conjoined twins
TRANSCRIPT
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 .
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Thank you