Twin Fetuses Papyraeci in a Spontaneous Triplet Pregnancy Presenting with Unexplained Preterm Contractions
A 39-year-old Nigerian grand multipara, was referred to University of Maiduguri Teaching Hospital at 27 weeks of gestation on account of persistent uterine contraction of 3 days prior to presentation. An accompanying ultrasound scan report revealed a live singleton fetus at 27 weeks 2 days gestation, presenting breech, with a fundally placed placenta. The history and general examination were unremarkable. The pulse rate was 86 beat per min and her blood pressure was 130/80 mmHg. The fundal height was 29 cm which was compatible with her date of 27 weeks. The fetal heart rate was 142 beats per min. There was one palpable uterine contraction, of moderate intensity and lasted 25 s. Vaginal examination was unremarkable. Results of initial investigations were: Packed cell volume (PCV) 28%, white blood cells 8 × 109/L, platelet normal, high vaginal swab (HVS) for microscopy, culture and sensitivity (MCS) – normal, urine MCS – normal, fetal kick count – normal, up until 31st March, 2010. A repeat ultrasound scan confirmed earlier report from the referring centre. She was placed on intravenous fluid, cefuroxime axetil 500 mg twice daily for 10 days, pentazocin 60 mg once in 8 h for 24 h and continued on tablets of ibuprofen. During the 9 weeks period of admission she had received steroids for fetal lung maturity, nifedipine, phenobarbitone, and hematinics. The contractions never abated completely but it waxed and waned despite the tocolytics. An ultrasound scan at 34 weeks put the estimated fetal weight at 2320 g. She complained of reduced fetal movement at 36 weeks, 2 days and a review of the fetal kick count showed 5 kicks in the preceding 14 h. Her PCV then was 32% and urinalysis was negative for protein and glucose. She was offered emergency caesarean section and the products were two macerated male fetuses with monochorionoc placenta, weighing 150 g and 130 g. The live female fetus weighed 2.3 kg with Apgar score of 7 and 10 in 1st and 5th min, respectively. The placenta of the surviving twin and that of the twin papyraceous weighed 500 g and 200 g, respectively. She was discharged on the third post-operative day with her baby. Both had no complaints at the 6th week post-natal visit.