American Journal of Medical Genetics 87:455–456 (1999)
Book Review
AN ATLAS OF MULTIPLE PREGNANCY.
BIOLOGY AND PATHOLOGY.
By G.A. Machin and L.G. Keith (with contributions
by F. Bamforth, and D. Teplica; Forewords by
J.J. Sciarra and E. Papiernik)
Parthenon Publishing Group, New York, 1999,
208 pp.
Since the days of the diòs kúroi (Castor and Pollux)
conceived by Leda after her seduction by Zeus in the
form of a swan, and hatched, in due time, from their
egg (q.v. Leonardo’s depiction of the happy event), the
study of twins has become a dull affair, indeed. Is not
the hypothesis that the form of the father determines
the type of birth (oviparous in this case) as charmingly
mythogenic as that of Romulus and Remus, twin
founders of Rome, being nursed by a she-wolf (spoil-
sports such as Lew Barness notwithstanding, who in
his study of wolf milk once showed, at considerable risk
to himself, that the stuff was unfit for human consump-
tion)? For a while there, I thought the discovery of po-
lar body twinning by Fred Bieber, Walter Nance, and
co-workers would restore some of the old excitement to
gemellology, but Drs. Machin and Keith, authors of the
present atlas, in an equally spoil-sport manner, damn
that example also, one of the twins being diploid, the
other triploid, hence “cannot be considered an example
of close twin similarity.” Indeed—especially since one
of the twins has acardia-acephaly!
In his scientific and scholarly efforts Geoff Machin, a
pediatric pathologist of renown and expert on twin-
ning, likes to collaborate with twins. Thus, in a recent
report and review on “Twin Zygosity Testing for Medi-
cal Purposes” (Am J Med Genet 1998; 77:412–414) his
two first authors were the twins David M. and John B.
St. Clair, the subjects of the report (Fig. 7.2 in the
Atlas), who told the story that one of them, after Corti-
narius speciosissimus mushroom poisoning, developed
interstitial nephritis requiring a renal transplant, in
this case from his twin, presumed dizygotic on the basis
of apparent discordance. Fifteen years later, after find-
ing out that they were in fact monozygotic, immuno-
suppression was discontinued but not until after com-
plications of several bouts of pneumonia, infections
with viral warts, cushinoid changes due to prednisone,
and the ever-present fear of potential transplant rejec-
tion.
In the case of this monograph, Dr. Machin’s coau-
thor, Louis G. Keith, Professor of Obstetrics and Gyne-
cology at Northwestern Medical School and President
of the Center of Multiple Birth in Chicago, dedicates
his contribution to his brother Donald (both in Fig 7.1
in the Atlas), “who for 41 years was my dizygotic (’fra-
ternal’) twin and who, through the application of blood
tests, then became my monozygotic (’identical’) twin
brother.” He attributes this transformation to Walter
Nance, another major authority on twinning in North
© 1999 Wiley-Liss, Inc.
America, and notes that this diagnosis “brought us
closer together than we ever dreamed possible. Our
original blood group analysis had recently been rein-
forced by state-of-the-art DNA testing.” Indeed, there
is no part of medicine that has not been affected by—in
fact, revolutionized by—the impact of DNA testing,
which also is not an infallible diagnostic twin method.
This is, in fact, one of the attractions of this book; the
vagaries of DNA testing in twin diagnosis are dis-
cussed expertly. One quibble I do have with this oth-
erwise well-written and beautifully produced book is
that neither author seems to have arrived at a satis-
factory synonym for “twinning,” Dr. Machin calling the
phenomenon “multiple pregnancy,” a highly unsatis-
factory term causing confusion with multigravidity,
and Dr. Keith presiding over a “Center . . . of Multiple
Birth” causing confusion with multiparity (e.g., gravida
5, para 4). Why not twinning, the English equivalent of
gemellity, the conception, gestation, and birth of two or
more infants at the same time? I suppose “polyem-
bryony” would also do, but the twins and their parents
would probably look somewhat askance at this arcane
term.
The text is organized into three sections. Section 1
discusses epidemiology, zygosity and related issues,
the placentas of twins, superfecundation due to “repro-
ductive technology”, some reasons why monozygotic
twins are not identical, and twins in research (pp.14–
24). Section 2, on antepartum diagnosis and manage-
ment of twin pregnancies, discusses external sexual
differentiation; number of placental discs; number of
sacs; structure of septal membranes and significance of
the delta sign (place where the double membranes of
dichorionic, diamniotic twins join the chorionic paren-
chyma); number of embryos; Doppler studies; vanish-
ing twins (perhaps 10 times as many twins conceived
as are born); complications of monochorionic twin preg-
nancy; congenital anomalies; prenatal diagnosis of ge-
netic disease; antenatal zygosity testing; selective ter-
mination; antenatal surgery in twin pregnancy; ante-
natal diagnosis of higher-order multiple pregnancy;
assessment of fetal well-being; and further improve-
ments in ultasonography (pp. 26–35).
Section 3, on the pathology of twin pregnancies, re-
views, again succinctly, the statistics on morbidity and
mortality; preterm labor and delivery; specific prob-
lems and complications of monochorionic twin preg-
nancy; anatomy of monochorionic twin placentas;
mechanism of twin-twin transfusion; mechanism of
acardias; monochorionic placental vascular patterns
and perinatal outcomes; discordance for congenital
anomalies in monozygotic (MZ) twins; management of
complications of monochorionic twin pregnancy; pa-
thology in monoamniotic twin pregancy; conjoined
twinning; and higher-order multiple pregnancy (pp.
38–51).
Part II of the synoptic text bears on the practical
456 John M. Opitz
aspects of twinning and includes sections on how to test
twins for zygosity (by Fiona Bamforth) and how to pho-
tograph twin faces for medical purposes (by David Tep-
lica).
Part III addresses the issues of parents’ knowledge of
twins; nature and nurture in twins; impact of zygosity
on the lives of twins; impact of chorionicity on the lives
of twins; familial twinning; conjoint twinning; and mir-
roring in MZ twins. The selected bibliography empha-
sizes more recent publications (e.g., Virginia Baldwin’s
authoritative Pathology of Multiple Pregnancy, the Be-
nirschke-Kaufmann Pathology of the Human Placenta,
and the standard text by Keith et al. on Multiple Preg-
nancy), but, to my regret, does not include such great
classics as Gedda’s Studio dei Gemelli (1951), New-
man, Freeman, and Holzinger’s Twins (1937), New-
man’s Multiple Human Births (1940), Koch’s Twins
(1966), Shields’ Monozygotic Twins (1962), Bulmer’s
The Biology of Twinning in Man (1970), and the three-
volume sets of Nance on Twin Research (1977) and of
Gedda, Parisi, and Nance on Twin Research (1981).
Nevertheless, the 90 or so publications cited form a
good guide to the most important recent publication on
twinning, twin gestations, and twin pathology.
The great advantage of this book, which clearly sets
it apart from other twinning texts, is the atlas with its
many beautiful and clear diagrams and clinical illus-
trations in color. A few of the black-and-white ultraso-
nographs are of mediocre quality (e.g., Fig 2.1d, delta
sign not clear); however, there are many other spec-
tacular illustrations that make important points very
effectively (Fig.1.9: MZ twins discordant for Wiede-
mann-Beckwith syndrome with hepatoblastoma in the
affected infant; MZ twins, one with anencephaly, and
concordance for anterior wall defect; the several
acephalus-acardia twins; discordance for holoprose-
notocephaly; a disprosopus with thanatophoric dyspla-
sia; and many more). The section on photographic ap-
proaches to twin diagnosis is superb (standard AP, R &
L profile, R & L oblique and a mental/nasal view with
head tilted back). The example of the two venerable
twin ladies, both having just developed the “same” two
gray hairs in the same eyebrow, is provided with the
thought-provoking comment “that the depigmentation
of hair as an aging phenomenon is precisely timed and
affects specific hair follicles in a clear pattern,” a not
surprising hint at determinism, considering the inter-
est of the authors. Dermatoglyphic analysis in twin di-
agnosis and development is not mentioned. Neverthe-
less, this is an altogether wonderfully interesting and
well-produced volume, which I found enjoyable and di-
dactically highly valuable. The price of almost $140.00
is not surprising considering the number of good color
illustrations, but probably puts the book out of reach of
most clinical geneticists. Nevertheless, the book is such
an important resource I would recommend it strongly
for every divisional library in pediatric genetics and
pediatric pathology.
John M. Opitz
Editor-in-Chief