1. conjoined twins Presented by Dr. Qurrat ul Ain Post graduate trainee Gynae unit II Senior Registrar Dr. Nazia Ayub (FCPS) Associate Professor Dr .Naela Tarique (FRCOG)

2. Patient’s Profile Name Seema W/O Shahid Age 25 years Married for 05 years Parity G3P2 Last Born 02 years Unbooked

3. 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…

4. Twin Pregnancy Labour Pains 05 hr Vaginal leaking / bleeding Nil Fetal movements Normal Presenting Complaints

5. 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

6. 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…

7. EXAMINATION 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

8. ABDOMENAL 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

9. Vulva & vagina healthy Cervical Os 7-8cm Cervix effaced Vx -3 , push able Presenting part poorly applied to cervix Membrane bulging VAGINAL EXAMINATION

10. 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

11. PROGRESS & EVENTS 12: 25pm Spontaneous rupture of membrane Patient drained clear liquor of normal amount Pelvic Examination Cervical Dilatation 8cm Cervix Effaced Vx -3 , well applied Moderate 2/10 uterine contractions of 35 sec

12. 02: 45pm Cervix was fully dilated Patient shifted to labour room stage II 03 : 45 pm Patient remained fully dilated for 1 hour Presenting part at +1 station PROGRESS & EVENTS

13. 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

14. 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

15. 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

16. 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

19. Post operative period was un eventful Post op Hb% was 5 gm/dl 3units of blood transfused Injectible iron given Antibiotic cover given Patient discharge on 4th post op day in good health Post op management

20. Conjoined twins 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

21. 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….

22. GENETICS OF CONJOINed TWINS 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

23. Embryology 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%.

24. 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

25. Diagonosis critaria 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

26. 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

27. 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

28. Constitute about 35 % of conjoined twins Anterior union of the upper half of the trunk Joined at the chest THORACOPAGUS

32. Usually, only the liver is involved.

34. Usually, only the liver is involved.

36. 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

37. 06% of the conjoined twins Joined at the pelvis. Anterior union of lower half of body Ischopagus

38. Separation is physically possible Excretion and sexual impairment might result. Ischopagus

39. Craniopagus 2% of conjoined twins Joined at the cranium. Separation is possible, depending on how much of the brain is shared.

40. Craniopagus High risk of brain damage

42. Two faces on the opposite side of the head characterize the union.

43. Share a heart well as a brain

46. Very rare incidence

48. When the twins are extensively connected then the duplicated part is named.

50. 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

51. Thank you