- Case report
- Open Access
- Open Peer Review
Discordant twins with the smaller baby appropriate for gestational age – unusual manifestation of superfoetation: A case report
- Noopur Baijal†1,
- Mohit Sahni†1,
- Neeraj Verma†1,
- Amit Kumar†1,
- Nittin Parkhe†2 and
- Jacob M Puliyel†1Email author
© Baijal et al; licensee BioMed Central Ltd. 2007
- Received: 19 May 2006
- Accepted: 19 January 2007
- Published: 19 January 2007
Documentation of superfoetation is extremely rare in humans., The younger foetus has invariably been small for gestational age (estimated from the date of the last menstrual bleed) in all the cases reported in the literature. We report a case where the younger twin was of appropriate size for gestation.
The first of twins was of 32 weeks gestation and the baby was of appropriate size and development for the gestational age. The second twin was of 36 weeks gestation. Gestational age was estimated with the New Ballard score, x-ray of the lower limbs, dental age on x-ray, and ophthalmic examination.
Bleeding on implantation of the first foetus probably helped demarcate the two pregnancies. Dental age and the New Ballard score can be used to diagnose superfoetation in discordant twins, when detailed first trimester ultra-sound data is not available.
- Retinal Vessel
- Intrauterine Growth Retardation
- Ophthalmic Examination
- Last Menstrual Period
- Placental Insufficiency
Superfoetation implies fertilization and subsequent development of an ovum when a foetus is already present in the uterus. Growth discordance in multiple pregnancies due to placental insufficiency, twin to twin transfusion or aneuploidy need to be differentiated from superfoetation. In most instances the larger twin is nearer appropriate size for gestational age calculated from the last menstrual period (LMP). We report a case where superfoetation was likely superfoetationbecause the smaller of the twin was of appropriate maturity, weight and length for gestational age. These circumstances argued against intrauterine growth retardation in the smaller twin.
Ante-natal ultrasonography findings at 26 weeks after LMP
26 weeks +/- 2 weeks
30 weeks +/- 2 weeks
Differences between the twins at birth
Twin A (Gestational age range in weeks +/-2SD)
Twin B (Gestational age range in weeks +/-2SD)
Circumference head (cm)*
New Ballard Score
15 (30 +/- 2 weeks)
32 (36 +/- 2 weeks)
Epiphysis lower end of femur
Absent (Less than 31 weeks)
Present (31 – 40 weeks)
Epiphysis upper end tibia
Absent (Less than 34 weeks)
Present (34 – 5 post natal weeks)
Calcified crown of 1st deciduous molar
Absent (less than 33 weeks)
Present (more than 33 weeks)
Calcified crown of 1st deciduous molar
Absent (less than 36 weeks)
Present (more than 36 weeks)
Retinal vessels migration
Not reached nasal ora serrata (less than 36 weeks)**
Complete on the nasal side and near complete on the temporal side. (more than 36 weeks)**
Retinal vessels normally reach nasal ora serrata by 36 weeks and periphery on the temporal side by 40 weeks.
Ophthalmological examination of Twin Ashowed a hazy cornea and the underlying papillary membrane was not visualised. The retinal vessels had not reached the nasal ora serrata. In Twin B the cornea was clear, there was no papillary membrane and the retinal vessels migration was complete on the nasal side and near complete on the temporal side.
Intrauterine growth retardation (IUGR) is the usual cause of discordance in multiple pregnancies. We did not find anyreport in the literature of discordance due to one baby being large-for-date. In this case the smaller twin was of appropriate size and maturity for gestation assessed from LMP. The second twin was approximately a month too large and mature. Superfoetation was considered as a possible explanation for the observation. Bleeding one month after conception occurs in about 8% pregnancies and represents a physiological response to implantation or slight bleed from the endometrium in early pregnancy . We therefore also considered the possibility that both twins were conceived simultaneously a month prior to the presumed date of the LMP, and the smaller Twin A was small-for-date.
Detailed neurological and physical assessment is considered the most reliable method of estimation of gestational age, in circumstances where IUGR is suspected and there is uncertainty in using LMP . Using the New Ballard Score  the first of the twin was 30 weeks and the second was 36 weeks (+/- 2 weeks). This evidence of disparity in the gestational ages of the 'twins', was corroborated by the estimation of age based on anthropometric measurements, weight, length and head circumference, ophthalmic examination, bone age and dental age estimates. The twins had not received ante-natal steroids which, which had they been given, may have influenced some of the markers of foetal maturity. The evidence taken together, suggests that there was a real difference of approximately 4 weeks in the gestational ages of the twins and this was in keeping with the findings of the ante-natal ultrasound examination.
Among the evidence listed above, anthropometric measurements and bone maturation are delayed in first-trimester-malnutrition and results in symmetric growth retardation [2, 5]. However the work of Kuhns et al  suggest that the age of calcification of the crowns of the molars is not affected by IUGR and we use this criterion along with the New Ballard Score and the ophthalmic examination to confirm the disparity in gestational ages of the neonates. Harrison et al  have recently reported a case of superfoetation and suggested that in growth-discrepant multiple deliveries, skilled neurosonography and ophthalmic examination may be used to support the diagnosis of superfoetation when detailed first trimester data is lacking. We would like to add the role of the New Ballard Scoring and, as they may help clinch the diagnosis, even where suggestive fortuitous circumstances as in this case (distinct marker separating the two fertilizations in the form of bleeding on implantation of first ovum) are not available.
Written consent was obtained from the guardian of these twins for publication.
- Ballard JL, Khoury JC, Wedig K, Wang L, Ellers-Walsman BL, Lipp R: New Ballard Score, expanded to include extremely premature infants. J Pediatr. 1991, 119: 417-23. 10.1016/S0022-3476(05)82056-6.View ArticlePubMedGoogle Scholar
- Kuhns LR, Finnstrom O: New standards of ossification of the newborn. Radiology. 1976, 119: 655-660.View ArticlePubMedGoogle Scholar
- Kuhns LR, Sherman MP, Poznanski AK: Determination of neonatal maturation on the chest radiograph. Radiology. 1972, 102: 597-603.View ArticlePubMedGoogle Scholar
- Guttmacher SH: Frequency and significance of bleeding in early pregnancy. J Am Med Assoc. 1954, 19;155: 712-5.Google Scholar
- Vik T, Vatten L, Jacobsen G, Bakketeig LS: Prenatal growth in symmetric and asymmetric small-for-gestational-age infants. Early Human Development. 1997, 48: 167-76. 10.1016/S0378-3782(96)01852-X.View ArticlePubMedGoogle Scholar
- Harrison A, Valenzuela A, Gardiner J, Sargent M, Chessex P: Superfetation a cause of growth discordance in multiple pregnancy. J Ped. 2005, 147: 254-5. 10.1016/j.jpeds.2005.04.038.View ArticleGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/7/2/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.