SIGNS AND DIAGNOSIS OF TWIN PREGNANCY.
The signs of twin pregnancy are either probable or certain. ' We shall first discuss the probable signs. The size and shape of the abdomen are peculiar in certain cases. There is generally, a greater, abdominal development in twin pregnancies than would be expected in single preg nancies. Sometimes this is not true, and again, the size is such as at once to suggest multiple pregnancy. This is especially the case when the children are large, or the amniotic fluid very abundant. The size is, however, extremely variable. The shape of the abdomen is at times characteristic, and depends on the presentation. In a case cited by Herr gott, where the two heads occupied the fundus uteri, the womb resem bled in shape the representation of a heart on playing-cards. Depaul and Gu6niot call especial attention to one abdominal sign of twin preg nancy, viz., supra-pubic oedema. Localized above the pubes, this oedema presents a prominence, sometimes distinctly circumscribed, and sometimes diffuse. Occasionally, it forms in the hypogastrium a sort of sac or pocket, which stands out plainly from the abdominal wall. While this oedema occasionally occurs in single pregnancy, it is the rule in twin preg nancies. It is not a certain sign, but should always suggest multiple pregnancy and the propriety of searching for certain signs. Women often " feel life " at two points on opposite sides of the abdomen, and complain of an aggravation of all the discomforts of pregnancy, as heaviness, diffi culty in walking, dyspncea, varicose veins, hemorrhoids, etc. The certain signs are furnished by palpation, auscultation and vaginal touch.
1. Palpation:—The first sign obtained by palpation is exaggerated ab dominal tension. Pinard emphasizes this sign, stating that the uterine wall, instead of presenting its usual suppleness and elasticity, is so tense as to give the uterus a peculiar resistance, which he compares to the re sistance offered by the wall of a well-filled cyst. But the absolutely cer tain sign is the discovery, on palpation, of two heads or of two breeches, whether above or below, and recognizable by their respective characters. It is possible, later, to map out two backs or several small foetal mem bers, in different positions.
2. Vaginal touch will show the presence of one head in the pelvis, while cephalic ballottement will plainly reveal another at the fundus uteri, or in one iliac fosse. Pinard thus recognized a triple pregnancy. De paul's ballottement is often obtained. Depaul has called attention to a sign already noted by Duges and Lachapelle—the existence, during labor, of two consecutive bags of waters. Depanl attaches especial importance to auscultation. When there are two fcetuses, each foetal heart has a different point of maximum intensity, and the hearts beat with a differ ent rhythm. This is satisfactory proof of the presence of two foetuses,
provided that the difference between the number of pulsations be well marked, from ten to sixteen at least. According to Depaul, the best way to obtain positive information is to have two practised observers simulta neously count the heart-sounds at their two points of maximum inten sity, thus establishing or disproving their synchronism. But the diagno sis is sometimes very difficult, if, one foetus being dead, only one heart beats, or if, owing to uterine contractions, to hydramnios, or excessive thickness of the abdominal walls, the foetal parts can not be made out by palpation. We must, therefore, never rest content with one method of exploration, but if suspicion of multiple pregnancy be aroused, we should successively employ palpation, auscultation and vaginal touch. It is upon the ensemble of data thus obtained that the certain diagnosis of twin pregnancy is to be based. Although there are cases of twin pregnancy which may be easily diagnosticated, there are others presenting great difficulties, and we can not be too sure of the fact before making an an nouncement to the patient, which, for the majority of women, is a disa greeable surprise.
Although twin pregnancy does not make the prognosis bad, for either mother or children, it is still far from leaving the woman in so satisfac tory a state as does single pregnancy. The large size of the abdomen, the marked edema of the lower extremities, the mechanical interference with digestion, respiration and circulation, being more pronounced than in single pregnancies, induce so much fatigue and suffering, as to sometimes seriously impair the health. The patient must also undergo a double labor, as it were. As a result of the exaggerated abdominal distension she is exposed in some cases to uterine atony, resulting in hemorrhage. Be sides, as we shall see, operations are often necessary in consequence of abnormal presentations. Besides these abnormal presentations, which ex pose the children to danger, there is another circumstance which unfavor ably affects the prognosis for them—the fact that twin pregnancies rarely reach full term. Twin pregnancy also often coexists with hydramnion of one ovum. These facts show the necessity of reserve as to the prognosis in twin pregnancy.
Triple, Quadruple and Quintuple Pregnancies.—These cases are very exceptional. From the standpoint of anatomical circumstances relating to the ovum, we may find a combination of all the varieties described in our remarks on twin pregnancy. There may be three separate placenta, two united placenta, with one separate placenta; or three united placenta, and consequently, three isolated fcetal sacs; two united sacs with one sep arate sac, one single foetal sac, etc.