A Case of Multifetal Pregnancy (Breech-Breech)

ANNAH S. TEVES, MD
Post-Graduate Intern
Vicente Sotto Memorial Medical Center
Department of Obstetrics and Gynecology
July 13, 2019

ABSTRACT

Multifetal pregnancy is an obstetrical complication that leads to increased risks for both the mother
and fetus, some mechanisms of which are fatal. These pregnancies require more monitoring and fetal
surveillance in order to ensure a succesful outcome.

This is a case of I. Q., a 24-year-old female with an OB score of G2P1(1001) upon admission.
Patient inititally came in as an OPD consult with late ultrasound. Prenatal check-ups were done at the
local health center where she was suspected of twin pregnancy at 8 months age of gestation due to
increased abdominal girth. Patient was then immediately advised to obtain an ultrasound but complied
late due to financial reasons. Ultrasound confirmed multifetal pregnancy (cephalic-breech). Patient was
advised to seek consult at a tertiary hospital but only did so upon onset of painful uterine contractions and
was noted to be in labor. Stat cesarean section was immediately scheduled and patient delivered livebirth
twins in breech-breech presentation by primary low segment transverse cesarean section (LSTCS).

Keywords: Multifetal pregnancy, Twins, Breech

INTRODUCTION

Multifetal pregnancy is a common obstetrical complication that occurs due to

multiple fertilzation events or from the aberrant division of a zygote after fertilization.
These mechanisms increase the load of the pregnant mother and ultimately caused
increased risks for both the mother and the resulting fetuses. It complicates the natural
pregnancy process and more often than not requires more pregnancy surveillance and
monitoring.

The infant mortality rate of those born in a multifetal pregnancy is __ compared to

that of a single pregnancy. Modern technology has allowed a better understanding of the
differences involved in such and subsequently developed the necessary procedures in
order to ensure better fetal outcome.
CLINICAL DATA

A case of I.Q., a 24 year old female, G2P1(1001), married, currently residing in

Malubog, Cebu City, admitted for the first time at this institution on July 11, 2019.

Patient is non-hypertensive, non-diabetic, with no prior hospitalizations nor

surgeries done and no known heredofamilial diseases as claimed. No known food or drug
allergies.

Patient had her menarche at the age of 14, with subsequent menses lasting a
regular interval of 4 days, consuming approximately 2-3 moderately soaked pads per day.
Menses are occasionally associated dysmenorrhea on the first day. She had her
coitarche at the age of 19 with one partner. She claims to have no history of sexually
transmitted infections.

Patient’s last menstrual period was October 17, 2018, past menstrual period
September 17, 2019. She was 38 3/7 weeks age of gestation by LMP upon interview.
First prenatal check-up was done at around 20 weeks age of gestation, done by a midwife
at the local health center. She had a total of 4 prenatal check-ups with no noted
unusualties. First ultrasound was done at 34 1/7 weeks age of gestation which showed
Multifetal pregnancy: Twin A, intrauterine pregnancy, 34 1/7 weeks AOG by fetal
biometry, live, complete breech; Twin B, intrauterine pregnancy, 33 3/7 weeks AOG by
fetal biometry, live, cephalic presentation. Single placenta noted, anterior, grade II-III, high
lying. No separating membrane visualized. Consider monochorionic diamniotic
placentation. There is 3.4% fetal growth discrepancy noted.

Medications taken during pregnancy include multivitamins, folic acid, and iron, with
good compliance.

Patient has an obstetric store of G2P(1001). Her previous pregnancy was in 2016
at 21 years old to a full term live male neonate weighing 3200g delivered via normal
spontaneous vaginal delivery at the local health center. No perinatal complications were
noted.

Patient is an occasional alcoholic beverage drinker, usually consuming 1-2 bottles

of beer, however has had no alcohol intake since pregnancy. She is a non-smoker.

Patient is currently unemployed and is the primary caregiver in the household.

One month prior to admission, patient went to the local health center for her
scheduled prenatal check-up. Abdomen was noted to be larger than usual and multifetal
pregnancy was considered. Patient was requested ultrasound and advise to seek consult
at a tertiary hospital. Patient complied with ultrasound which confirmed multifetal
pregnancy but did not seek further consult.
 One week prior to admission, patient noted onset of non-bloody watery vaginal
discharge. She returned to the local health center and was again advised to seek consult
at a tertiary hospital. No contractions or other associated symptoms were noted.
Condition was tolerated and no further consult was done.

On the morning prior to admission, patient noted onset of contractions. She went
to VSMMC OPD for consult. Internal examination of the vagina was done which was found
to be 4cm hence was immediately referred for admission.

Upon examination at the admitting section, patient was ambulatory, coherent,

oriented, with the following vital signs: blood pressure – 100/60 mmHg, heart rate – 82,
respiratory rate – 19, temperature – 36.3 C, afebrile. Internal examination showed a
cervical dilatation of 5cm with 50% effacement, ruptured bag of watt, station -3. Fundal
height was 38cm with an estimated fetal weight of 2800g. The rest of the physical
examination was unremarkable.

The admitting diagnosis was G2P1(1001), pregnancy uterine, 38 1/7 weeks age
of gestation by last menstrual period, multifetal pregnancy (breech-cephalic), in labor,
premature rupture of membranes x 1 week.

Plan of care was primary low segment transverse cesarean section with
prophylactic uterine artery ligation.

CASE DISCUSSION

Multifetal pregnancy is an obstetrical complication that occurs due to aberrant

mechanisms that occur during the early stages of fertilization. This can occur due to
multiple fertilization events or from a solitary fertilization that is succeeded by an
unregulated division or from a combination of the two. Although much research is still
needed in order to understand the exact stimulus of these events, it has been proven that
this deviation from normal regulation increases both fetal and maternal risk throughout
the pregnancy.

In the case presented above, the mother initially presents with no major risk factors
as a young mother of early reproductive age with no history of co-morbidities or previous
pregnancy complications. However, the late diagnosis of a multifetal pregnancy along
with the absence of adequate prenatal check-up with a licensed physician greatly
increased the morbidity of the case. Patient presented out of the norm as being 38 1/7
weeks age of gestation by LMP and 38 3/7 weeks age of gestation by late ultrasound,
since one of the most common risk factors for multifetal pregnancy is preterm labor, as
high as 60% for twins with incidence increasing with the number of fetuses involved.
Nevertheless, stat cesarean section was still warranted since the patient was already
term, in labor, with one of the twins presenting as breech per the latest ultrasound.

Twinning is generally classified according to the number of zygotes and chorions

involved in the pregnancy. Dizygotic twinning occurs when two zygotes are fertilized and
subsequently develop on their own while monozygotic twinning occurs when a single
zygote is fertilized and by some understood mechanism undergoes a second division
resulting in the development of two embryos. This is further classified according to the
when the division happens. Zygotes that undergo division within 72 hours result in two
embryos, two amnions, and two chorions and is called a diamnotic, dichorionic twin
pregnancy. The placenta may also be double or may be a single and fused. Zygotes that
undergo division 4-8 days after fertilization result in a diamnionic, monochorionic
pregnancy. From days 8 onwards, development of most of the chorion and amnion has
occurred forcing the fetuses to share in a monoamniotic, monochorionic pregancy. This
is also the type of pregnancy in conjoined twins. The number of amnions, chorions, and
placenta is important because it is vital to sustaining the increased number of fetuses.
Morbidity is higher with monoamniotic, monochorionic pregnancies because fetuses tend
to “compete” for nutrition and the single amnion and chorion can cause unequal
distribution causing one twin to receive more than the other.

Factors that affect the incidence twinning include race, maternal age, parity,
heredity, nutritional factors, pituitary gonadotropin and infertility therapy. For this case,
the greatest factor is heredity since the mother has both a maternal and paternal history
of twinning and maternal history of twinning is more important than that of the father. Race
does not seem to be an important factor as the East Asia and specifically the Philippines
has not shown to have a high incidence of twinning but external rather than genetic factors
could probably be attributed to that such as the decreased use of assisted reproductive
therapy than in first world countries and maybe even due to inadequacy of data collected
regarding the matter.

Management of multifetal pregnancies involve increased monitoring throughout

with ultrasound monitoring specifically of growth and fetal discordancy especially with
monochorionic twins. Research recommends an ultrasound of at least every 2 weeks to
ensure early detection of vascular anomalies that would contribute to the mortality of fetal
discordance. Delivery route mainly depends on fetal presentation with anticipation of
changes of presentation during delivery. A cephalic-cephalic presentation can be delivery
via normal spontaneous vaginal delivery while studies are still divided regarding the best
route for cephalic-noncephalic presentation which is what the patient initially presented
with. If the first twin is breech, it has the same problems with that of a singleton breech
pregnancy and cesarean section is moe often than not preferred.
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