INTERLOCKING IN TWIN

(A Case Report)

by v. T. PARMAR*, M.D., D.F.P.; A. v. PANCHAL**, M.B., B.S. and J. H. FONSECA***, M.D.

Interlocking due to apposition of Abdominal examination revealed a full­ the inferior surfaces of the chins of term with twin pregnancy. One foetus presented by vertex and the other both twins above or below the pelvic by breech. They were not engaged. The inlet is a rare complication of labour foetal heart sounds were normal. The in twin pregnancy. Braun gave the foetuses seemed to be below average incidence of locked twins as 1: 90,600 weights. There was no . She was not in labour and her pelvis was deliveries or 1: 1000 twin gestations adequate. Other systems were normal. (Moir, 1964). Lawrence (1949) She had 8 gms. of haemoglobin and thq could collect reports of only 28 cases urine was clear. Since we were certaii of locked twins published between of our diagnosis of twin pregnancy and pre'­ 1907 and 1949. Recently Cohen et al sentation of foetuses, radiological examina­ (1965) gave the incidence as tion of the abdomen was not performed. She was kept under observation and was ~ 1: 71,664 deliveries or 1: 817 twin adv;' sed complete rest in bed, d.iur.ecics, gestations. Though not quite as rare haematinics and sedation. as previously thought, a case of lock­ On the next day, i.e. on 11-11-1966 at ed twins is of sufficient interest to 3-0 P.M. she went into labour. A vaginal merit publication. examination, done after · 3 hours, revealed two fingers' dilatation, a completely taken Case Report up cervix, presence of bag of membranes M. X., aged 24 years, was admitted as and a breech presentation. At 9-0 P . M . an emergency case to the Lokmanya Tilak on the same day, the membranes ruptured Municipal General Hospital, Bombay, on and within 10 minutes, twin A presented 10-11-1966 at 3-10 P.M. for pre-. by buttocks at the vulval introitus. One She was a primigravida at full-term. She of us (A.V.P.) attempted to conduct the had moderate oedema of feet, vulva and breech delivery, but failed to extract the '---..... abdominal wall. Her blood pressure was aftercoming head. The patient was having 140/ 90 mm. of mercury, and pulse was 80 strong uterine contractions. The cervix per min·:.1te; she was averagely built. was fully dilated. The vertex (occipita­ posterior position) of twin B was felt in *Registr ·!lr. the pelvis just above the ischial spines and **House Surgeon. it was well jammed into the pelvis. The ***Ron. Obstetrician & Gynaecologist. occiput of the aftercoming head was very Lokrnanya Tilak Municipal General high in the abdominal cavity. Its chin could not be palpated owing to the pre­ Hospital, Bombay. sence of the forecoming head of twin B. Received for publication on 9-12-66. The condition of locked twins was diagno~ _...~'" INTERLOCKING IN TWIN PREGNANCY 219

ed and it was decided to deliver them under It is difficult to anticipate this anaesthesia. Meanwhile the cord pulsa­ tion of twin A had disappear ed , but the peculiar complication of labour in foetal heart sounds of twin B were regular: twin pregnancy. Large pelvis, small By 9-45 P. M. the patient was given babies, oligohydramnios and · primi­ general anaesthesia, but we failed to push parae are predisposing factors. Our up the forecoming head of twin B as it was case, a primiparous patient, had not well jammed into the pelvis and the patient t.V'as having strong uterine contractions. diminished liquor amnii. Cohen et al As the occiput of the aftercoming h ead was (1965) advise routinely lateral and not accessible per vaginam, craniotomy of postero-anterior x-ray plates of abdo­ the head could not be p erformed. The men, stating that locking may be ex­ trunk of twin A was delivered by decapita­ pected if twins have opposite poles tion with the help of Gigli's saw. The head of twin A was then pushed up. Twin and parallel lies in the vertical axis. B was delivered by forceps at 9-55 P .M. Unfortunately we have had not It was face to pubis extraction. The head enough cases to verify this point of twin A , which was pushed up b efore the though the radiological examination forceps delivery of twin B, was extracted is worth considering. by applying a bulldog volsellum to its stump of neck. The uniovular placenta was Disparity in the sizes of the foetal expelled immediately. Both the twins skulls may favour the interlocking w ere female and premature. Twin A of twins as enough space in the pelvis weighed 1500 gms. and twin B weighed is available for the head of twin B to 2000 gms. The latter cried immediately descend even if the head of twin A after the forceps delivery. The patient had an uneventful puer­ is present. This, we think, was an perium in the hospital. Her blood pres­ important predisposing factor in the sure came down to 120/ 70 mm. of mercury present case. The difference in and the oedema of feet was much less. She weights of the two foetus was 500 was discharged on 17-11-1966. The mother gms. and the baby were in good condition at the lime of discharge. As happened in our case, the com­ plication is usually diagnosed late in Discussion labour. Nondescent of the first Four varieties of locked twins have foetus, in the presence of effective been described. They are ( 1) lock- uterine contractions, leads one to i._ng of two forecoming heads, (2) think, in addition to locked hvins, - -- -:•rinP' of forecoming and after- of various other causes such as an commg heaas, \ <>) wc~i'.... E, - __ ,_f ovarian or uterine tumour · >struct- •'aftercoming head of one foetus jug the birth -passage, presence of with the shoulder of the other, aftercoming hydrocephalic head, ----1 ( 4) locking when both foetuses pre- double-headed monster and constric­ sent with breech and with limbs pro- tion ring. The interlocking of twins lapsed. Our case belongs to the can be diagnosed wih reasonable ac­ second variety which incidentally is curacy by proper examination. the commonest one. Nissen (1958) , reviewing the world literature, states Treatment that 45 cases of locked twins of the The treatment of locked twins con­ breech and vertex combination have sists of disengagement and assisting b€en described till 1957. the delivery whenever possible. In

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.t 220 JOURNAL OF AND GYNAECOLOGY OF INDIA a case like the present one, it may be nancy (breech and vertex combi!la­ possible to push up the forecoming tion) is described and its diagnosis head of twin B, specially early in and management disc~ssed. labour, and deliver twin A. Con­ tinued breech extraction may result Acknowledgement in an irreversible impaction in the Our thanks are due to Dr. V. N. pelvis necessitating instrumental de­ Panse, M.D., D.P.H. for allowing us livery, with sacrifice of the first baby. to quote hospital case records. Craniotomy of the aftercoming head whenever possible should be attempt­ ed. Failing that, is References necessary. In our case, we had used 1. Cohen, M., Kohl, S. G. and Rosen­ Gigli's saw for decapitation of twin thal, A. H.: Am. J. Obst. & Gynec. A. The operation was smooth and 91: 407, 1965. clean. Lawrence ( 1949) believes 2. Lawrence, R. A.: J. Obst. & Gynec. that should be con­ Brit. Emp. 56: 58, 1949. sidered liberally in cases of locked 3. Moir, C. J.: Munro Kerr's Opera­ twins. No cases of rupture of the uterus, however, have been reported. tive Obstretics, ed. 7, London, 1946, Balliere, Tindall & Co., p. 221. Summary 4. Nissen, E. D.: Obst. & Gynec. 11: A case of interlocked tvvin preg- 514, 1958.

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