"A Rare Case of Superfetation"
A Case Report
"A WOMAN DELIVERS BABIES 3 MONTHS APART": Longest Documented Delivery Interval in a Rare Case of Superfetation. A Case Report Desiree F. Manlapaz-Gonzales,MD. 1 ABSTRACT: Background: "J.A had her first delivery on January 2010 to a live term female neonate. On April 2010, 3 months after,, she again delivered to a live term male neonate. A rare condition called Superfetation." Superfetation is defined as the simultaneous occurrence of more than one stage of developing embryo in the same animal. In mammals, it manifests as the formation of a fetus from a different menstrual cycle while another embryo is already present in the uterus. On the contrary, it should not be confused with Superfecundation, where there are two separate instances of fertilization during the same cycle. Superfetation is claimed to be common in some species of animals but is extremely rare in humans. In mammals it can occur only where there are two uteri or where the menstrual cycle/ovulation continues throughout pregnancy. Because of its rarity only 10 cases were documented worldwide making Superfetation a medical mystery. Key words: Superfetation; Superecundation 2 INTRODUCTION: Superfetation is conception while already pregnant, most properly defined as the simultaneous occurrence of more than one stage of developing embryo in the same animal.1 In mammals, it manifests as the formation of a fetus from a different menstrual cycle while another embryo is already present in the uterus. In humans, reports of superfetation has often been treated with suspicion and some has been clearly discredited. Other explanations have been given for different levels of development between twins. It would seem to be impossible but apparently this is not heard of. Superfetation is very rare among humans. In fact, it is so rare that there is no prevalence or incidence. The medical literature, in fact, shows only 10 cases among humans considering superfetation as a Medical Mystery.2 3 REVIEW OF LITERATURE: Animals that have been claimed to be subject of superfetation include rodents (mice and rats), farm animals(horses and sheep), marsupials(kangaroos and sugar gliders), fish (poeciliid) and rearely primates(humans). In humans, reports of superfetation were documented as follows: In 1992, Taylor and Evan Barth conceived 4 weeks apart were born in Hawaii USA to Michelle and John Barth. Taylor, the one conceived later was born first. In 2007, Ame and Lia Herrity conceived 3 weeks apart was born in the United Kingdom to Amelia Spence and George Herrity. In May 2007, Harriet and Thomas Mullineux also conceived 3 weeks apart, were born in Benfleet, Essex UK to Charlotte and Matt Mullineux. In 2009, Todd and Julia Grovenburg of Forth Smith, Arkansas received international media attention for Mrs. Grovenburg's conception of additional child while already pregnant with a child conceived two and a half weeks earlier. 4 CASE HISTORY: J.A a 31 y/o G1P1 (1001) of Cainta Rizal came in to Salve Regina Hospital with complaints of severe abdominal pains and cold clammy perspiration. She was seen by resident on duty and initial examination revealed a tender hard abdomen on palpation. She was asked when was her last menstrual period and claimed she just delivered January 2010. Upon having this information she was immediately referred for OB-GYN clearance. After a thorough history was done a routine internal examination was made. IE revealed an almost fully dilated cervix with fetal head presenting at the intoitus at station 0. Patient was then admitted and wheeled to the delivery room for delivery. PAST HEALTH HISTORY: Unremarkable PERSONAL SOCIAL HISTORY: Non Smoker, Non alcoholic beverage drinker FAMILY HISTORY: Unremarkable (-) Hx of twins 5 MENSTRUAL HISTORY: LMP= ? patient claimed to have given birth January 2010 OB-GYNE HISTORY: G2P1(1001) G1= January 2010 delivered to a live term female neonate BW= 3.200grams at a birthing home/ lying in. No birth complications. G2= present pregnancy ADMITTING DIAGNOSIS: PU ? weeks AOG, Cephalic in labor, G2P1(1001) COURSE IN THE WARD: On the day of admission, (April 13, 2010 2:30 am), patient was admitted to the delivery room. She was placed on NPO. Venoclysis was started with Dextrose 5 in Lactated Ringers Solution 1L at 32 gtt/min. 3 hrs post admission, patient delivered to a live term baby boy BW= 3 kgs AS=7,9 MI= 40 wks. 13 hrs post admission/ 10 hrs post partum patient was placed on Diet As Tolerated, breast feeding and gradual ambulation encouraged. 6 1 � day hospital day, she was sent home stable with medications: 1.) Amoxicillin 500 mg/ cap 1 cap TID for 5 days 2.) Mefenamic Acid 500mg/cap I cap q 6 hrs for pain on full stomach 3.) Lactagogue (Natalac) 1 cap 3 x a day for 5 days and 4.) Methylergometrine maleate (Methergin) 125 mg/tab 1 tab 3 x a day for 2 more days FINAL DIAGNOSIS: PU delivered to live term baby boy BW=3 kgs AS= 7,9 MI= 40 weeks, G2P2(2002) DISCUSSION: It was not surprising that staffs at Salve Regina Hospital including the author be taken aback by the patient's history, especially that there was no documented case of superfetation in the Philippines - the country where Baby Janz Reiver was born. Other doctors at the operating room present during the delivery raised eyebrows saying that it may just be a case of twin gestation or uterine didelphys ( an anatomical condition of having 2 separate uterus) but for the mother it was confusion, she questioned herself how come it was not documented on her previous ultrasound? How will she explain to her husband and her in-laws that she is giving birth again after 3 months of giving birth to a baby girl especially that her husband is an Overseas Filipino Worker (OFW) who left the country knowing he only has one child? To her it was more of a stigma and even if her conscience is clean (being in a monogamous relationship) it will be very difficult for her to explain the situation to other people especially those who question paternity. 7 In retrospect, J.A. is a nursing student who was about to be married to V.G. the father of her child. The marriage was scheduled after she finishes College. Since she was studying she kept her pregnancy from her family and had irregular prenatal check-ups on her first pregnancy. She claimed to have had an ultrasound done during her first pregnancy but cannot recall during which trimester it was taken and which she claimed only showed a single male fetus but of which she failed to produce a copy. On the day she delivered to her first child, she was away from home. She asked help from a bystander to bring her to a place where she can deliver because she is already experiencing labor pains and bloody show. She was brought to a nearby birthing home/ lying in where she delivered to a live term female neonate BW= 3.2 grams with no complications. The delivery was uneventful but she was surprised to give birth to a female child expecting it would be a male on ultrasound. Without any complications she was sent home stable the following day. Few days after delivery, close friends and classmates would joke with her that she is still pregnant because instead of her abdomen becoming small it is still big in size. She was never alarmed knowing it would not resume to its normal size until 2 months postpartum. She attributed the absence of her menses to her breastfeeding and there are times when she felt movements in her abdomen which she attributed to intestinal/bowel movements. Two months postpartum, she started to get worried because her abdomen is not getting smaller. It was very unusual to feel something moving inside your abdomen but she is in denial knowing she just delivered and the ultrasound she claimed to have undergone revealed only one fetus. But there are times when she would think about her classmates' jokes about having another fetus left in her abdomen. Despite all the confusion she never consulted a professional nor undergone the routine post partum check up after two weeks and after two months. She went on with her life assuming nothing is wrong with her and all the things she is experiencing are just part of the post partum period. Superfetation is a very rare medical condition wherein a woman conceives a second child while she is already pregnant. Such pregnancies occur when a woman continues ovulating after becoming pregnant and when that second, fertilized egg is able to implant itself in the lining of the womb -- two things that wouldn't happen in a normal pregnancy. Typically, hormonal changes prevent further ovulation and thicken the lining of the uterus to preclude a second embryo from attaching.3 8 Since LMPs are unknown to the patient it is safe to say that the second baby which is a boy was conceived 3 months after she was pregnant with her first child which is a girl (figure 1 & 2) It has to be differentiated from identical twins which is defined as one fertilized egg that splits into two and fraternal twins wherein two separate eggs are ovulated and simultaneously fertilized. It should also be differentiated from Superfecundation where in 2 separate eggs are fertilized on two different occasions but in the same menstrual cycle. There are only 10 documented superfetation cases in the whole world. The last was delivered in December 2009 and January 2010. The longest interval documented between deliveries was 4 weeks that of Taylor and Evan Barth of Hawaii in 1992.1, 4 There was one case featured by Philippine media in the news a few months before the cases of Baby Girl Ma. Venice Jeline and Baby Boy Janz Reiver but which was not properly documented nor published. The usual criteria to assume a case of superfetation include the finding of discordantly developed young within the uterus during post mortem or parturition of young after a birth interval shorter than the assumed pregnancy length. Often the occurrence of superfetation is concluded because other explanations of reproductive artifacts are missing. 5 According to Obstetrician Dr. Micheal Muylaert, cases of superfetation can only be confirmed after delivery by chromosomal and metabolic studies on the baby. 9 The parents of Baby Girl Ma. Venice Jeline and Baby Boy Janz Reiver decided to have their case submitted for case report because they have experienced a certain point of discrimination from the society. The company which the father of the newborns worked was skeptical on his claim for the children's benefits questioning him why the children were born closely apart and even asked him if the second child has a different mother. When the children were registered with the Health Insurance Company the system rejects the data entry of one of the child. One purpose this paper was made is to settle confusions and correct misconceptions. We are working towards the completion of this case however no copies of laboratory test and diagnostic tests pertaining to the first delivery were provided. Our record of the second delivery is intact. Due to financial and time constraints, they weren't able to have the chromosomal studies done on both babies and metabolic (newborn screening) done on Baby Girl Ma. Venice Jeline. Baby Boy Janz Reiver has normal newborn screening. 10 ACKNOWLEDGEMENT: The author wishes to thank first, the God Almighty for continued guidance, her family, who gave unending encouragement in the pursuance of her dreams, her friends and her superiors for their continued support especially to Dr. Esther Salazar Ongkeko of Victor R. Potenciano Medical Center who always believed in her. Special thanks to Prof Zion Ben Rafael, founder and co-chairman of COGI Congress for guiding me along the way in the completion of this manuscript. 11 BIBLIOGRAPHY: 1. Superfetation- Wikipedia, the free encyclopedia[Internet] Available at: http://en.wikipedia.org/wiki/Superfetation 2. Jacob Stephanie (September 2009) [Internet], "Superfetation Double Pregnancy" Available at(http://www.aolhealth.com/condition-center/pregnancy/superfetationdouble-pregnancy) 3. TIME Health and Science[Internet] "How can a pregnant woman be pregnant again" http://www.time.com/time/health/article/0,8599,1926414,00.html 4. Pape O, Winer N, Paumier A, Philippe HJ, Flatr�s B, Boog G. "Superfetation: case report and review of the literature"J Gynecol Obstet Biol Reprod (Paris). 2008 Dec;37(8):791-5. Epub 2008 Jul 29. Review. French. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18667283 5. Roellig K, Menzies BR, Hildebrandt TB, Goeritz F."The concept of superfetation: A critical Review on a "myth" in mammalian reproduction" Biol Rev Camb Philos Soc. 2010 Apr 14. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-185X.2010.00135.x/abstract 12