Allen, L.A.

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Suid·Afrikaanse Tydskrif vir Geneeskunde South African Medical JournalKaapstad, 4 April 1959 Deel 33 No. 14 Volume 33 Cape Town, 4 April 1959THE MANAGEMENT OF TWIN PREGNANCYL. A. Au.E ,M.B., CH.B. (CAPE ToWN), M.R.CO.G., Late RegisTrar, Churchill HospiTal, OxfordIt is not generally realized that there is a considerable foetalwastage, and also an increased risk to the mother, associatedwith twin pregnancy. In order to emphasize these dangersI have analysed 105 cases of twin pregnancy delivered atAddington Hospital, Durban, during the period 1 January1954 to 30 June 1958. I have also used figures from theavailable literature.If one is to anticipate the complications of twin pregnancyit is essential in the first instance to establish the d1agnosis.This may be surprisingly difficult: At Addington the ante-partum diagnosis was made in 69% of cases before delivery.Guttmacher1 diagnosed 70 % of term twin pregnancies.DiagnosisThe condition should be suspected if the uterus is undulylarge for the period of gestation, although this sign is.some-times very misleading, even during early pregnancy. Onpalpation the most reliable evidence is the finding of 3 foetalpoles, either 2 vertices and a breech, or 2 breeches and avertex. Diagnosis by auscultation depends upon 2 observerssimultaneously hearing 2 foetal hearts, separated by a silentarea and beating at different rates. Since a second observeris seldom available auscultation is of little practical value indiagnosis. Vaginal examination may prove helpful inestablishing the diagnosis.When the diagnosis is not clear there should be no hesitationin resorting to radiography. The chance ·of malignantdisease occuring before the age of 10 years, following X-rayexamination in utero, according to Stewart et al.,2 is less thanI in 1,000. On the other hand, with twins there is a heavyperinatal mortality due largely to prematurity, and this maybe reduced if early diagnosis is made. A single antero-posterior exposure covering the whole abdomen will suffice.Brownes states that when twins are suspected X-rays shouldalways be used, if available, since they indicate the lie ofthe foetuses, gross foetal abnormality and the possiblecomplications of delivery.Complications ofPregnancyThe minor ailments of pregnancy, such as varicose veins,constipation, oedema of the legs and shortness of breath,are usually exaggerated. Hyperemesis, contrary to the usualteaching, was not a significant feature in this series of twinpregnancy; no patient required admission on this account.Since anaemia is common in pregnancy, and more so intwin pregnancy, there is good reason to give an iron prepara-tion as a routine to every pregnant woman.~ Ferrousgluconate is well tolerated. To ensure that the haemoglobinconcentration is near normal, the haemoglobin level shouldbe estimated not only at the first visit but again at the 32ndand 36th week; if less than 1O·4g. or 70%, a full blood countshould be obtained to identify the nature of the anaemia.After the 36th week of pregnancy there is little time left tocorrect an anaemia before delivery. ]f at the 36th week thehaemoglobin level is less than 10·4 g. or 70 %, parenteraliron should be prescribed. Irnferon is a suitable intramuscularpreparation. If delivery is imminent and the haemoglobinlevel is below 8·9 g. or 60% a slow transfusion of packedcells is advisable.PrenwTure LabourThe high foetal mortality is directly related to the incidenceof premature labour. Of the Addington infants 56 % weighedless than 5t lb. (2,500 g.). One foetus papyracetls was de-livered. Munnell and Taylor5 found that only 53 % of twinpregnancies reached 36 weeks. This incidence has beensignificantly reduced by early admission to hospital for bedrest. Russell" has shown that this is particularly importantin the Iow-income group, in whom there is a significantlyhigher incidence of premature labour than in the uppersocial classes. He believes that this is explained· by thebetter diet of the high-income group and by the fact thatthey enjoy more leisure and consequently more rest duringtheir pregnancies. It is now well-established practice in someobstetric units to admit cases of twin gestation to hospitalfrom the 3Q-34th week of pregnancy. The patient can thenbe discharged with the knowledge that the foetuses willhave an improved chance of survival should prematurelabour supervene. Such management naturally necessitatesthe early diagnosis of twin pregnancy. The importance ofradiography has already been s·tressed. Early hospitalization·is unfortunately usually not practicable, and weekly atten-dance at the antenatal clinic is then essential so that com-plications may be recognized early.ToxaemiaPre-eclampsia with multiple pregnancy is about 3 timescommoner than with single pregnancy, occurs earlier inpregnancy, and is more severe than in single pregnancy.The incidence of toxaemia in 472 twin pregnancies seen byBender7 was 24 %. Eclampsia, likewise occurs more often.At Addington the incidence of pre-eclampsia was 31 %. Twopatients developed eclampsia.Strict control of weight gain is essential and the earliestsign of pre-eclampsia necessitates hospital admission. ]fpossible, pregnancy should be allowed to continue tillterm, in the hope of obtaining more mature infants. Afterthe 37th week, however, if deterioration occurs, labour shouldbe induced by artificial rupture of the membranes. A carefulexamination should always be made after surgical inductionto exclude prolapse of the cord, particularly if the first foetusis presenting by the breech.285286 S.A. MEDICAL JOURNAL 4. April 1959HydramniosIt is accepted that the presence of hydramnios shouldalways suggest the possibility of a twin gestation. An X-rayis advisable, firstly to exclude gro s foelal abnormality andsecondly to determine the number of foetuses and theirpresentations. Since tbe diagnosis of hydramnios dependslargely on individual impressions, no attempt has been madeto ascertain the incidence in the present series. Bender7noted an occurrence of 10·6% in twin as against 0'5% insingle pregnancies.Antepartum HaemorrhageThe incidence of antepartum haemorrhage in this seriesis surprisingly low. R1acenta praevia was not encountered,but one patient had an antepartum haemorrhage which wasnot classified. The large placenta apparently seldom en-croaches onto the lower segment. Potter and FullerS recordedan incidence of I ·2% of placenta praevia in twin pregnancies.The general rate is o· 5 %.3The incidence of accidental haemorrhage, likewise, is littlehigher than with single pregnancy. Accidental haemorrhageoccurred in I· 7 % of Bender's cases, as compared with therate of 1 . 3 % in single pregnancies over the same period.'MalpresentationThe foetuses usually lie longitudinally. In about 20% thefirst foetus presents by the breech. In 5 of the Addingtonseries the diagnosis of twin gestation was made only afterexternal cephalic version bad been attempted. Version isof course contra-indicated when twins are present.It is important to remember that the lie of the foetusesmay change during pregnancy. This is well illustrated bythe radiographs taken of one patient at the 30th and 36thweek of pregnancy (Figs. 1 and 2). It is therefore necessaryto re-examine the patient carefully on admis ion to the labourward. Vaginal examination is invaluable in difficult cases.THE MA 'AGEMENT Of TWIN LABOURThe following special precaution should be taken in twinlabour:(1) An anaesthetist should be available.(2) Forceps and episiotomy tray should be kept in readi-ness, with 1 % procaine for local infiltration.(3) An infant resuscitation tray should be prepared.(4) F~cilities for dealing with premature infants should beavailable.Bender,7 contrary to common belief, was unable to confirmthat with twin deliveries labour is significantly prolonged.The delivery of the first infant usually causes little or nodifficulty. When the membranes rupture, an immediatevaginal examination is made to exclude prolapse of theumbilical cord. If the first twin presents by the breech, oneshould be prepared for episiotomy, and hav.e a forceps trayin readiness. Fortunately twin breech deliveries are usuallynot complicated.After the first infant is born the cord is tied and dividedbetween two ligatures. The lie of the second twin is thenimmediately determined by abdominal and vaginal exami-nation. If transverse, the lie is corrected by external versionto a longitudinal one.The foetal heart is carefully observed during the periodof waiting which follows. The average interval betweenbirths, with(jut interference, has been found to be between12 and 15 minutes. 5 , 7 It therefore seems reasonable torupture the second bag of membranes after a lapse of 10minutes, or sooner if the contractions return.Rarely is the delivery of the second twin delayed. Underthese circumstances it has been my practice to deliver thesecond twin after 1 hour if delivery is not imminent, eitherby forceps or breech extraction. De Lee and Greenhill9advocate such interferance and they wam of the dangers ofwaiting, namely haemorrhage and death of the second twindue to asphyxia from placental-site retraction.If a general anaesthetic has been necessary in the courseof delivery of the first infant one should empty the uterus.It is unfair to the patient not to do so; moreover, operativeinterference may again become necessary. Aaron andHalperin10 take routine steps to deliver the second twinimmediately after the first is born, and with good results(foetal loss 9·8 %).Immediate delivery of the second twin is indicated if theplacenta separates, the cord prolapses, or foetal distresssupervenes. Since one cannot anticipate these complications,an anaesthetist should be present at all twin deliveries. Therewere 2 cases of intrapartum haemorrhage in the Addingtonseries.If ergometrine is inadvertently. given after the birth of thefirst twin to a woman in whom twin pregnancy has hithertobeen unsuspected, the secon~ twin should immediately beextracted.Premature LabourThe high incidence of premature labour has already beenstressed. If early labour supervenes, the following wellknown precautions should be taken:Sedatives and analgesics must be sparingly used becauseof their depressant action on the respiratory centre, whichis not fully developed in the premature infant. Morphiashould be avoided.In the hope of reducing the risk of neonatal haemorrhage,10 mg. of vitamin K should be given to the mother severalhours before delivery or alternatively O' 5 mg. vitamin Kto the infant immediately after birth.The second stage of labour is dangerous since the prematureinfant is' particularly prone to intracranial injury. The headis best protected from excessive moulding by elective episioto-my under local anaesthesia as soon as perineal pressure4 April 1959 S.A. TYDSKRIF VIR GENEESKUNDE 287begins. A multipara with a relaxed introitus will naturallynot .need an episiotomy. It is controversial whether theroutine use of outlet forceps lowers the incidence of intra-cranial haemorrhage.The prognosis for the newborn premature infant willobviously be heavily influenced by the facilities available fortheir care.Postpartllm HaemorrhageThe 25 %-incidence in the Addington series (Table n whereergometrine is not used as a routine, is disturbingly high.Bender? was able to reduce the incidence of postpartumhaemorrhage fTom 10· 4 % to 2· 7 % by the intravenousadministration of ergometrine at the end of the second stage.TABLE l. POSTPARTUM HAEMORRHAGE [N TWIN PREGNA ClES (%)Potter and FullerS (1949) 10·0Bender? (1952) 10·6Addington series (1958) .. 25·0Ergometrine, O' 5 mg., is a suitable dose. In the 1955 editionof Britsh Obstetric Practicell it is suggested that a supply ofcompatible blood be available for every twin delivery. Thepatient should remain under constant supervision for atleast 3 hours to ensure that relaxation of the uterus does notoccur.Twin LockingThis is very rare and dangerous. The presentationsassociated with locking are usually breech and vertex. Ifthe first foetus can be easily disimpacted and delivered,then this is the correct treatment. If disengagement is im-possible, then Caesarean section is probably safer than atraumatic vaginal delivery.Maternal MortalityNo death occurred in this series, but the maternal deathrate in twin pregnancy is undoubtedly high. Guttmacher1reported 23 maternal deaths (2 %) in a total of 1,163 casesof twin pregnancy collected from the literature.Foetal LossThe perinatal mortality in this series was 6 %, which iscomparatively good. Russe1l6 recorded a foetal mortalityof 16% in 49 booked cases at the Aberdeen MaternityHospital. Prematurity was a factor in all but 2 cases.TABLE 11. FOETAL LOSS IN TWIN PREGNANCY (%).FoetalCases Morlalitv%.Russe1l6 (1952) 49 16·0Palter and FullerS (1949) 252 14·0Aaron and Halperin10 (1955) 376 9·8Bender? (1952) 472 11·0Toxaemia, complications of delivery and crowding in theuterus also contribute to the high foetal wastage.1 ! Thecomparative percentage figures in other series are shown inTable II.Operative Interference at DeliveryRussell8 found that operative interference, excluding un-complicated assisted breech delivery, was necessary in 16of 49 cases. Of the Addington patients 15 (14 %) requiredoperative delivery (excluding· the 2 patients delivered byCaesarean section). The commonest manipulations wereforceps delivery, internal version, and breech extraction.Contrary to others, Potter et al.S insist that there is no in-creased hazard for the second twin.Bender? reported that operative delivery of the secondtwin was necessary in 85 of 472 consecutive twin deliveries.He also found that operative delivery of the second twinwas not associated with an increased risk to the infant.Caesarean Section in Twin PregnanciesThere is no appreciable difference in the incidence ofCaesarean section in multiple and single pregnancy. Abou5 % of women in hospital are now delivered by the abdominalroute. 4Two of the Addington series were delivered by lower-segment Caesarean section. Both were undiagnosed twingestations. Abdominal delivery was necessary io the firstbecause of previous section for contracted pelvis, and in thesecond for a transverse lie with prolapse of the cord inTABLE rn. CAESAREAN SECTION IN TWIN PREGNA 'CIES (%)Munnell and Taylor' (1946) 3·3Potter and Fuller" (1949) 5·9Bender? (1952) 4·4early labour. The other usual indications for Caesareansection are severe pre-eclamptic toxaemia and placentapraevia. The comparative percentage figures in other seriesare shown in Table Ill.The management of deliveTy in twin pregnancy followinga previous Caesarean section is of some interest. In multiplepregnancy the uterus is usually over-distended and the riskof scar rupture may be increased. 13 Repeat section ti:lereforeseems justifiable in near-term twin pregnancies.SUMMARYI. Attention is drawn to the apparent difficulty in thediagnosis of twin pregnancy. The use of radiographs isdiscussed.2. Since prematurity is the major factor in the highfoetal mortality, the importance of early admittance tohospital between the 30th and 34th week, as a prophylaticmeasure, is emphasized.6 This is especially advisable in thelow-income group.3. The importance of being adequately prepared for twinlabour is stressed. This entails the presence of an anesthetistat the delivery.4. The particularly high incidence of postpartum haemorr-hage in the Addington Hospital series is noted. This incidencecan be reduced by the prophylactic administration of ergome-trine at the end of the second stage of labour.1 am grateful to Dr. J. Tanchel, Medical Superintendent, andMr. H. Renton, M.D., F.R.CO.G., Senior Consultant Obstetri-cian and Gynaecologist, Addington Hospital, Durban, for per-mission to publish this article. My thanks also to Mr. B. Murless,ER.CS., ER.CO.G. for helpful criticism.REFERENCESI. GUllmacher, A. F. (1939): Amer. J. Obslet. Gynec., 38, 277.2. Stewart, A., Webb, J. and Hewill. D. (1958): Brit. Med. J., J. 1495.3. Browne, F. J. and Browne, J. C. McC. (1955): Anunatal and Pos/lla/al Care,p. 137. London: Churchill.4. Lewis, T. L. T. (1956): Progress in Clinical Obstetrics and Gynaecology,p. 27. London: Churchill.5. Munnell, E. W. and Taylor, H. C. (1946): Amer. J. Obstet. Gynee., 52, 588.6. Russell, J. K. (1952): J. Obslet. Gynaec. Brit. Emp., S9, 208.7. Bender, S. (1952): 'bid., 59, 510.8. POller, E. L. and Fuller, H. (1949): Amer. J. Obstet. Gynec., S8. 139.9. De Lee, J. B. and Greenhill, J. P. (1948): Princioles and Practice of Ob-stnrics. p. 425. Philadelphia and London: W. B. Saunders.10. Aaron, J. B. and Halperin, J. (I955): Amer. J. Obstet. Gynec., 69.794.I!. Maclennan, H. R., Wrigley, A. J. and Pereival, R. in Holland, E. L. (1955):British OhsUlric and Gyna~C{)I09icalP~ac(ir~. p. 644. London: Heinemann.12. Record, R. G., Gibson, J. R. and MeKeown, T. (1952): J. Obstet. Gynaee.Brit. Emp.. 59, 471.13. Brody, S. (1956): Amer. J. Obstet. Gynec., 72. 19."

The management of twin pregnancy

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The management of twin pregnancy

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