Missed Diagnosis of Twin Pregnancy and Mis-Diagnosed Fetal Hydrocephalous

Abstract

We present a 41 year old booked grandmultipara with twin gestation erroneously diagnosed as singleton pregnancy with fetal hydrocephalous and scheduled for elective caesarean delivery at term but subsequently went into spontaneous labour at 35weeks of gestation and had vaginal delivery of two live male babies while awaiting emergency caesarean section. The babies had good Apgar scores with no clinical hydrocephalous. The 1^st twin had spina bifida cystica. Multiple clinical and ultrasound diagnostic errors leading to wrong clinical decision taking and unnecessary intervention can occur even in experienced hands. Correct diagnosis following sequential and meticulous forward clinical reasoning serves the clinician and patients interest better.