Clinical Meeting

1. CLINICAL MEETING
PRESENTED BY
DR. MAIMUNA SAYEED

2. Particulars of the Patients
Name: D/O Taslima
Age: Day 4
Outborn
Address: Pabna
Date of admission: 21.07.16
Date of examination: 21.07.16

3. Presenting Complaints
 Born before date
 Twin attached at head since birth

4. History of Present Illness
 Mother Taslima, 32 years old, Para 2+1
(abortion), having blood group O+ve and the
father’s blood group is O+ve. She received 5
regular antenatal checkup and got 2 doses of
tetanus toxoid. She has no h/o PIH, GDM,
hypothyroidism, PROM or any other chronic
illness. She had no h/o taking ovulation
inducing drug and no family h/o twin. At 28
weeks of gestation USG revealed single viable
pregnancy with mild hydrocephalus and BPD
is 9cm which corresponds to 36 weeks.

5. History of Present Illness
(Contd.)
So mother was advised to take neurology
consultation about the outcome of baby. After
consultation from neurologist, as she heard
about the poor outcome of the baby, she
planned for elective LUCS. At 35 weeks of
gestation, elective LUCS was done in a local
clinic and a twin female babies were born with
their head attached together. Both babies cried
immediately after birth, APGAR score was 6/10
& 7/10 at 1st & 5th min respectively but birth
weight was not documented.

6. History of Present Illness
(Contd.)
 Then the babies were kept with mother and
was on EBF. Both of them passed urine and
meconium within first 12 hours of life. Later the
babies were referred to BSMMU for further
evaluation & management. At day 4 of post-
natal age, the babies were transferred to
BSMMU by an ambulance in mother’s lap with
proper wrapping and transportation time was
about 7 hours without any difficulties.

7. Birth History
 Antenatal: Mother received 5 ANC and the
period was uneventful.
 Natal: Conjoint twins were delivered by
LUCS at 35 weeks of gestation.
 Postnatal: Both of the babies cried
immediately after birth, APGAR score was
6/10 & 7/10 at 1st & 5th min respectively, and
both of them passed urine and meconium
within first 12 fours of life.

8. Family History
 They are the 2nd issue of non-
consanguineous parents. Other sib is 5-
year-old and healthy.
 There is no family h/o twins.

9. Socioeconomic History
 Parents are from middle socio-economic
background.
 Both parents are private school teacher.

10. General Examination
First twin:
 Pink in room air
 Icteric up to leg
 Reflexes and activities: good
 CRT: <3 sec
 Anterior fontanel: open, not bulged
 Skin survey: Normal

11. General Examination (Contd.)
 Umbilicus: Healthy (2 arteries, 1 vein)
 Genitalia: female pattern
 Anus: Patent
 CBG: 5.6 mmol/L
Vital signs:
 HR – 138 b/min
 RR – 42 br/min
 Temp - 98˚F

12. General Examination (Contd.)
Second twin:
 Pink in room air
 Icteric up to leg
 Reflexes and activities: good
 CRT: <3 sec
 Anterior fontanel: open, not bulged
 Skin survey: Normal

13. General Examination (Contd.)
 Umbilicus: Healthy (2 arteries, 1 vein)
 Genitalia: female pattern
 Anus: Patent
 CBG: 5.6 mmol/L
Vital signs:
 HR – 142 b/min
 RR – 46 br/min
 Temp - 98˚F

14. General Examination (Contd.)
 Head examination:
Both babies were
attached together over
a part of both parietal
and occipital region of
head.

15. General Examination (Contd.)
Anthropometry:
 Weight – 2780gms (combined)
First Twin:
 Length – 47 cm (50th - 75th centile)
 OFC – 31 cm (25th centile)
Second Twin:
 Length – 47 cm (50th - 75th centile)
 OFC – 30 cm (10th centile)

16. Resp. System Examination
First Twin:
 RR – 42 br/min
 Chest in-drawing: absent
 No grunting
 Bilateral good air entry in both lungs with
no added sound

17. Resp. System Examination
(Contd.)
Second Twin:
 RR – 46 br/min
 Chest in-drawing: absent
 No grunting
 Bilateral good air entry in both lungs with
no added sound

18. CVS Examination
Both twins
 Apex beat: left 4th intercostal space on the
mid-clavicular line.
 Heart Sound: first and second heart
sounds are audible in all four areas. No
murmur was present.

19. GIT Examination
Both twins
 Abdomen: soft, not distended
 No organomegaly
 Bowel sound present

20. Urinary System Examination
Both twins
 Kidney: not ballotable
 Urinary bladder: not palpable

21. Other systemic examination reveals no
abnormal findings.

22. Salient Features
 D/O Taslima, outborn, 2nd issue of non-
consanguineous parents, hailing from Pabna
was admitted on their 4th post-natal age due to
prematurity and fused head with each other
from birth. Mother Taslima, 32 years old, Para
2+1 (abortion), having blood group O+ve was
on regular antenatal checkup and was
immunized against tetanus. She has no h/o
PIH, GDM, hypothyroidism, PROM or any
other chronic illness. No h/o taking ovulation
inducing agents.

23. Salient Features (Contd.)
 At 28 weeks of gestation antenatal USG
revealed a single viable pregnancy with mild
hydrocephalus. At 35 weeks of gestation, due
to risk of poor outcome of baby, elective LUCS
was done in a local clinic and a twin female
babies were born who were fused together at
head. They cried immediately after birth,
APGAR score was 6/10 & 7/10 at 1st & 5th min
respectively of both twin, birth weight was not
documented. They passed urine and
meconium within first 12 hours of life. At day 4
of post natal age babies were referred to
BSMMU for further evaluation & management.

24. Salient Features (Contd.)
 On examination, babies were pink in air, icteric
up to leg, reflex activities were good,
normothermic, well perfused, euglycemic,
vitals within normal range, both head were
fused with each other over part of both parietal
and part of occipital region, anthropometry of
each baby were in centile chart, combined
weight was 2780 gm, systemic examinations
revealed nothing abnormality.

25. Provisional Diagnosis
?
Preterm (35wks), 2780gm, Conjoint twin
(craniopagus), Neonatal Jaundice

26. Treatment on admission
 Thermal care
 Cup feeding with EBM
 Inf. 10% dextrose in 0.225% NaCl

27. Investigations after
admission(21.7.16)
Investigatio
ns
Findings
Twin 1 Twin 2
CBC
Hb
WBC-TC
DC
Platelet
19.4 gm/dl
12x109/L
N 53%, L 40%,
M 05%, E 02%
350x109/L
18.8 gm/dl
12x109/L
N 50%, L 44%,
M 05%, E 02%
350x109/L
PBF Non-specific morphology Non-specific morphology
S. Total Bilirubin 19.9 mg/dl
[Phototherapy level
17mg/dl,
Exchange level 22 mg/dl]
20.5 mg/dl
[Phototherapy level
17mg/dl,
Exchange level 22 mg/dl]

28. Investigations after
admission(Contd.)
Investigation
s
Findings
Twin 1 Twin 2
S. Electrolytes
Sodium
Potassium
Chloride
T-CO2
134 mmol/L
6.3 mmol/L
103 mmol/L
15.5 mmol/L
142 mmol/L
5.0 mmol/L
110 mmol/L
17.1 mmol/L
S. Calcium 1.7 mmol/L 2.2 mmol/L
S. Creatinine 0.2 mg/dl 0.2 mg/dl
PT 32.0 sec 32.0 sec
APTT 12.0 sec 12.0 sec

29. Investigations after
admission(Contd.)
 X-ray skull

30. Investigations after
admission(Contd.)
 X-ray chest A/P view

31. Consultation: Paediatric
Surgery
Advice:
 Thermal care
 Nutritional support
 Proper & careful nursing
 Only baseline investigations including x-ray
skull
 Plan for OT after neonatal period
 Keep the patient in cabin

32. Follow up on 5th PNA (22.7.16)
Subjective Objective Assessment/Pla
n
Intervention
 Low
urine
output
Good reflex activity
HR: 138 b/min
RR: 42 br/min
CRT <3 sec
AF: at level
Dehydration: absent
Edema: absent
CBG: 4.2 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended, no
organomegaly
U. Bladder: not palpable
Input IV+BF 60+30 ml/day
Urine output 0.7 ml/kg/hr
(25 ml/day)
Stool passed 1 time
Wt: 2610 gm(6.1% wt loss)
Oliguria  Full IVF started
 Single surface
phototherapy

33. Follow up on 5th PNA (22.7.16)
Subjective Objective Assessment/Pla
n
Intervention
No new
events
Good reflex activity
HR: 134 b/min
RR: 38 br/min
CRT <3 sec
AF: at level
Dehydration: absent
Edema: absent
CBG: 3.6 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended, no
organomegaly
Input IV + BF 203 ml/day
Urine output 3.8 ml/kg/hr
(150 ml/day)
Stool passed 2 time
Static Continue previous
treatment

34. Bilirubin Trend
Twin 1
17 17 17 17 17
22 22 22 22 22
19.9
18.5
16.4
14.2
15.7
DAY 4 DAY 4 (6HRS LATER) DAY 5 DAY6 DAY 7
Photolevel exchange TSB

35. Bilirubin Trend
Twin 2
17 17 17 17 17
22 22 22 22 22
20.5
18.7
15.8
13.2
14.9
DAY 4 DAY 4 (6HRS LATER) DAY 5 DAY6 DAY 7
Photolevel exchange TSB

36. Follow up on 13th PNA (30.7.16)
Subjective Objective Assessment/P
lan
Intervention
 Low
urine
output
Reflex activity: reduced than
previous day
HR: 136 b/min
RR: 52 br/min
CRT <3 sec
AF: at level
Dehydration: absent
Edema: absent
CBG: 3.2 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended, no
organomegaly
U. Bladder: not palpable
Input Demand BF
Urine output 0.3 ml/kg/hr +
1 time (10 ml + 1 time)
Stool passed 3 times
Oliguria  Correction of
electrolyte
imbalance
S. Electrolytes
Na+ 123 mmol/L
K+ 6.3 mmol/L
Cl- 92 mmol/L
TCO2 17.8
mmol/L
S. Creatinine
0.99 mg/dl

37. Follow up on 13th PNA (30.7.16)
Subjective Objective Assessment/Pla
n
Intervention
No new
events
Good reflex activity
HR: 140 b/min
RR: 32 br/min
CRT <3 sec
AF: at level
Dehydration: absent
Edema: absent
CBG: 3.8 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended, no
organomegaly
Input Demand BF
Urine output 4.2 ml/kg/hr
+ 5 times (150ml + 5
times)
Static Continue previous
treatment
S. Electrolytes
Na+ 132 mmol/L
K+ 6.1 mmol/L
Cl- 92 mmol/L
TCO2 17 mmol/L
S. Creatinine
0.53 mg/dl

38. Follow up on 14th PNA (31.7.16)
Subjectiv
e
Objective Assessment/Pl
an
Intervention
 Low
urine
output
Good reflex activity
HR: 136 b/min
RR: 30 br/min
CRT <3 sec
AF: at level
Dehydration: absent
Edema: absent
CBG: 3.2 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended, no
organomegaly
U. Bladder: not palpable
Input 360 ml/day
Urine output 0.8 ml/kg/hr + 1
time (30 gm + 1 time)
Stool passed 1 time
Wt: 2980 gm(1.01% wt gain)
Persistent
oliguria
 Correction of
electrolyte
imbalance
 Ca++ gluconate
added
 Nephrology
consultation
Treatment:
 NaHCO3
 Inj. Furosemide
 Nebulization by
salbutamol
 20% curtail IVF
S. Electrolytes
Na+ 124 mmol/L
K+ 7.4 mmol/L
Cl- 93 mmol/L
TCO2 12.2
mmol/L
S. Creatinine
0.78 mg/dl

39. Follow up on 14th PNA (31.7.16)
Subjective Objective Assessment/Pla
n
Intervention
No new
complaints
Good reflex activity
HR: 140 b/min
RR: 40 br/min
CRT <3 sec
AF: at level
Dehydration: absent
Edema: absent
CBG: 3.8 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended, no
organomegaly
Input 360 ml/day
Urine output 8 times
Stool passed 2 times
Static  Correction of
electrolyte (Na+)
imbalance
 Continue
previous
treatment
S. Electrolytes
Na+ 129 mmol/L
K+ 6.2 mmol/L
Cl- 95 mmol/L
TCO2 14.9 mmol/L
S. Creatinine
0.65 mg/dl

40. Consultation: Paediatric
Nephrology (01.08.16)
Investigations to evaluate:
 Urine pH, urinary Na+
 Urine R/M/E
 S. Creatinine
 S. Electrolytes
 RBS
 USG of the whole abdomen with special
attention to the adrenal glands

41. Follow up on 16th PNA
(02.08.16)
Subjective Objective Assessment/Pla
n
Intervention
 No urine
output in
last 10
hrs
Good reflex activity
HR: 142 b/min
RR: 38 br/min
CRT <3 sec
Pulse volume: good
AF: at level
Dehydration: absent
Edema: absent
CBG: 3.4 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended
U. bladder: not palpable
Weight: 3080gm (static)
Input IV+BF 161+144
ml/day
Urine output 0.2 ml/kg/hr
(20 ml/day)
Persistent oliguria N/S bolus 10 ml/kg
Inj. Lasix 1 mg/kg
N/S bolus repeat
20% fluid curtail
S. Electrolytes
Na+ 130 mmol/L
K+ 5.8 mmol/L
Cl- 99 mmol/L
TCO2 17.8 mmol/L
S. Creatinine
0.54 mg/dl

42. Follow up on 16th PNA
(02.08.16)
Subjective Objective Assessment/Pla
n
Intervention
No new
complaints
Good reflex activity
HR: 152 b/min
RR: 36 br/min
CRT <3 sec
AF: at level
Dehydration: absent
Edema: absent
CBG: 4.2 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended, no
organomegaly
Input IV+BF 221+172
ml/day
Urine output 3.8 ml/kg/hr
(210 ml/day)
Stool passed 3 times
Static Continue previous
treatment

43. Follow up on 17th PNA
(03.08.16)
Subjective Objective Assessment/Pla
n
Intervention
 No urine
output in
last 24
hrs
Good reflex activity
HR: 136 b/min
RR: 42 br/min
CRT <3 sec
Pulse volume: good
AF: at level
Dehydration: absent
Edema: absent
CBG: 3.2 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended
U. bladder: not palpable
Weight: static
Input IV+BF 135+101
ml/day
Urine output nil
Stool passed 1 time
Anuria  N/S bolus 10
ml/kg
Inj. Lasix 1 mg/kg
 Nephrology
consultation
Advice:
 Observe the
twins
 No more Lasix if
anuria
S. Electrolytes
Na+ 131 mmol/L
K+ 4.7 mmol/L
Cl- 98 mmol/L
TCO2 20.9 mmol/L
S. Creatinine
0.44 mg/dl

44. Follow up on 17th PNA
(03.08.16)
Subjective Objective Assessment/Pla
n
Intervention
No new
complaints
Good reflex activity
HR: 152 b/min
RR: 36 br/min
CRT <3 sec
AF: at level
Dehydration: absent
Edema: absent
CBG: 4.2 mmol/L
Lungs: B/L good air entry
CVS: S1+S2+M0
Abd: soft not distended, no
organomegaly
Input IV+BF 132+156
ml/day
Urine output 0.6 ml/kg/hr
+ 7 times (20 gm + 7
times)
Static Continue previous
treatment

45. Investigation
Investigation
s
Findings
(04.08.16)
Twin 1 Twin 2
S. Electrolytes
Sodium
Potassium
Chloride
T-CO2
133 mmol/L
6.4 mmol/L
97 mmol/L
20 mmol/L
137 mmol/L
5.2 mmol/L
98 mmol/L
23 mmol/L
S. Creatinine 0.53 mg/dl 0.63 mg/dl

46. Investigation (Contd.)
 USG Brain:
Both Twins
i. Single 3rd ventricle.
ii. Single set lateral ventricle.
iii. 4th ventricle could not visualized.
iv. Brain parenchyma echotexture
normal.
v. No evidence of hemorrhage.

47. Investigation (Contd.)
 USG of whole abdomen:
Twin 1 Twin 2
Urinary bladder not
visualized
Left sided mild
hydronephrosis

48. On 19th PNA the babies were discharged on
request due to financial constrain and advised to
follow up after 15 days.

49. Final Diagnosis
Preterm (35wks), 2780gm, Conjoint Twin
(craniopagus) with Neonatal Jaundice
(resolved), Electrolyte imbalance (hyponatremia,
hyperkalemia -corrected)