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Annals of African Medicine
Annals of African Medicine Society
ISSN: 1596-3519
Vol. 7, Num. 1, 2008, pp. 50-51
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Untitled Document
Annals of African Medicine, Vol. 7, No. 1, 2008, pp. 50-51
Letter to the Editor
Spontaneous Vaginal Delivery of
Undiagnosed Bipagous Conjoint Twins
P. C.Ibekwe1 and C. E. O.Onuoha2
1Department
of Obstetrics and Gynaecology, Ebonyi State University Teaching Hospital, P. M.
B .077, Abakaliki, Ebonyi State, Nigeria
2Department
of Paediatric Surgery, Ebonyi State University Teaching Hospital, P. M. B .077,
Abakaliki, Ebonyi State, Nigeria
Code Number: am08011
Conjoint twins are usually rare events. The incidence in our
environment has not really been documented but there have been previous
reports.1,2 Conjoint twins are classified in different ways. If they are fully formed except for the parts of con-junction, they are called bipagous conjoint twins (or duplicata completa).
Vaginal delivery of conjoint twins was documented in 19503 and 19814 in Western countries. None, to our knowledge, has been reported in Nigeria. We report a case of undiagnosed bipagous conjoint twins that were delivered by Spontaneous vaginal delivery, unassisted and in a primary level health facility.
A 29-year old woman on the 18th of September 2004 with history of delivery of a
set of conjoint twins at a Rural Health Centre.
She was gravida 4 para 3 with 2 living children. Though she registered for
antenatal care in a private hospital, she did not carry out any investigation
including ultrasound or plain x-rays. She had nothing suggestive of “big –for-
date” pregnancy or polyhydramnios during the pregnancy. At about 39weeks, she
went into spontaneous labor and was rushed to the nearest rural health center
where she was assisted by the attendant midwife to have a spontaneous vaginal
delivery of a set of conjoint twins. Both twins cried immediately after birth,
passed meconium from their respective ani and also passed urine normally. They
were promptly referred to our Teaching Hospital.
At presentation the babies were about four hours old, cold to touch and wrapped in
their mother’s delivery cloths. Both were females with a combined weight of 2.7kg.
They were both conscious, satisfactorily active with good intermittent cries.
They were neither pale nor jaundiced. Their skins were joined from the sternum
down to the hypogastrium. Twin 1 looked smaller and dehydrated. There was
cyanosis on the left leg and right foot. There was also edema on the left foot.
Her respiratory rate was 34 cycles per minute, the heart rate was 120bpm, and
the femoral pulse on that left leg was not palpable. First and second heart sounds
were heard; there were no murmurs. The breath sounds were vesicular in both
lungs fields. The Bowel sounds were present and normal. A rectal examination
confirmed that she had patent anal orifices with good sphincteric tone. All
other systems were grossly normal. Twin 2 was bigger and looked generally
healthier than twin 1. All her vital signs and clinical findings were
essentially normal. The diagnosis of Thoraco-omphalopagous conjoint twins was
then made.
Size 6 feeding tube was successfully passed into the stomach of each of the babies and
gastric juices with bile were obtained from each of them. 10% Dextrose in 1/5
normal saline was set up on each of them to run as calculated by their combined
weight. Vitamin K injection was given to each intramuscularly. The babies were
kept warm by wrapping with warm packs and blanket. It was decided to refer them
to center that is conversant with management of conjoint twins. After three
days at the referral hospital, the babies suddenly died one after the other. Aspiration
of feeds was highly suspected, because there were no ante-mortem signs of
distress.
Postmortem examination revealed that all the joining from the sternum to the hypogastrium
was predominantly at the skin level. No organs were shared. The sternae, the
ribs, the thoracic cavities and viscera were all separate. However, the heart
of twin 1 had a single chamber from which emanated the aorta. The heart of twin
2 had the usual 4 chambers but they were enlarged. Other systems were
essentially normal. Cause of death was then ascribed to Heart failure.
The exact incidence of conjoint twinning is unknown and figures are unreliable
because not all cases reach the hospital; some are aborted while some are
thrown away as monsters. The figure however is in the range of 1 in 14 000 births in the non-caucasian.5
Although vaginal delivery for conjoint twins has been reported, 1when
diagnosed in utero, the recommended mode of delivery is cesarean section not
vaginal delivery, because of the attendant risks to both mother and twins.2,4 Undiagnosed conjoint twins may cause dystocia in labor leading to emergency operative delivery thereby endangering the survival of the twins. Surprisingly, there were none of such in this case. When diagnosis is made after birth,
prompt transfer to a more ideal institution is a wise decision, as was done for
these twins.
There is great need to improve the health care delivery system to make it available
and accessible to all our pregnant women. Education of our women on the need
for antenatal registration, regular antenatal clinic attendance and hospital
delivery should be emphasized. This will make for early detection of such
anomalies so that proper arrangement could be made for safe delivery and
management of the conjoint babies.
Reference
- Grower JI, Teste DW, Teich S. Dicephalic dipus
dibrachius an unusual case of conjoint twins. J
Pediatr Surg. 1996;31:1698-1700.
- Owolabi AT, Oseni SBA, Sowande OA, et al.
Dicephalus dibrachius dipus conjoined twin in a
triplet pregnancy. Trop J Obstet Gynaecol.
2005;22:87-889.
- Siegel I. Thoracopagous. Vaginal delivery without
destructive operation. Med J Aust. 1950;97:40.
- Green DJ. Vaginal delivery of conjoint. Med J
Aust. 1981;2:356-360.
- Nelson MM, Bhethay E, Beighton P. Excessive
Siamese twinning. S Afr Med J. 1976;50:697-698.
Copyright 2008 - Annals of African Medicine
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