Conjoined twins: A rare case report - PharmSciDirect

Available online atwww.pharmscidirect.comInt J Pharm Biomed Res 2013, 4(3), 187-188Case reportInternational Journalof PHARMACEUTICALAND BIOMEDICALRESEARCHISSN No: 0976-0350Conjoined twins: A rare case reportN.Deepika 1 *, Arun Kumar 21 Department of Obstetrics and Gynaecology, Sri Devaraj Urs Medical college, Tamaka, Kolar-563 101, Karnataka, India2 Department of Obstetrics and Gynaecology, Indira Gandhi Medical College, Shimla-171 001, Himachal Pradesh, IndiaReceived: 15 Aug 2013 / Revised: 23 Aug 2013 / Accepted: 25 Aug 2013 / Online publication: 02 Sep 2013ABSTRACTConjoined twin is a rare occurance in obstetric practice. In the present case study, we are reporting one case ofcranithoracophagus conjoined twins. A 30 year old women unbooked gravida 3 para 2 living 2 reported to antenatal OPD forroutine antentatal check up. Obstetric scan was done which revealed twin pregnancy, monochorionic monoamnioticconjoined twin of 26 weeks 5 days. The separation of conjoined twins is associated with increased chance of perinatalmortality. Therefore, making an early diagnosis with ultrasonographic examination provides the parents a chance to opt forpregnancy termination.Key words: Conjoined twins, Craniothoracophagus1. INTRODUCTIONTwins is not an uncommon phenomenon but conjoinedtwins are indeed a rarity, since the event occurs only once in50,000–60,000 births [1]. If twinning is initiated after theembryonic disc and amniotic sac have formed and if thedivision of the embryonic disc is incomplete, conjoined twinsresult [2]. Approximately 40-60% of conjoined twins arrivestillborn, and about 35% survive only one day. The overallsurvival rate of conjoined twins is somewhere between 5 and25%.We report a rare case of conjoined twins who presentedrecently in our department.2. CASE REPORTA 30 year old women unbooked gravida 3 para 2 living 2reported to antenatal OPD for routine antentatal check up.Her LMP was 26.08.2011 and her period of gestation was 28weeks 3 days.*Corresponding Author. Tel: +91 9916054700Email: deepikang@gmail.comFax:©2013 PharmSciDirect Publications. All rights reserved.Obstetric history:First child was FTND of female baby at a governmenthospital, baby 5 years old, alive and healthy. Secondpregnancy was FTND of female baby at government hospital,baby 2 years old, alive and healthy. There was no history oftwinning in the family. On her examination, she was averagebuilt and nourished. Her general physical and systemicexamination was normal. Obstetrical examination: fundalheight was 32 weeks, fetal parts were palpable and exactpresentation could not be made out.Investigations:Hb 10.8g%, blood group O+ve, urine examination wasnormal. Obstetric scan was done which revealed twinpregnancy, monochorionic monoamniotic conjoined twin of26 weeks 5 days. Presentation was cephalic, placenta fundal,AFI of 16-17cm, fetal heart of both twins present and therewas fusion of head, chest and abdomen of both fetuses. Thepatient and her relatives were counselled about theincompatibility of life and after arranging blood she wasinduced with 50µg of misoprostol, 2 doses 6 hours apart. Shehad vaginal delivery of twin female babies which were stillborn and weighed 2.4kg (Fig.1). The baby had four arms,four legs, one head and chest and abdomen was fused (Fig.2).The placenta was single and weighed 650g. Third stage wasuneventful.

N.Deepika and Arun Kumar, Int J Pharm Biomed Res 2013, 4(3), 187-188 188Fig 1: Cranithoracophagus conjoined twinsapproximately 13-15 days postovulation. Most conjoinedtwins are female, with the ratio of women to men beingreported as 2:1 or 3:1. Many of these infants are deliveredprematurely and are stillborn. They are classified accordingto their site of union. The most common location is the chest(thoracopagus), followed by the anterior abdominal wall fromthe xiphoid to the umbilicus (xiphopagus), the buttocks(pygopagus), the ischium (ischiopagus), and the head(craniopagus) [3]. Organs may be shared to varying degreesin different sets of twins. Major congenital anomalies of oneor both twins are not uncommon. Polyhydramnios is said tobe present in almost one half of the reported cases ofconjoined twins. Antenatal diagnosis by ultrasound ispossible in modern day obstetrics. Ultrasonographicidentification of any of the following classical signs maysuggest the diagnosis: both fetal heads in the same plane,unusual backward flexion of the cervical spine, no change inthe relative position after maternal movement and manualmanipulations and inability to separate fetal bodies aftercareful observation [4].Caesarean delivery near term is the preferred method ofdelivery to minimize maternal and fetal injury. If the twinsare thought to have a poor chance of surviving and are smallenough to pass through the birth canal without damaging themother, vaginal delivery might be considered.Separation of conjoined twins is complicated procedure.The importance of multidiscipline team with rehearsal of allaspects (surgical, anaesthetic and nursing) of the operativeprocedure cannot be overemphasized. Although the outcomeis influenced by careful planning and organization from allparticipants, the prognosis is often predetermined by theunderlying anatomy which may preclude successfulseparation [5].4. CONCLUSIONFig 2: X-ray of the conjoined twinsThe separation of conjoined twins is associated withincreased chance of perinatal mortality. Therefore, making anearly diagnosis with ultrasonographic examination providesthe parents a chance to opt for pregnancy termination.REFERENCES3. DISCUSSIONConjoined twins occur with a frequency of about 1 per50,000 deliveries and are an extremely rare complication ofmonochorionic twinning. The precise etiology of conjoinedtwinning is unknown, but the most widely accepted theory isthat incomplete division of a monozygotic embryo occurs at[1] Tan, K.L., Goon, S.M., Salmon, Y., Wee, J.H., Acta Obstet GynecolScand 1971, 50, 373-380.[2] Cunningham, F.G., MacDonald, P.C., Gant, N.F., Williams Obstetrics,21 st Edn. McGraw-Hill, New York 2003.[3] Malone, F.D., D’Alton, M.E., Clin Perinatol 2000, 27, 1033-1046.[4] Kalchbrenner, M., Weiner, S., Templeton, J., Losure, T.A., J ClinUltrasound 1987, 15, 59-63.[5] Miller, D., Colobani, P., Buck, J.R., Dudgeon, D.L., Haller, J.A., J PedSurg 1983, 18, 373-376.