Full term conjoined twins, weighing 4000 grams, were brought to our hospital at 3rd hour of life. They were delivered by emergency cesarean section, to a 32 years old lady, already having 8 children. There was no family history of twinning. Ante-natal ultrasound was done only once 4 days prior to delivery. It showed twin alive pregnancy of 38 weeks ± 01 week with cephalic presentation and adequate liquor with no comments on conjoining.
The twins were fused at the lower halves of their bodies with a single umbilicus at the mid. There was a horizontal scar of about 3 ½ cm extending to the right of umbilicus. The healthier looking active pink neonate, termed Twin A, had normal head, neck and upper limbs. There was gradual broadening of the torso above umbilicus. The smaller neonate, termed Twin B, was a thin, emaciated, cyanosed, microcephalic neonate, with small torso and feeble reflexes. There were two separate lower limbs at the left side of Twin A and a fused lower limb at the right side. The anal orifice was absent and two orifices were found in perineum draining urine. Umbilicus had a single set of umbilical vessels. External genitalia were incompletely developed to assign gender to either neonate. Cardiac murmur was audible on auscultation in both the twins (Fig. , ).
Figure 1: Ischiopagus tripus conjoined twins
X-ray babygram revealed fusion at the lower abdomino-pelvic region. Scoliosis of dorsolumbar spine noted in both neonates, which was more marked in the Twin B. Pubic symphyses were widely separated and ischio-pubic bones were deformed on the right side with sacral dysgenesis of Twin B. The hip joints were abnormally oriented and horizontally oriented femora were attached to a large pelvic ring bilaterally. On one side, there was synostosis of femora. Calvarial defect with torticollis was present in Twin B (Fig. ).
Figure 3: X-ray babygram of the conjoined twins
Ultrasound abdomen examination of Twin A showed hydronephrosis and hydroureter on both the sides while rest of the viscera were normal. In the Twin B, spleen and the left kidney were well formed but other viscera could not be clearly visualized. There was a large anechoic cystic structure in the pelvis representing bladder. Cystogram performed via the two small orifices in the perineum revealed non-visualization of urethra with pooling of contrast in the single reservoir representing shared urinary bladder. (Fig. )
Figure 4: Cystogram - showing pooling of contrast in a single reservoir (common urinary bladder)
MRI revealed moderate hydronephrosis bilaterally in both babies. In Twin B there was lack of visualization of other viscera. Normal lung and mediastinum were also not seen in Twin B who also had small skull, deformed and devoid of normal brain tissue, replaced by a cystic space. The Twin A showed normal thoraco-abdominal viscera bilaterally. Multiple prominent cystic areas were noted in the centre likely representing bowel loops. There was failure to identify separate urinary bladders. Because of the limited multi-dimensional views of MRI, internal genitalia were not appreciable. (Fig. )
Figure 5: MRI of conjoined twins
On the second day of life, sigmoid loop colostomy was made under local anesthesia through the already present scar on the abdomen. The peritoneal cavity was not explored. The stoma started functioning following day and the Twin A was allowed top feed via nasogastric tube that was tolerated. The clinical condition of the Twin B remained critical throughout with feeble reflexes, abnormal breathing patterns and oxygen desaturation most of the times. Twin B who later died following which Twin A’s condition also deteriorated but he also passed away within few hours on the 6th post-operative day.