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Management of a cesarean delivery of an omphalopagus conjoined twin pregnancy
Abstract Number: F-54
Abstract Type: Case Report/Case Series
The frequency of conjoined twins has been estimated as 1 in every 50,000-100,000 pregnancies. Reports on pregnancy management in cases of conjoined twins are exceptionally rare, as many are terminated, 40 to 60% are stillborn, with an overall survival of 5-25%. Information on anesthetic management for delivery of conjoined twins is limited. We report a successful cesarean delivery of omphalopagus twins under neuraxial anesthesia.
A 23 year-old (G2P1001) diagnosed with a conjoined twin pregnancy at 19+2 weeks gestation by ultrasound with further imaging revealing monochorionic, monoamniotic conjoined twins with a posterior placenta. Two small thoraces were noted each containing a heart, two separate hypoplastic lungs, joined at the upper abdomen and shared the medial portion of the diaphragm. One single large liver and gallbladder was noted, the majority of the liver in twin A. The small bowel and large bowel was shared. Each had two kidneys and shared a single urinary bladder. Each had a separate spine with severe scoliosis and two fully formed upper and lower extremities. An elective cesarean section was planned for 37 weeks however, she presented with preterm premature rupture of membranes (PPROM) at 36+2 weeks, dilated cervix with fetal feet palpated at the cervical os. A cesarean delivery was performed under a combined spinal epidural (CSE) at the L3/4 interspace in the lateral decubitus position with a spinal dose of 12mg of 0.75% bupivacaine, 20 mcg of fentanyl and 200 mcg of DuramorphR. Delivery was via a classical uterine incision. One fetus presented with an omphalocele accidentally ruptured at delivery. Each twin weighed 2300g, APGARs 81 and 85. They did not require intubation, were transferred to the NICU and subsequently to the children’s hospital for further management and eventual surgical correction.
Discussion: Conjoined twins are classified according to the site of fusion. Thoraco-omphalopagus twins are most common and associated with the highest mortality mainly as a consequence of sharing a heart. Omphalopagus twins as in this case share a liver, and portions of bowel. Imaging can diagnose conjoined twin pregnancies early and usually by mid-pregnancy, the extent of conjoined areas can be defined. Few case reports describe the modality of delivery of conjoined twins, mainly by cesarean, however, the anesthetic management is limited. Scant case reports include CSE and general anesthesia for cesarean section. Intraoperative concerns include postpartum hemorrhage from large uterine incisions, uterine atony and the possibility for conversion to general anesthesia. We report a successful delivery of omphalopagus conjoined twins under CSE. A multidisciplinary approach with good communication and antenatal planning is essential for a successful outcome.
References:1.Drake, E. et al. (2008). International Journal of Obstetric Anesthesia. 17:174-176