LOCKED TWINS (Case Reports)

by PRAFUL H. MUNSHI, * M.D. and JYOTIKA c. SHAH,** M.D., D.G.O., D.A.

Being a rare condition the occur­ ted with a history of 9 months' amenorrhoea rence of locked twins is very interest­ and labour pains. She had 4 full-term nor­ mal deliveries, all alive. The patient was ing. According to Braun, as stated by fairly well built and nourished. There was Munro Kerr, it only occurred once in mild degree of anaemia and slight oedema 90,000 deliveries in the two Vienna was present over the legs. Pulse was 100/ clinics. According to Harder, it is not min. and B.P. was 150/ 90. Systemic exam­ ination detected nothing abnormal. The so uncommon. He derived the latter abdomen was found bigger than usual. Fun­ fact from his observation in the last dal height was 16" while abdominal girth few years. Nissen had reviewed about was 44". Multiple foetal parts were felt 70 collected cases of locked twins. Ac­ and 2 heads at the lower pole of cording to him, 45 cases of locked uterus. Two separate foetal heart sounds twins, both babies having vertical lie, were heard. The cervix was 2 ems dilated. The membranes were bulging. The pre­ have been described till 1957. Law­ sentation could not be properly made out. rence (Leeds) described 3 · cases of Pelvis was normal. locked twins and tabulated 28 previ­ A diagnosis of twin pregnancy was made ously recorded cases. The types of tentatively and the patient was observed locking in 31 cases were as follows:- vigilantly. X-ray of abdomen for confirma­ tion of presentation and position could not Vertex and vertex 10 be taken due to certain technical difficulties. Breech and vertex 16 It was not considered essential as the Vertex and transverse 4 diagnosis of twins was almost certain and Breech and breech 1 both the babies were found to be having vertex presentation. Recently we came across 2 cases of After five hours of the first examination locked twins which are reported in the membranes ruptured spontaneously. this paper. Cervix was 6-7 ems dilated and a head•was found to be presenting. The patient was Case 1 observed for two more hours but there was A multipara, H.A., 30 years, was admit- no progress of labour in spite of the patient having good uterine contractions. A vaginal *Honorary at Sheth L. G. Hospital, examination was repeated. Head had under­ Ahmedabad. gone moulding and a caput had formed. In **Ex-Registrar at Sheth L. G. Hospital, the postero-lateral aspect a distinct groove Ahmedabad. was felt which was found to be the groove between the two heads. Now Lecturer in Obst. & Gynec., M. P. Management: Under general anaesthe­ Shah Medical College, Jamnagar. sia, after an unsuccessful attempt to push Received for publication on 9-1-68. the head of the second twin up, the abdo- 760 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA men was opened, as foetal heart sounds of coming head of first and shoulder both the babies were present. There was with prolapsed arm of the second one. no difficulty in delivering the twins, but the first baby, being severely asphyxiated iv. Locking of two babies presenting could not be revived. It expired within few by breech with four legs prolapsing minutes of birth. The second baby did quite into the vagina. well. The babies weighed 4 and 4.5 lbs Of these, the first is the least seri­ respectively. Tubal sterilisation was also ous variety. done at the same time. The patient was discharged on the tenth day of the opera­ In the majority of cases, this com­ tion. plication is diagnosed very late in labour for two reasons. First, because Case 2 of its rare occurrence, it is not A primipara, I.P., aged 20 years, was ad­ - mitted as an emergency patient with a his­ thought of earlier, and secondly, tory of rupture of membranes 3 hours there are no diagnostic points by previously and impacted after-coming which the complication can be antici­ head. On examination of the abdomen the pated early in labour. But there are uterus was found to be slightly above the certain conditions which when asso­ umbilicus. The head was felt and no other parts of foetus could be detected. No foetal ciated with twin pregnancy, suggest heart sounds were recordable. On vaginal this complication, especially if the examination the baby was found to have de­ labour does not progress satisfactorily livered up to the neck which was greatly in s_pite of good uterine contractions. stretched as a result of previous attempts These are as follows: (i) oligohydra­ at delivery of the head by pulling on the trunk of the baby, A second head with mnios, (ii) primigravidity, (iii) very vertex presentation was found in the sacral premature babies, (iv) very large pel­ hollow. The other parts of second foetus vis. According to Horder, oligo­ were difficult to palpate per abdomen as hydramnios is an important predis- . it was a small one lying behind the head posing factor for locking. Also, it is of the first baby. Management: As it was futile to try to more common in primigravidae. The push the head of the second baby up and space available to the foetuses is de­ as both the babies were dead, the neck of creased in oligohydramnios while in the first baby was severed with scissors. primigravida, due to tight abdominal After severance, the head of the first baby could be pushed up and the second baby and uterine wall, the space is res­ was delivered by forceps. The head of the tricted. Locking is also more likely first baby was delivered by hooking into when babies are premature andj or the foramen magnum by volsellum forceps. when pelvis is large. Here it is due The babies weighed 3 and 3.5 lbs. respec­ to more available space in the pelvis, tively. The patient made an uneventful recovery and was discharged on the 5th which allows parts of both the foe­ day of the delivery. tuses to enter the pelvis simultane­ ously. In our second case who was a Discussion primigravida the babies were very Munro Kerr has described the fol­ small. So in this case primigravidity, lowing varieties of locked twins viz. i. small size of the babies and possibly Locking of two fore-coming heads. ii. oligohydramnios were the contribu­ Locking of the after-coming head of tory factors. In the first multiparous the first child and fore-coming head case it may be that the large pelvis of the second. iii, Locking of after- may have contributed. The babiecaesarean section or embryotomy -of presenting by vertex. If the babies one of the foetuses may have to be are quite small it is possible in the carried out to effect the delivery. majority of cases to push the head of If this complication is not diag­ the second baby up. If this becomes nosed till late in labour the babies impossible even under general anaes­ usually die. Maternal distress also thesia, one has to resort to caesarean develops and the uterus mo.y rupture. section if the babies are living. As The danger with vaginal manipula­ Munro Kerr advises, forceps should tion also risks rupture of uterus due never be applied to the head of the to already overstretched uterus which first twin lest severe injury should may be stretched further by vaginal result to the mother. If the baby is manipulations. This danger is greatly moribund and is unlikely to survive, obviated by caesarean section early either craniotomy or decapitation of in the course of this complication. the first head becomes necessary. Also, the latter procedure gives the In the second case, locking was of maximum chance for the survival of the second variety i.e. the after-com­ the babies. ing head of the first baby was held up Summary by chin of the second baby presenting by vertex. If the babies are small, it Two cases of inter-locking of twins is advisable to push the head of the are presented. second child up and the head of the Acknowledgement ' first baby is delivered. If this mano­ We are very thankful to the Supe­ euvre proves unsuccessful, and the rintendent, Dr. A. J. Baxi, F.R.C.S. head of the second baby has descend­ for permitting us to publish the hos­ ed well into the pelvis, one should pital records. decapitate the first baby and the second baby is delivered either by for­ References ceps or craniotomy. The head of the 1. Bradlow, B. A.: Brit. Med. J. 2: first baby is removed afterwards. 532, 1944. In the third variety of locking i.e. 2: Cohen, M., Kahl, S. G. and Ros:m­ when an after-coming head of the thal, A. H.: Am. J. Obst. & Gynec. first baby and shoulder with the pro­ 91: 407' 1965. lapsed arm of the second baby be­ 3 Horder C. H.: Brit Med. J. 1: 783, come impacted, caesarean section is 1944. the best course to avoid rupture of the 4. Moir, C. J.: Munro Kerr's Opera­ uterus. But if this is impossible, de­ tive Obstetrics, ed. 7, London, caritation of the first baby and ver­ 1946. Bailliere, Tindall and Cox, sion with breech extraction of the p. 221. other baby may be done. 5. Parmar, V. T., et al: J. Obst. & In the fourth and very rare Gynec. India, 17: 218, 19£7.