Conjoined Twin

CLINICAL MEETING

PRESENTED BYDR. MAIMUNA SAYEED

Particulars of the PatientsName: D/O TaslimaAge: Day 4OutbornAddress: PabnaDate of admission: 21.07.16Date of examination: 21.07.16

Presenting Complaints Born before date Twin attached at head since birth

History of Present Illness Mother Taslima, 32 years old, Para 2+1

(abortion), having blood group O+ve and the father’s blood group is O+ve. She received 5 regular antenatal checkup and got 2 doses of tetanus toxoid. She has no h/o PIH, GDM, hypothyroidism, PROM or any other chronic illness. She had no h/o taking ovulation inducing drug and no family h/o twin. At 28 weeks of gestation USG revealed single viable pregnancy with mild hydrocephalus and BPD is 9cm which corresponds to 36 weeks.

History of Present Illness (Contd.)So mother was advised to take neurology consultation about the outcome of baby. After consultation from neurologist, as she heard about the poor outcome of the baby, she planned for elective LUCS. At 35 weeks of gestation, elective LUCS was done in a local clinic and a twin female babies were born with their head attached together. Both babies cried immediately after birth, APGAR score was 6/10 & 7/10 at 1st & 5th min respectively but birth weight was not documented.

History of Present Illness (Contd.) Then the babies were kept with mother

and was on EBF. Both of them passed urine and meconium within first 12 hours of life. Later the babies were referred to BSMMU for further evaluation & management. At day 4 of post-natal age, the babies were transferred to BSMMU by an ambulance in mother’s lap with proper wrapping and transportation time was about 7 hours without any difficulties.

Birth History Antenatal: Mother received 5 ANC and the

period was uneventful.

Natal: Conjoint twins were delivered by LUCS at 35 weeks of gestation.

Postnatal: Both of the babies cried immediately after birth, APGAR score was 6/10 & 7/10 at 1st & 5th min respectively, and both of them passed urine and meconium within first 12 fours of life.

Family History They are the 2nd issue of non-

consanguineous parents. Other sib is 5-year-old and healthy.

There is no family h/o twins.

Socioeconomic History Parents are from middle socio-

economic background. Both parents are private school

teacher.

General ExaminationFirst twin: Pink in room air Icteric up to leg Reflexes and activities: good CRT: <3 sec Anterior fontanel: open, not bulged Skin survey: Normal

General Examination (Contd.) Umbilicus: Healthy (2 arteries, 1 vein) Genitalia: female pattern Anus: Patent CBG: 5.6 mmol/L

Vital signs: HR – 138 b/min RR – 42 br/min Temp - 98˚F

General Examination (Contd.)Second twin: Pink in room air Icteric up to leg Reflexes and activities: good CRT: <3 sec Anterior fontanel: open, not bulged Skin survey: Normal

General Examination (Contd.) Umbilicus: Healthy (2 arteries, 1 vein) Genitalia: female pattern Anus: Patent CBG: 5.6 mmol/L

Vital signs: HR – 142 b/min RR – 46 br/min Temp - 98˚F

General Examination (Contd.) Head

examination:Both babies were attached together over a part of both parietal and occipital region of head.

General Examination (Contd.)Anthropometry: Weight – 2780gms (combined)First Twin: Length – 47 cm (50th - 75th centile) OFC – 31 cm (25th centile)Second Twin: Length – 47 cm (50th - 75th centile) OFC – 30 cm (10th centile)

Resp. System ExaminationFirst Twin: RR – 42 br/min Chest in-drawing: absent No grunting Bilateral good air entry in both lungs

with no added sound

Resp. System Examination (Contd.)Second Twin: RR – 46 br/min Chest in-drawing: absent No grunting Bilateral good air entry in both lungs

with no added sound

CVS ExaminationBoth twins Apex beat: left 4th intercostal space

on the mid-clavicular line. Heart Sound: first and second heart

sounds are audible in all four areas. No murmur was present.

GIT ExaminationBoth twins Abdomen: soft, not distended No organomegaly Bowel sound present

Urinary System ExaminationBoth twins Kidney: not ballotable Urinary bladder: not palpable

Other systemic examination reveals no abnormal findings.

Salient Features D/O Taslima, outborn, 2nd issue of non-

consanguineous parents, hailing from Pabna was admitted on their 4th post-natal age due to prematurity and fused head with each other from birth. Mother Taslima, 32 years old, Para 2+1 (abortion), having blood group O+ve was on regular antenatal checkup and was immunized against tetanus. She has no h/o PIH, GDM, hypothyroidism, PROM or any other chronic illness. No h/o taking ovulation inducing agents.

Salient Features (Contd.) At 28 weeks of gestation antenatal USG revealed

a single viable pregnancy with mild hydrocephalus. At 35 weeks of gestation, due to risk of poor outcome of baby, elective LUCS was done in a local clinic and a twin female babies were born who were fused together at head. They cried immediately after birth, APGAR score was 6/10 & 7/10 at 1st & 5th min respectively of both twin, birth weight was not documented. They passed urine and meconium within first 12 hours of life. At day 4 of post natal age babies were referred to BSMMU for further evaluation & management.

Salient Features (Contd.) On examination, babies were pink in air,

icteric up to leg, reflex activities were good, normothermic, well perfused, euglycemic, vitals within normal range, both head were fused with each other over part of both parietal and part of occipital region, anthropometry of each baby were in centile chart, combined weight was 2780 gm, systemic examinations revealed nothing abnormality.

Provisional Diagnosis

?Preterm (35wks), 2780gm, Conjoint twin

(craniopagus), Neonatal Jaundice

Treatment on admission Thermal care Cup feeding with EBM Inf. 10% dextrose in 0.225% NaCl

Investigations after admission(21.7.16)

Investigations

Findings

Twin 1 Twin 2

CBC HbWBC-TCDC

Platelet

19.4 gm/dl12x109/LN 53%, L 40%,M 05%, E 02%350x109/L

18.8 gm/dl12x109/LN 50%, L 44%, M 05%, E 02%350x109/L

PBF Non-specific morphology

Non-specific morphology

S. Total Bilirubin

19.9 mg/dl[Phototherapy level 17mg/dl, Exchange level 22 mg/dl]

20.5 mg/dl[Phototherapy level 17mg/dl, Exchange level 22 mg/dl]

Investigations after admission(Contd.)

Investigations

Findings

Twin 1 Twin 2

S. ElectrolytesSodiumPotassiumChlorideT-CO2

134 mmol/L6.3 mmol/L103 mmol/L15.5 mmol/L

142 mmol/L5.0 mmol/L110 mmol/L17.1 mmol/L

S. Calcium 1.7 mmol/L 2.2 mmol/L

S. Creatinine 0.2 mg/dl 0.2 mg/dl

PT 32.0 sec 32.0 sec

APTT 12.0 sec 12.0 sec


X-ray skull


X-ray chest A/P view

Consultation: Paediatric Surgery

Advice: Thermal care Nutritional support Proper & careful nursing Only baseline investigations including x-

ray skull Plan for OT after neonatal period Keep the patient in cabin

Follow up on 5th PNA (22.7.16)

Twin 1Subjective

Objective Assessment/Plan

Intervention

Low urine output

Good reflex activity HR: 138 b/minRR: 42 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 4.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyU. Bladder: not palpableInput IV+BF 60+30 ml/dayUrine output 0.7 ml/kg/hr (25 ml/day)Stool passed 1 timeWt: 2610 gm(6.1% wt loss)

Oliguria Full IVF started Single surface

phototherapy


Twin 2Subjective


Intervention

No new events

Good reflex activity HR: 134 b/minRR: 38 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.6 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput IV + BF 203 ml/dayUrine output 3.8 ml/kg/hr (150 ml/day)Stool passed 2 time

Static Continue previous treatment

Bilirubin Trend Twin 1

day 4 day 4 (6hrs later)

day 5 day6 day 7

17 17 17 17 17

22 22 22 22 2219.9

18.516.4

14.215.7

Photolevel exchange TSB

Bilirubin Trend Twin 2

day 4 day 4 (6hrs later)

day 5 day6 day 7

17 17 17 17 17

22 22 22 22 2220.5

18.7

15.8

13.214.9

Photolevel exchange TSB


Twin 1Subjective


Intervention

Low urine output

Reflex activity: reduced than previous day HR: 136 b/minRR: 52 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyU. Bladder: not palpableInput Demand BFUrine output 0.3 ml/kg/hr + 1 time (10 ml + 1 time)Stool passed 3 timesWt: 2950 gm (2.4% wt gain)

Oliguria Correction of electrolyte imbalance

S. ElectrolytesNa+ 123 mmol/LK+ 6.3 mmol/LCl- 92 mmol/LTCO2 17.8 mmol/LS. Creatinine0.99 mg/dl


Twin 2Subjective


Intervention

No new events

Good reflex activity HR: 140 b/minRR: 32 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.8 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput Demand BFUrine output 4.2 ml/kg/hr + 5 times (150ml + 5 times)Stool passed 2 time


S. ElectrolytesNa+ 132 mmol/LK+ 6.1 mmol/LCl- 92 mmol/LTCO2 17 mmol/LS. Creatinine0.53 mg/dl


Twin 1Subjective


Intervention

Low urine output

Good reflex activity HR: 136 b/minRR: 30 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyU. Bladder: not palpableInput 360 ml/dayUrine output 0.8 ml/kg/hr + 1 time (30 gm + 1 time)Stool passed 1 timeWt: 2980 gm(1.01% wt gain)

Persistent oliguria

Correction of electrolyte imbalance

Ca++ gluconate added

Nephrology consultation

Treatment: NaHCO3 Inj. Furosemide Nebulization

by salbutamol 20% curtail IVF



Twin 2Subjective


Intervention

No new complaints

Good reflex activity HR: 140 b/minRR: 40 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 3.8 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput 360 ml/dayUrine output 8 timesStool passed 2 times

Static Correction of electrolyte (Na+) imbalance

Continue previous treatment


Consultation: Paediatric Nephrology (01.08.16)

Investigations to evaluate: Urine pH, urinary Na+

Urine R/M/E S. Creatinine S. Electrolytes RBS USG of the whole abdomen with special

attention to the adrenal glands


Twin 1Subjective


Intervention

No urine output in last 10 hrs

Good reflex activity HR: 142 b/minRR: 38 br/minCRT <3 secPulse volume: goodAF: at levelDehydration: absentEdema: absentCBG: 3.4 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distendedU. bladder: not palpableWeight: 3080gm (static)Input IV+BF 161+144 ml/dayUrine output 0.2 ml/kg/hr (20 ml/day)Stool passed nil

Persistent oliguria

N/S bolus 10 ml/kg

Inj. Lasix 1 mg/kg

N/S bolus repeat

20% fluid curtailS. ElectrolytesNa+ 130 mmol/LK+ 5.8 mmol/LCl- 99 mmol/LTCO2 17.8 mmol/LS. Creatinine0.54 mg/dl


Twin 2Subjective


Intervention

No new complaints

Good reflex activity HR: 152 b/minRR: 36 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 4.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput IV+BF 221+172 ml/dayUrine output 3.8 ml/kg/hr (210 ml/day)Stool passed 3 times



Twin 1Subjective


Intervention

No urine output in last 24 hrs

Good reflex activity HR: 136 b/minRR: 42 br/minCRT <3 secPulse volume: goodAF: at levelDehydration: absentEdema: absentCBG: 3.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distendedU. bladder: not palpableWeight: staticInput IV+BF 135+101 ml/dayUrine output nilStool passed 1 time

Anuria N/S bolus 10 ml/kg

Inj. Lasix 1 mg/kg

Nephrology consultation

Advice: Observe the

twins No more Lasix

if anuria



Twin 2Subjective


Intervention

No new complaints

Good reflex activity HR: 152 b/minRR: 36 br/minCRT <3 secAF: at levelDehydration: absentEdema: absentCBG: 4.2 mmol/LLungs: B/L good air entryCVS: S1+S2+M0Abd: soft not distended, no organomegalyInput IV+BF 132+156 ml/dayUrine output 0.6 ml/kg/hr + 7 times (20 gm + 7 times)Stool passed 3 times


InvestigationInvestigations

Findings(04.08.16)

Twin 1 Twin 2

S. ElectrolytesSodiumPotassiumChlorideT-CO2

133 mmol/L6.4 mmol/L97 mmol/L20 mmol/L

137 mmol/L5.2 mmol/L98 mmol/L23 mmol/L

S. Creatinine 0.53 mg/dl 0.63 mg/dl

Investigation (Contd.) USG Brain:

Both Twinsi. Single 3rd ventricle.ii. Single set lateral ventricle.iii. 4th ventricle could not visualized.iv. Brain parenchyma echotexture

normal.v. No evidence of hemorrhage.

Investigation (Contd.) USG of whole abdomen:

Twin 1 Twin 2

Urinary bladder not visualized

Left sided mild hydronephrosis

On 19th PNA the babies were discharged on request due to financial constrain and advised to follow up after 15 days.

Final DiagnosisPreterm (35wks), 2780gm, Conjoint Twin

(craniopagus) with Neonatal Jaundice (resolved), Electrolyte imbalance

(hyponatremia, hyperkalemia -corrected)

Conjoined Twin

Health & Medicine