LOCKED TWINS

(A Case Report)

by

MANJU M. DOMADIA*

Locking of twins is a very rare comph­ CASE REPORT cation during labour. The incidence of Mrs. K. K. S., aged 22 years, was transferred locked twins is said to be 1: 90,000 to B.Y.L. Nair Charitable Hospital from a peri­ deliveries i.e. once in about every 1000 pheral maternity hospital, for prolonged labour. On admission the patient was getting strong twin deliveries. This statement was pains. The membranes had ruptured at 1-30 made by Von Braun of Vienna, but in p.m. The cervix was fully dilated from 5-30 view of the number of cases recorded p.m., and in spite of good uterine contractions during the last ten years, it seems that the the patient had not delivered till 10-30 p.m. condition is not quite so uncommon. It She was a 4th gravida and 2nd para, she had two full-term normal deliveries. There was no is indeed surprising, that locking does not history of prolonged labour or operative inter­ occur more often, and most of the busy ference in the past deliveries. The patient gave obstetricians do not come across a single a history of one at 4 months. The last case during their many years practice. delivery was 3 years ago and the last abortion Munro Kerr saw only one case in over was one and half years ago. There was no past history or family history of twin delivery. 44 years. Wright (1942) appears to be On examination, her general condition was the only obstetrician to have treated good. The was unduly enlarged and 3 cases personally and that too within multiple foetal parts were felt. From the cli­ a period of 6 years. Lawrence (1942) nical examination, diagnosis of multiple preg­ - also reported 3 cases of locked twins. So nancy was made. The first baby was present­ ing by the vertex. The head of the first baby far about 168 cases have been reported in was deeply engaged. The second foetal head the literature. was felt at the level of the symphysis pubis. It The complication is not recognised until was fixed and not freely ballotable. Both foetal late in the second stage. The abnormal heart sounds were regular. sequence of events are catastrophic and The cervix was fully dilated. The membranes were absent. The presenting :part (vertex of tax the ingenuity of even an experienced the first baby) was at the level of the ischial obstetrician. Although the results with spines. The position was left occipitoanterior. respect to the mother are good, they are The second foetal head was very high and could devastating for the foetus, and carry a not be felt per vaginam. The pelvis was ade­ high perinatal mortality rate. For this quate. A provisional diagnosis of prolonged labour reason collective review of the literature due to the locking of two fore-coming heads was has been undertaken and because of its made. Urgent x-ray abdomen was taken which infrequency an additional case is confirmed the diagnosis (Fig. 1). presented. The patient was reexamined under general anaesthesia. The first foetal head was felt in • Assistant Professor of Obst. & Gynec., Topi­ the pelvic cavity, and the neck of the first baby wala National Medical College and B.Y.L. Nai,. was unduly stretched. The second head was Charitable Hospital, Bombay-8. also trying to engage simultaneously and was Received for publication on 31-7-73. felt just by the side of the neck of the first / LOCKED TWINS 271

baby. Since the patient was already a case of far (1958) . Head B was invariably prolonged labour, due to the entanglement of impacted or compacted between the chin two fore-coming heads, it was decided to termi­ and the shoulder of baby .A at or below nate the labour by forceps delivery. The head of the second baby was disimpacted and pushed the pelvic inlet. up. The disimpaction was very easy. First Out of 17 cases, 16 were primigravidas baby was delivered by forceps, using long for­ and 1 was a multipara. In the present ceps. The application of the blades, and the case report the patient was 4th gravida. extraction was very easy. After the birth of the first baby, vaginal examination was repeat• Details of these 17 cases have been given ed to find out the station of the second foetal in the following Table: ' head It was in occipitoposterior position and Ten infants were lost, 6 of which were one hand was also felt by the side of the head. The hand was reposited, and ~the second foetal baby A. Foetal destruction was necessary head was also delivered by forceps as face to to effect delivery in 3 cases. There were pubis delivery. The delivery was very easy. no maternal deaths or rupture uteri. Since the patient was under deep gene1:al anaes­ thesia, manual removal of the placenta was done. Group III Baby A vertex Baby B The placenta was single and normal. Explora­ transverse. tion of the uterine cavity was done. It was There were five cases in this group. In intact and there was no cervical or vaginal tear. First baby cried after five minutes. Second all, either a prolapsed arm or shoulder baby cried immediately. First baby was female of baby B prevented descent of head A. and weighed 2.2 kg. Second baby was male and weighed 2.1 kg. First baby had swelling over Group IV Baby A Breech Baby B Breech the face and neck which subsided spontaneously This is the least common entanglement, after 48 hours. Puerperium was uneventful. Both having been reported only twice. Both babies and mother were discharged on seventh were nulliparous, the first case double day in good condition. knee presentation. Both infants were Discussion still born. In the second case the after­ Nissen reviewed the world literature coming head A collided with a flayed leg. from 1882 to April 1957 and reported of B. Infant A died, but B survived. 69 cases of locked twins. He defined the Etiological considerations: terms collision, impaction, compaction and interlocking in cases of entanglement of (1) Age and Parity: In young twin foetuses. He also divided these cases primigravidae locking of twins is parti­ into four groups. (Baby A,- reters to cularly common in Nissen's series; out the infant with the lowest foetal pole). of 69 patients 7'7 per cent w~re under the age of 30 years and 72 per cent were Group I Baby A Breech B-Vertex. primigravidas. The basic tone of the This was the commonest type in hi~ uterus is probably higher in the first series--45 cases out of 213 total cases. , thereby manifesting strong 50 per cent of the infants were lost and contractions during labour. The resultant of these 80 per cent were baby A. expulsive force, particularly if sustained or craniotomy accounted for may drive two closely opposed foetal the foetal de;:lths. There were no rupture poles along parallel axis into the pelvic uteri and not a single . inlet together. Group II Baby A vertex Baby B-Vertex. (2) : Seventeen cases have been reported so Premature rupture of second sac was

.k '\ I TABLE . N'_, ~ GROUP II. BABY A-VERTEX, BABY B-VERTEX (from Nissen. E. D.) Age Para Type Mother Infants Weights Treatment Remarks 1. Boerma (1907) 27 0 head B L&W A-1 & W 2600 B-disengaged neck A B-1 & W 3000 A & B-version & ex- hypertonic uterus traction 2. Vallois (1909) 27 0 head B L&W A-1 & W 2930 B-disengaged hypertonic uterus neck A B-1 & W 3100 B-version & extraction sacs ruptured artificially

3. Vallois (1909) 23 0 headB L &W A-s. b. 1850 B-disengaged eclamptic convulsion before neck A B-s.b. 2170 A & B-forceps and after delivery. 4. Commandeur IUld ? 0 head B L & W A-s.b. 2300 A-forceps 1 membrance ruptured accident- Eparvier (1923) neck A B-s.b. 2130 B-forceps ally during examination; hy- pertonic uterus 5. Phillips (1926) ? 0 head B L &W A-s.b. 2495 A-decapitation hypertonic uterus; oligohy- c.. chest A B-s.b. 2268 B-forceps dramnios 4'' aperture between 0 sacs c:: 6. Kittson & Scott & 29 0 head B L& W A-s.b. 2724 A-craniotomy ; premature Claye (1934) neck A B-s.b. 3632 B-version & extraction rupture of membrance 7. Coleman (1936) 29 1 head B L&W A-1 & W 2636 B-disengaged head B extended due to tight ~ neck A B-1 & W 4068 A & B-forceps cord about neck 0 .... '"Zj i 8. Coleman (1936) 27 0 head B L&W A-1 &W 2495 B-disengaged second sac unruptured neck A B-1 & W 3132 A & B-forceps 0 ttl 9. Dawson (1936) ? 0 headB L& W A-1 & W 2722 Laparotrachelotomy oligohydramnios sac A & B (/l shoulder B-1 & W 3255 t;j A 10. Petch & Best (1938) head B A-1 & W i~tact~ 24 0 L&W 1814 B-disengaged oligohydramnios sac B ..... shoulder B-1 & W 1701 A & B-forceps (') A Ul 11. Vagna (1938) 31 0 head B L&W A-1 & W 2700 membrance ruptured artifi- shoulder B-1 & W 2600 cially monoamniotic? hYJler- ~ A tonic uterus t:J 12. Contardo (1939) 29 0 head B L&W A-s.b. 3200 A-decapitated membrance ruptured sponta- neck A B-1 & W 3000 B-forceps neously z~ 13. Horder (1944) 30 0 head B L&W A-1 &W 2438 B-disengaged virtually no amniotic fluid neck A B-1 & W 2325 A & B-forceps ~ 14. Cunningham 26 0 head B L&W A-1 &W 2296 B-disengaged membrances ruptured - artifi- 0 (1947) should~r B-1 & W 2608 A & B-forceps cially, oligohydramnios t"' A 0 Q 15. Lawrence (1949) 27 0 head B L&W A-1 & B 2900 B-disengaged sac A ruptured spontaneously neck A A-1 & B 3200 A & B-forceps sac B ruptured artificially ><: 0 16. Carty (1957) 30 0 head B L&W A-1 &W 1906 Laparotrachelotomy hypertonic uterus sac A rup- '"Zj neck A B-1 & W 2360 tured spontaneously 17. Swann (1957) 22 head B L&W A-s.b. 1900 A-forceps Chest A crushed; Pitocin for -z chest A B-1 & W 2965 B-spontaneous 2 days for inertia >t:1 I f 1 \ I ·- \ r ··- ) LOCKED TWINS 273 noted in 33 per cent and oligohydramnios because of relative rigidity collision and in 23 per cent. In the present case the impaction are more common. second sac had ruptured prematurely. It is recommended that llie. disengage­ One or both these conditions could induce ment of head B be attempted whenever more proximate foetal position. the cervix is sufficiently dilated. If both are dead, destruction of one infant would (3) Deflexion: be preferable to abdominal delivery. In Extension of one or both foetal heads, the present case the head B was and breech-vertex presentations are disimpacted easily and then both were prerequisites for chin-chin interlocking extracted by forceps delivery. In the Fundal placentation, ab:r1't>rmally short cases reported so far, 8 cases were cords, space filling intrauterine tumours, delivered by forceps after disimpaction of uterine anomalies and obstructing foetal the head B. In 2 cases destructive parts may all impede the descent, thereby operations were carried out. Two cases initiating deflexion. In the present case were delivered as breech after internal the second foetal head was extended. podalic version. In 1 case forceps was Foetopelvic disproportion applied for the head A and B delivered spontaneously. Two cases were delivered Small foetuses negotiating very large by caesarean section. passages are more likely to collide. The small or widely disproportionate sized Dawson (1936) reported a case of 2nd infants descending into a roomy pelvis gravida, who failed to progress after could engage simultaneously and thus 24 hours of labour, in spite of sufficient become compacted. About 30 per cent dilatation of cervix and good uterine of the infants in the series recorded contraction. One foetal head could be weighed less than 2000 gm. palpated easily above the pelvic brim, but the second head could not be palpated. Management Liquor amni was scanty. The key to successful 'treatment is X-ray abdomen showed two foetuses obviously early recognition. The failure presenting as vertex. The head of the of descent in the presence of effective second foetus was in collision with the uterine contractions and adequate pelvis head and the shoulder of the first. He should arouse suspicion. Liberal but decided to do caesarean section because judicious use of X-rays, - lateral and (1) both foetuses were alive and of good anteroposterior films will resolve the size so that disengagement would have issue. been difficult. (2) liquor was scanty. Group I - Baby A Breech - Baby B­ (3) cervix was not sufficiently dilated. vertex Under general anaesthesia caesarean Disengagement of the vertex should be section was done. The head of the second attempted. If this fails continued breech foetus was pushed through the uterine extraction may produce irreversible en­ incision by fundal pressure. The first tanglement and abdominal delivery would b~by was delivered by breech. The first be indicated. baby was male weighing 6 pounds and the second was girl weighing 5 founds and Group II Baby A Vertex Baby B Vertex 10 ounces. These are less likely to be compacted Another case of locked twins delivered 10 274 JOURNAL OF AND GYNAECOLOGY OF INDIA by caesarean section was reported by Summary Vagna in 1938. The patient was a One case of locked twins of vertex­ primigravida, membranes were ruptured vertex group has been reported in this artificially and probably it was a case of article. Detailed review of other 18 cases hypertonic uterine action. Caesarean reported so far of the same, Group has section was done. The first baby, weighed been done. Etiological factors and the 2700 gm. and the second 2600 gm. It was management has been discussed in short. a case of . Acknowledgement Group III Baby A Vertex-Baby B I thank Dr. E. J. Sequeira, the head of Transverse the Gyn. and Obst. Deptt. for his guidance Group III vertex-transverse. The baby and the Dean, Dr. M. S. Kekre for of H prevents head A from entering the allowing me to publish this case. pelvic inlet, and collision results. Disengagement must be tried first and References if it fails classical caesarean section is 1. Dawson, J. B.: Interlocked twins treated indicated. caesarean section J. Obst. & Gynec. BE., 43: 507, 1936. Goup IV-Baby A Breech-Baby B 2. Niseen, E . D .: Obst. & Gynec. 11: 514, Breech 1958. 3. Nicolson, L.: J. of Obst. & Gynec. Brit. In double breech presentations Emp.' 46: 162, 1942. abdominal delivery will avert a traumatic 4. Lawrence, R. F.: J. of Obst. & Gynec. and calamitous . If both Brit. Emp., 56: 58, 1949. infants are dead, disarticulation of one or 5. Masani, K. M.: Text Book of Gynec. edition both lower extremities of the obstructing 4 Bombay, Popular Book Depot. P. 378 . foetus may permit vaginal delivery of the 6. Parikh, M. N.: J. Obst. & Gynec. of India, other foetus. 17: 703, 1967.

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