrst baby vagindliy; thefe-was of multiple severely asphyxiated and ,nd.u"rur"an deliveries in management f twin was also unaorlnrf V C"il*t"A such devastating .resuscitaled' uneventful recovery thus anticipating and obviating could not be Shle- 'made an fr"gnrn.iu, on American College of obstetricians .and poitoperativ" t're and was discharged Io-,ipti.utions'o ,ir with routine elective abdominal delivetl as day with advice to come for postnatal Gynaecologlsts recommends eleventh postoperati.ve presenting as mode of delivery if the firsttwin is aftelsix weeks'' tl-re preferred revlew diagnosis of interlocking : ul."u.t.,r or transverse lie since the first foetus may often occurs late in second stage when the Discussion havesufferedadverseconsequencesofimpaction,This]s current obstetrics This makes the case Twin interlocking is exceedingly rare in usually the case in low-resource settings' mortality and ultrasound' practice and is associated with high foetal for routine monitoring of twin pregnancywith the foetuses are often morbiditY. lf diagnosis is made late In labour when u with each has to be fl Twins may only collide in the pelvis or truly interlock dead and the case infected, management ti of the four ways under deep H other. Such occurrences may occur in one individualized. Disengagement/dis-impaction twin''7 which ilt depending on the presentation of the first and second general anesthesia is to be attempted first failing maneuver has also ti l.Bothvertices:firstvertexdescendsintothepelvisbutthe iecapitation should be done' Zavenelli's the first outcome't Hexoprenaline second vertex g.ets jammed besides the thorax of been r"ported with successful i'i to facilitate dis-impaction of ,ii fo etu s. ,rtOt',r,u'to relax the uterus offirstfoetus 2. First breech /second vertex: after-coming head lockedfoetalheadsandsecurevaginaldeliveryhasalsobeen Johannesberg, South Africa'' A unique method gets held up atthe pelvic brim bythe descending head ofthe reported from locking was described by interlocking) of' of chin-to-chin iecond one (true chin-to-chin held up the fimU-att and Rand in 1950' The asslstant 3.Bothbreechpresentations:Bothbreechattemptstoengage ii undel|veredbreechwhilePiper,sforcepswasapplledtothe ..i together. There may be prolapse of up to four legs including headofthesecondtwin'Afterdeliveryoftheheadofthe loops of cord. of both twins is affected by second twin, simultaneous dellvery or transverse: first twln catches 4. First vertex/second breech ,."rrf traction.'Although in this case neither twin survived' of second twin' one or even both on some Part several cases are reported in whlch either that of Nissen's This classification is very similar to babies were salvaged ''" who further defined the types of twin and Sharma' classification Ghosh, Chatterjee and Konar from Kolkata" as follows:' similar dismal peri- entanglement Rnand'and Khajuria'o from Jammu report parts of one baby with its co- 1. Collision:The contact of any natal outcomes as this case' twin prevenfing engagement of either' twin onto the surface of its 2. lmpaction: lmpactof part of one Conclusion thereby causing only partial engagement of both issues' co-twin Twin pregnancies present with a lot of management to ante-partum sim ultaneouslY. twln-iocking is best prevented by liberal resort of leading delivery 3. Compaction: The simultaneous full engagement and intra-partum ultrasonography' and abdomlnal the pelvic cavity and than allow labour foetal part of both twins thus filling when first twin has malpresentation rather of either' preventing either descent or disengagement to progress into this catastrophe' 4. lnterlocking: The intimate contact of undersurface of a chin Editor's comment ofonetwinwiththatofitsco-twinabove/belowthepelvic Complication is Treatment of each case must be individualized' brim, of labour' This is an not recognized until late in the second stage purported to be implicated in the occurrence Obstetric factors where both foetuses were lost due to late foetuses' unfortunate case, this condition include primigravidae, small be avoided of presentation to hospital' Foetal mortality can only unusually roomy pelvis, severely reduced liquor volume' and timely by identifying the potential cases wjth ultrasound mono-amniotic twins, hypertonicity and extension of the intervention by caesarea n section' leading Part.'

volume ?, No,4, Oct-Dec,2017 - lndian Obstetrics & Gynaecology =-=

References 8. Strickland N, Saneman P. Locked twins. Report of 3 cases, Gy n e co I t9 67 29 (2) :211-2. 1. Delry SK. Two cases of locked twins . Br Med J L96O; 1 O b stet ; (5780):1,17 4-77 . 9. Adams DL, Fetterhoff CK. Locked twins. A case report, 2. Gordon R. lnterlocked,twins: a case report and brief review O bstet Gy n e co I 197 1; 38(3) :383-5. of the iliterature. SAfr Med J 1956; 30(28);661-3. 10. Pandey MR, Ghimire P, Ghimire P. Successful vaginal 3. Nissen ED. Twins: collision, impaction, compaction, and delivery of locked twins in a tertiary care centre of lvesterf region of Nepal. Nepal Journal of Medicot Sciences 201.4; i nte rlocki n g. O b stet G y n e c o t 1958 ; L1-(5) :51-a-26. 3(1]r:74-75. 4. Kurzel RB. Twin entanglement revisited. Twin Res 7998; 1(3):138-41. 1l-. Veena P, Chaturvedula L. Two rare complications of twin gestation manifesting as arrest of descent in second stage of 5. Saad FA, Sharara HA. Locked twins: a successful outcome - labour. lntJ Adv Med Heolth Res20l6;3(2):94-96. after applying the Zavanelli manoeuvre. I Obstet Gynaecol 12. Borah Das A. Locked twins: a rarily. Ann Med Health 5ct 1997;17 (4):366-7 . I Res 2012;2(2\:204-5. 6. Sevitz H, Merrell DA. The use of a beta-sympathomimetic Chatterjee DP, Konar M. lnterlocking in tuin drug in locked twins. Case report. B r J Obstet Gynoecol 198L) 13. Ghosh B, ' 88(7):76-7. p regn a n cy (A case re po rtl : lO G I t97 6 ; 3,55 -L57 . 7. Kimball AB Rand PR. A maneuver for the simultaneous 14. Sharma S, Anand A, Khajuria R. lnterlocked twins: A case delivery of chin-to-chin locked twins. Am J Obstet Gynecol report, JKScie n ces 2Ot4; 16(4) : 188-189.

_ L950;59(5):1167-8.

volume 7, No' 4, oct'Dec,z o1rl .I t_-Jf-re - ! ,0612-2321542 E ,0612-2320s39 I THE PATNA JOURNAL OF MEDICII{E ESTD : 1925 A rnonthly Publication Under The Joint Auspices of the Bihar State Branch of the lndian Medical Association and Patna Medical Association Eusrness Secretary Editor DR. (Prof.) Umesh Sharma DR. A.K. JHA'AMAR' M.D; DCP. M.B.B.S. (Hons), M.D. (Skin) Professor & H.O.D. Ph.D (Derrn) FIAMS (Skin) Departmenfof M icrobiology Professor of Dermatology. P.M.C. Patna P. M. C. H. Patna Office Address ,,Assoclate Editors I.M.A. BUILDING DR. (MRS.) VEENA CHOUDHARY DR. A.K.N. SINHA PATH, M.B.B.S., M,S. (Obst. & Gynae) SOUTH - EAST GANDHI MAIDAN DR. UDAY KUMAR PATNA - 800 004. l.G.l.M.S., Patna. E -mail : [email protected]

aer. ruo.P././.?/.2" rv D ate. C.3 :..e..?. :..2: t X.

To, Dr. Tripti Sinha Assistant Professor) Department of Obstetrics & Gynaecology, Sri Krishna Medical College & Hospital Muzaffarpur.

Dear Sir / Madam, With pleasure, we have to inform you that your article entitled "RUPTURE UTERUS : REYIEW OF MANAGEMENT IN A MEDICAL COLLEGE IN NORTH BIHAR " has been accepted for publication in the Patna Journal of Medicine. Thanking you,

Yours sincerely, 1- l\ #,)'" .''( _ ( ,rr,,, , iI A^M i ' ,-'l '\{ "-' (Amar Wil"'Amar') Editor Rupture Uterus: Review of management in a medical college in North Bihar lntroduction: '. The obstetrical calamity- - continues to contribute significanily to maternal and peri-natal morbidity and mortality especially in less and least developed countries and regions of the world. lt remains uneradicated even in developed countries due to rising Cesarean section rates. (.,1) present The study reviews the causes, the management strategies adopted there and the maternal and fetal outcome of uterine rupture in patients admitted to a medical college in North Bihar which predominantly serves a rural population.

Materialand methods:

The study is a retrospective analysis of the case notes of patienis of uterine rupture admitted to the labor ward of Sri Krishna Medical College Hospital, Muzaffarpur in Bihar. The salient points in the demographic and obstetric profile were collected and analyzed to give an indication of the etiological factors for uterine rupture in this predominantly rural population often living far from any primary or higher health care facilities. The definitive surgery performed and maternal and fetaloutcomes were noted also. Results:

There were 31 cases of uterine rupture during the period o1to4l2o16-31103/2017 in this institution with an average annual delivery rate of 9000-110O0(prevalence 0.31 %). Although in terms of percentage this may not appear significant numerically these cases cannot be ignored because of the impact upon the survival, quality of life and future reproductive aspirations of these women.

Table { summarizes age, religion and parity profile of the cases. There were no teenage pregnancies, 21 cases were between 20-30 years (67.74%), 9 were between 31-40 years (29.03%) and 1 was above 40 years (3.23%). There was 1 case documented as primigravida (3.23%) , 23 were multips (74.1o/o) and 7 weregrandmultipara (22.58o/o).24(77.41%)womenwereHindus andT(Z2.S1%)were Muslims. Allwere living in rural areas from where they were referred to the terliary centre. lZ(38.1%) previous cases had cesarean section, had gone into spontaneous labor and were admitted to the hospital late whereas in others (n=19, 65.5%) obstructed labor was the etiological factor for uterine rupture.

Table 2 shows the type of surgical interventions done in the 31 cases of rupture of uterus studied in our institution.l2 cases ( 38.7o/o) had only repair of uterlne rent done, 10 cases (32.22o/o)had rent repair combined with bilateral tubectomy, 8( 25.8%) had subtotal hysterectomy and only l{Z.23Vo) had total hysterectomy. Among those who had rent repair, either alone or combined with sterilization operation 11(35'480/0) had rupture of unscarred uterus; 20 (66.520/0) had a uterine scar which had ruptured or had dehiscence. ln 7(25.58o/o) cases with only uterine repair the future reproductive potential was preserved by omitting sterilization operation procedure after counseling about the risks in future pregnancy and labor.

All cases which had subtotal hysterectomy were cases in which the rupture occurred in an unscarred uterus. The single case in which total hysterectomy had been performed had a cesarean section previously. lt was not documented in the case notes why the uterus could not be preserved in this case. ' The post-operative period of all cases was largely uncomplicated without any major o:nplications. The women c were discharged in a satisractory condition. The peri-natal outcome was extremely poor. There were 26(g3.g7yo)stittoirttrs, alive but asphyxiated 4(12.go/o) were and onry 1 baby was born in a good condition (3.23%). Discussion: A wHo systematic review of maternal morbidity and mortality (1) rupture in an cites the incidence of uterine unselected population in less and leastdLu"rop"o countries". - based figures) *|!:.r]3y:_2.P,o/o (hospitat-bas"dfi;;;ffiralt o.oioy"-0.30%(community 0..1 o/o-1yo. tn the incidence is 1% in women developed countries with scarred uterus ddo in tho." <1/1000' 0' 1%)'The wiilr unscaired uterus (overa, incidence in this study is similar";J?/# to ilrat oioiirer rike Pakistan and countries in this region of the world Nepar and in o*rer government hospitat" oi tniiu our observations Q,3,4,5). regarding the epidemiolo;icai p;o;ii; and risk studies factors of the women in these are also similar to that of the profile of women-having rupture uterus in our series. Risk factors for rupture of uterus remains the same as before: poor antenati and delayed regarding decision- making abdominal delivery especially when labor "rr" was initially being managed at the primary health care setting initially' The incidence is rising owing to the comptunding effect of the section rates rising cesarean and misoprostol for induction of labor in uncontrolled dosages in different parts of the world (6) This has assumed worrying proportions in both urban and ruralareas. Lowering uterine rupture, the incidence of therefore, include strategies to reduce prir"ry a"rrru"n section rates such as using simplified partogram or a even a more simple clinical tool like ihu onu suggested be by Debdas (7) which can utilized easily by ANMs and nurses at ihe periprrery. cases of prolonged labor would be referred timely to FRUs and higher centers with facilities for abdominal delivery before obstructed they ended up in labor or rupture uterus in the worst scenario.

ln our series uterus was conserved in 70.93% cases and sterilization operation was performed only 32'23% cases leaving in both menstrual and reproductive function intact rupture although with risk of uterine in subsequent pregnancy and labor. Hysterectomy -subtotal and total- which compromised both menstrual and reproductive functions was done in 2g.3% cases. This is different from the management strategies in other series in which hysterectomy rates varied from 32o/o, 41.51%, respectively' (3'4'8' 46yo and 55o/o 9)'None of the cases required associated surgeries like bladder repair, repair of vaginal vault rents or internal iliac artery ligation to hemorrhage as was reported series compited by Sahu(4) "ortroipo"tp;r, in the

The choice of operation performed is dependent largely on the findings at operation-the site of rent and the extent of damage the to the adjacent structures .Another important consideration intention is the couple,s of whether or not to retain the woman's reproductive and I or menstrual potential. These issues need to be incorporated as part of the pre-operative counseling and informed consent procdureso that there are no medico-legal disputes subsequenily. Conctusion:

Rupture uterus is a completely avoidable obstetric prevention calamity. does not require high grade expensive technology but down -to- earth interventions like simple clinical tools. in patient referral minimizing delay and transport to FRUs and higher centers with facilities for abdominal delivery , good monitoring of labor in cases with previous cesarean deliveries so that VBAC becomes a safe and viable option for delivery and, most importantly, thoughtfulness before performing the primary cesarean section rather than doing it for flimsy, unsubstantiated indications. Prevention of grand multiparity by incorporating contraceptive counseling at every stage when the woman and her husband interact with the health care ,{

F

system needs to be stressed repeatedly to hospitaland community health care providers from commencement of their training. the time of

References

1' Hofmeyr Justus, Lale say, Giilmezoglu Metin. wHo systematic review morbidity: of maternal mortality and the prevarence of uterine rupture BJoG sept zooiittzliii,,l,,rjil'"'" 2' Qazi Qudira' Akhtar Zubaida, Khan I Kamran, Khan Amer Hayat woman health:Uterine its complication".lld.-T"n"g"r"nt rupture , in a teaching hospital, Bannu,p pakistan.. Medicine 2O12Vol71No. tll+o_53 - "vov'|rq'|, A Journal of clinical 3' sunitha K', lndira l.and sugun, p. clini""l study of Rupture Uterus - Assessment and Fetal outcome of Maternal tosR Journatof Dentat and Medicatsciences (tosR-JDMS) 0853, pJSSru. 22T9-0861.vorume e-tssN: 2279- 14, tssue 3 ver. vt (Mar. 201s), pp 3g_4s q" sahu Latika' A 10 year analysis of uterine rupture at a teaching institution obstet Vol. 56, No. J Gynecol tndia 6 November/ December 20A6 pg 502_506 5' Padhye sM" Rupture of the pregnant uterus- a yearreview 20 . Kathmandu university Medical Journat 2005 Vot 3(1 1) pg 234_238

6' Ezechio' Kalu B, Njokamma F,okaka G. vaginalmisoprostol lol: a Nigerian experience. hospital J Obstet Gyn ecol 2004 ;2ae) :23g-242).

7. veena L,sarojini,Anagondanahailiprathima, prakash, suchitra. study to compare betweenpaperless partogram and modified wHo partogr", in management of labor. Reprod Contracept, lnt J of , Obstet andGynecol20lg Jan; 7(1):99_103) 8' Rashmi' Radhakrishnan G, vaid NB, Agarwal N. Rupture uterus- changing lndian scenario. J lndian Med Assoc. 2001; 99(1 1):634_7

9' Diab AE. Uterine rupture yemen. in saudi Medicar Journar.20 os;26(2):264_269 Table 1: Demographic profile of cases of rupture uterus

Number Percentage

Patient cha racteristic (n) l%l

<20 0 0

Age 20-30 2L 67.74

(Years) 31,-40 9 29.03

>40 1" 3.23

Hindu 24 77.41

Religion Muslim 7 22.58

primip 1. 3.23

Parity Gz-G4 23 74.1

Grand 7 22.58 multip