Presented by

Dr. Qurrat ul AinPost graduate trainee

Gynae unit II

Senior Registrar

Dr. Nazia Ayub (FCPS)

Associate Professor

Dr .Naela Tarique (FRCOG)

conjoined twins

Name Seema W/O

Shahid

Age 25 years

Married for 05 years

Parity G3P2

Last Born 02 years

Unbooked

Patient’s Profile

Last Menstrual Period 24.12.08

Expected Date of Delivery 01.10.09

Duration of Pregnancy 41+3 weeks

Date of Admission 09.10.09

Time of Admission 10.00am

Cont…

Twin Pregnancy

Labour Pains 05 hr

Vaginal leaking / bleeding Nil

Fetal movements Normal

Presenting Complaints

Spontaneous conception & all trimester

uneventful

Obstetrical history was insignificant

Medical , surgical , menstrual history

insignificant

No H/O of Twins in the family

Poor socioeconomic status

history

She had 3 previous ultrasound scans from LGH

USS at 20 weeks showed single gestation

USS at 35 weeks showed twin gestation with

single placenta , number of sac’s not mentioned

USS at 37 weeks showed twins gestation with

single placenta , separate sac’s not mentioned

Cont…

GENERAL PHYSICAL EXAMINATION Pallor ++ Jaundice°, edema°, thyroid°, clubbing°,

lymph nodes°, cyanosis°, breast are normal

BP 110/70 mm Hg Pulse 88/ min Temp 98 °F R/R 18/min

EXAMINATION

SFH Large for dates (40cm)

Multiple fetal parts palpable

P/P 1st cephalic

2nd not determined

FHS 1st 150 bpm

2nd 150 bpm

Liquor adequate

Uterine contractions moderate 2/10 , 35sec

ABDOMENAL EXAMINATION

Vulva & vagina healthy

Cervical Os 7-8cm

Cervix effaced

Vx -3 , push able

Presenting part poorly applied to cervix

Membrane bulging

VAGINAL EXAMINATION

Investigations

CTG

Antibiotic cover & hydration

Arrangement of blood

USG to confirm status of 2nd fetus

Monitor progress of labour

Provisionally prepare for LSCS

Plan & management

12: 25pmSpontaneous rupture of membranePatient drained clear liquor of normal amountPelvic Examination Cervical Dilatation 8cm Cervix Effaced Vx -3 , well applied Moderate 2/10 uterine contractions of 35 sec

PROGRESS & EVENTS

02: 45pmCervix was fully dilated Patient shifted to labour room stage II

03 : 45 pmPatient remained fully dilated for 1 hour Presenting part at +1 station

PROGRESS & EVENTS

Right mediolateral generous episiotomy given

Vacuum applied but failed

Patient shifted to OT at 4:00 pm for Em. LSCS

Same pelvic findings

FHR 1st 70 bpm

2nd 70 bpm

PROGRESS & EVENTS

Pfannenstiel incision

Lower segment transverse incision in

uterus

1st baby delivered as cephalic followed

by delivery of limbs & trunk of both

babies & then head of second baby.

Conjoined twins diagnosed

( Thoraco-omphalopagus )

Placenta & complete membranes delivered

OperatiVE DETAILS

Monoamniotic & monochromic twins

Urinary bladder edematous & high up due to

prolonged 2nd stage of labour

Both fallopian tubes and ovaries healthy

Uterus & abdomen closed in layers

Episiotomy stitched in layers

ESTIMATED BLOOD LOSS 1200-1500 ML

Operative findings

Conjoined twins

Thoraco-omphalopagus

Both females , 4.0 kg .

Apgar 0/10 , 0/10

Both with cleft palate & cleft lip

Limbs were under developed

Attended & evaluated by

pediatrician but details not documented

Baby notes

Post operative period was un eventful

Post op Hb% was 5 gm/dl

3 units of blood transfused

Injectible iron given

Antibiotic cover given

Patient discharge on 4th post op day in good health

Post op management

These are identical twins whose bodies are

joined in utero.

It accounts for 1-2% of monozygotic twins.

Incidence 1 in 50,000 births to 1 in 200,000

births.

Higher incidence in Southwest Asia and

Africa.

The increased incidence of conjoined

twinning may have

genetic background

Conjoined twins

Survival rate for conjoined twins is approximately

25%

Many pairs born alive have abnormalities

incompatible with life.

40% are stillborn

75% of the live born die within 24 hours.

More common among females fetus , Ratio of 3:1

Cont….

Two contradicting theories

The older and most generally accepted theory is fission, in which the fertilized egg splits partially.

The second theory is fusion, in which a fertilized egg completely separates, but stem cell find like-stem cells on the other twin and fuse the twins together

GENETICS OF CONJOINed TWINS

Only monozygotic twins can be conjoint

Four days after fertilization the chorion differentiates.

If the split occurs before this time the monozygotic twins

will implant as separate blastocysts each with own

chorion and amnion. Result in dichorionic & diamniotic,

constitute 25%.

Eight days after fertilization the amnion differentiates.

If the split occurs between the 4th-8th days,twins will

share the same chorion but separate amnions. Results

monochorionic diamniotic , accounting for 75%.

Embryology

The embryonic disk starts to differentiate

on the 13th day.

If the split occurs between 8th- 13th days, twins

will share the same chorion and amnion. Result in

monochorionic monoamniotic twins.

If the split occurs after day 13, then the twins

will share body parts in addition to

sharing their chorion and

amnion.

Embryology

Often missed on radiography because of failure to consider it

SONOGNAPHIC DIAGNOSTIC CRITERIA

Demonstration of a continuous non separated

external skin contour

Bifid appearance of the fetal pole in the first

trimester

Conjoined body parts, inseparable bodies or

heads

Diagonosis critaria

Body parts of the twins are on the same

level & imaged in the same sonar plane

No change in the relative position of the

twins to one another & on

successive scans.

More than 3 vessels in a single umbilical cord

Complex fetal anomalies

Diagonosis critaria

There are many types of conjoined twins

Conjoined twins are typically classified by

the point at which their

bodies are joined

Types of conjoined twins

Constitute about 35 % of

conjoined twins

Anterior union of the upper half

of the trunk

Joined at the chest

THORACOPAGUS

THORACOPAGUS

• Heart is shared

• Separation is not possible

OMPHALOPAGUSThe second most common

type of conjoined twins, representing 30% of of the total.

Joined at the chest and abdomen

Similar to thoracopagus twins, but in this case the twins do not have a shared heart.

OMPHALOPAGUS• Highest rate of separation survival.

• Usually, only the liver is involved.

• Because the liver can regenerate itself, separation is possible.

OMPHALOPAGUS• Highest rate of separation survival.

• Usually, only the liver is involved.

• Because the liver can regenerate itself, separation is possible.

19 % of the conjoined twins

Joined at the posterior pelvis

Separation is possible

The survival rate is highest

Pyopagus

05% of the conjoined twins

Lateral or side union

Joined from the

thoracic cavity & downwards

Separation possible,

depending on the number

and sharing of internal organs

Life with artificial limbs is the result.

Parapagus

06% of the conjoined twins

Joined at the pelvis.

Anterior union of lower

half of body

Ischopagus

Separation is physically

possible

Excretion and

sexual impairment

might

result.

Ischopagus

Craniopagus

2% of conjoined twins

Joined at the cranium.

Separation is possible,

depending on how much

of the

brain is shared.

Craniopagus

High risk of brain damage

Cephalothoracopagus

•Ventral or frontal union

• Two faces on the opposite

side of the head characterize

the union.

• Share a heart well as a brain

• Not viable.

cephalophagus•Twins with conjoined necks and heads but separate bodies. •Due to malformations in the brain, these twins are never viable. •Those that are not stillborn die within a few hours.• Also called syncephalus or janiceps.

raciphagus

•Dorsal or rear union at the spine

•Very rare incidence

•Only one recorded.

Ileopagus

• Connected at the iliac bone.

•When the twins are

extensively connected then

the duplicated part is named.

•Dicephalus refers to two

heads with one body.

Situation in which an imperfect fetus

is contained completely within the

body of its sibling.

Fetus in fetu

Early prenatal diagnosis & typing of conjoined

twins allows better management of pregnancy ,

including counseling of parents, continuation of

pregnancy, elective mode of delivery,

with post-natal surgery, and in a selective

cases termination of pregnancy .

Take Home Massage

Thank you