SASUOG

South African Society for Ultrasound
in Obstetrics and Gynaecology

TEACHINGS / LECTURES / CASES


Conjoined Twins

HOSPITAL: BARAGWANATH FETAL MEDICINE UNIT

On the 24 June 2004, a 32-year-old woman was referred from the Johannesburg Hospital to the Baragwanath Fetal Medicine unit for conjoined twins.
She was P2 G3 and had two previous normal, singleton pregnancies.
On the 24 June 2004, the patient had an ultrasound to assess the two female fetuses, and the severity of the join, the L.M.P. was the10 January 2004, gestational age by ultrasound was 24weeks.

Table 1: showing the severity of the join
Anatomical structures
Structures sharedSeparate structures
INTERNAL ANATOMY
HeartKidneys
LiverBladder
Stomach
Duodenum
 
EXTERNAL ANATOMY
Inferior portion of the faceLower limbs
Anterior chest wallUpper Limbs
Medial portion of the neckSpine
Pelvis


The patient was councilled as to the severity of the condition and the possible complications of the pregnancy and she opted for a fetocide. The fetocide was booked 29 June.

On arrival for the procedure on the 29th the patient was found to be in the early stages of labour, during the procedure the labour progressed and Ipradol was administered intravenously and an Indomethacin suppository was given to tocolyse labour.
Once the mother had been settled the fetocide was completed by injecting 10mls of potassium chloride 15% into the shared heart of the fetuses. Once fetal death had been confirmed she was taken to theatre and a caesarean section was done to remove the fetuses as the severity of the join would have prevented normal vaginal delivery.
The caesarean section was done under general anaesthetic to prevent the mother from being further traumatised.
Once delivered the severity of the join could be assessed more closely.
The mother was given postoperative care and admitted to the ward for further management and observations.

PROGNOSIS If the conjoined twins had not been diagnosed prior to delivery she would have been in labour for a long time and eventually an emergency caesarean section would have been performed.
These babies would have been difficult for the mother to manage and the quality of life for the mother and babies would have been very poor.
The likely hood that the babies would have survived was very poor and if they did their life expectancy would have been a few months at the most. In days gone by the mother would have died in labour and the reasons for this would have gone with her to the grave.





FIG.1 Ultrasound images obtained



FIG.5 Photograph of twins (posterially)



FIG.6 Photograph of twins (Anteriorly)
INCIDENCE OF CONJOINED TWINS
Doctor E. Nicolaou and his team at he Baragwanath Fetal Medicine Unit saved the life of the mother by acting quickly and in the best interests of the mother.
Note for persons performing ultrasound:
Take care when scanning twins; make a careful note that the twins are completely separate if there is no separating membrane and when the twins are lying in the same direction this is a sign to look closely.
The join may not be as severe as this case was the join can be as minimal as the skin of the limbs touching and this could affect the delivery process.
By Nicolette McCabe
Wits Technikon Ultrasound Student