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Successful pregnancy in a separated conjoined twin
Successful pregnancy in a separated conjoined twin Leena P. Shah, MD, and Cynthia Chazotte, MD Bronx, New York A case of successful pregnancy in a separated conjoined twin is described. The patient underwent cesarean delivery because of the reconstructed pelvis and extensive perineal reconstruction, which resulted in dense fibrosis. Surgical records and communication with the patient's pediatric surgeons were helpful in planning for delivery. (AM J OBSTEl GYNECOL 1994;171 :1391-2.)
Key words: Conjoined twins, pregnancy outcome Conjoined twins occur in approximately 1 in 50,000 to 1 in 100,000 births.' Interestingly, 70% of live-born conjoined twins are female. Successful surgical separation is quite unusual and is associated with high operative morbidity and mortality. There is also a high incidence of late deaths in survivors.' We present the first case of pregnancy in a separated cortioined twin. Case report A 20-year-old primigravid woman entered prenatal care at 24 weeks' gestation. Her history was significant for prior surgical separation from her cotwin. Records revealed that the patient and her sister were conjoined twins of the omphalopelvoischiopagus tetrapus type, connected from the liver to the perineum. They shared the lower gastrointestinal tract but had separate urinary systems with bilateral crossed ureters, each with separate uterus didelphys and duplex vagina, a single perineum, and fused pelves. 2 At age 13 months surgical separation left our patient with the original upper gastrointestinal tract, distal one third of the common colon, and original rectum. Transverse ureteroureterostomies were performed for the crossed ureters. To facilitate closure and pelvic stabilization, iliac osteotomies were performed on each twin. The patient's twin sister died at age 3 years after aspiration of a bean. Our patient underwent subsequent orthopedic reconstructive procedures and treatment for recurrent bladder calculi. On physical examination the patient was 61 inches tall, weighed 105 pounds, and had mild lordosis. There was a vertical scar extending from the xiphoid to the perineum, with dense fibrosis in the hypogastric region. The extensively fibrotic perineum had a narrow eccentric introital opening leading to a vaginal pouch with an anterolaterally displaced cervix. No urethral opening could be identified; however, urine exited through the From the Department of Obstetrics and Gynecology, Bronx Muniapal Hospital Center, Albert Einstein College of Medicine. Received for publzcation March 1, 1994; accepted March 31, 1994. Reprint requests: Leena P. Shah, MD, Department of Obstetrzcs and Gynecology, Bronx Muniapal Hospital, Room 709, Pelham Parkway, Bronx, NY 10461. Copyrzght © 1994 by Mosby-Year Book, Inc. 0002-9378/94 $3.00 + 0 6/1/56542
Fig. 1. Abdominal x-ray film near term.
introital opening. The anal opening was immediately below the introital opening. Abdominal x-ray films showed lumbar lordosis, short sacrum, and iliac crests with evidence of old osteotomies but no pubic rami (Fig. 1). Her prenatal course was unremarkable except for one hospitalization for pyelonephritis. At 35 weeks' gestation premature labor with membrane rupture complicated a second episode of pyelonephritis. Cesarean section was performed because of the distorted pelvis and extensive perineal reconstruction with dense fibrosis. With the patient under epidural anesthesia a midline vertical incision was made. The uterus was found to be sharply dextrorotated with the left adnexa coursing over the anterior wall of the uterine fundus and adherent to the right pelvic sidewall. The right adnexa were not identified. A firm 4 X 6 cm mass that 1391
November 1994 Am J Obstet Gynecol
Sanchez-Ramos et al.
likely represented the duplicated uterus described in old records was palpated posterior to the uterus. There were multiple intraabdominal adhesions with peritoneal pseudocyst formation. The sigmoid colon was densely adherent to the left border of the uterus and descended anteriorly to the uterus. Because there was poor access to a very narrow lower uterine segment, a vertical fundal uterine incision was made. Delivery of the fetal head was difficult because it was trapped in a funnel of dense fibrosis that had replaced the pubic bones. The infant weighed 2100 gm and had Apgar scores of 5 and 8 at 1 and 5 minutes, respectively. The postoperative course was complicated by pyelonephritis. Mother and infant were discharged on postoperative day 8.
Comment Conjoined twins is an entity that remains intriguing to physicians and the general public, with separation a challenging problem. It is a true success when these surgically separated twins exhibit long-term survival without major complications and lead functional lives. The patient described here demonstrated this by achieving ultimate reproductive potential, the birth of a normal, healthy child. This case was unique because the
distorted perineal, uterine, and pelvic anatomy complicated our choice of delivery mode. Although cesarean delivery carries risks, especially in a patient with prior surgery, we thought that it was prudent not to disrupt the reconstructed pelvis and extensive perineal reconstruction. In planning for delivery we were fortunate in this case to be able to communicate directly with one of her pediatric surgeons and have her surgical records accessible in spite of the surgery having been performed in another city 18 years before. When pregnancy is undertaken after m~or reconstruction for congenital anomalies involving the abdomen, pelvis, genital tract, or perineum, we recommend careful review of surgical records to detail the reconstructed structures, to best plan for delivery. REFERENCES 1. O'Neill JA, Holcomb GW, Schnaufer L, et al. Surgical experience with thirteen conjoined twins. Ann Surg 1988; 208:299-312. 2. Rosenberg HK, Spackman TJ, Chait A. The Dominican Republic conjoined twins: ischiopagus, tetrapus, omphalopagus. AJR Am J Roentgenol 1978; 130:921-6.
Myocardial infarction during pregnancy: Management with transluminal coronary angioplasty and metallic intracoronary stents Luis Sanchez-Ramos, MD," Youssef G. Chami, MD,b Theodore A. Bass, MD,b Gerardo O. DelValle, MD; and C. David Adair, MD" Jacksonville, Florida A 29-year-old primiparous woman had an inferior myocardial infarction at 26 weeks' gestation. Coronary angiography showed subtotal occlusion of the right coronary artery. Percutaneous transluminal angioplasty and intracoronary urokinase infusion failed to relieve the obstruction. Placement of two Gianturco-Roubin flexible stents created adequate coronary perfusion. (AM J DBsrET GVNECOL ,1994; 171: 1392-3.)
Key words: Myocardial infarction, pregnancy, angioplasty coronary stents We describe a patient who experienced an acute myocardial infarction during pregnancy and underwent
percutaneous transluminal coronary angioplasty and intracoronary stenting.
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, a and the Section of Cardiology, Department of Internal Mediczne, b Unwersity of Florida Health Science Center. Received for publicatwn January 24, 1994; reVised March 21, 1994; accepted April 12, 1994. Reprznt requests: Luzs Sanchez-Ramos, MD, Department Obstetncs and Gynecology, 653-1 W. 8th St., Jacksonville, FL 32209-6561. Copynght © 1994 by Mosby-Year Book, 1nc. 0002-9378194 $3.00 + 0 6/1/56624
Case report A 29-year-old woman, gravida 2, para 1-0-0-1, was transferred to University of Florida Health Science Center in Jacksonville with the diagnosis of inferior myocardial infarction of 6 hours' duration. During the previous week she had complained of epigastric pain that worsened 1 hour before admission. She was at 26 weeks' gestation, on the basis of early ultrasonography.
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Key words: Conjoined twins, pregnancy outcome Conjoined twins occur in approximately 1 in 50,000 to 1 in 100,000 births.' Interestingly, 70% of live-born conjoined twins are female. Successful surgical separation is quite unusual and is associated with high operative morbidity and mortality. There is also a high incidence of late deaths in survivors.' We present the first case of pregnancy in a separated cortioined twin. Case report A 20-year-old primigravid woman entered prenatal care at 24 weeks' gestation. Her history was significant for prior surgical separation from her cotwin. Records revealed that the patient and her sister were conjoined twins of the omphalopelvoischiopagus tetrapus type, connected from the liver to the perineum. They shared the lower gastrointestinal tract but had separate urinary systems with bilateral crossed ureters, each with separate uterus didelphys and duplex vagina, a single perineum, and fused pelves. 2 At age 13 months surgical separation left our patient with the original upper gastrointestinal tract, distal one third of the common colon, and original rectum. Transverse ureteroureterostomies were performed for the crossed ureters. To facilitate closure and pelvic stabilization, iliac osteotomies were performed on each twin. The patient's twin sister died at age 3 years after aspiration of a bean. Our patient underwent subsequent orthopedic reconstructive procedures and treatment for recurrent bladder calculi. On physical examination the patient was 61 inches tall, weighed 105 pounds, and had mild lordosis. There was a vertical scar extending from the xiphoid to the perineum, with dense fibrosis in the hypogastric region. The extensively fibrotic perineum had a narrow eccentric introital opening leading to a vaginal pouch with an anterolaterally displaced cervix. No urethral opening could be identified; however, urine exited through the From the Department of Obstetrics and Gynecology, Bronx Muniapal Hospital Center, Albert Einstein College of Medicine. Received for publzcation March 1, 1994; accepted March 31, 1994. Reprint requests: Leena P. Shah, MD, Department of Obstetrzcs and Gynecology, Bronx Muniapal Hospital, Room 709, Pelham Parkway, Bronx, NY 10461. Copyrzght © 1994 by Mosby-Year Book, Inc. 0002-9378/94 $3.00 + 0 6/1/56542
Fig. 1. Abdominal x-ray film near term.
introital opening. The anal opening was immediately below the introital opening. Abdominal x-ray films showed lumbar lordosis, short sacrum, and iliac crests with evidence of old osteotomies but no pubic rami (Fig. 1). Her prenatal course was unremarkable except for one hospitalization for pyelonephritis. At 35 weeks' gestation premature labor with membrane rupture complicated a second episode of pyelonephritis. Cesarean section was performed because of the distorted pelvis and extensive perineal reconstruction with dense fibrosis. With the patient under epidural anesthesia a midline vertical incision was made. The uterus was found to be sharply dextrorotated with the left adnexa coursing over the anterior wall of the uterine fundus and adherent to the right pelvic sidewall. The right adnexa were not identified. A firm 4 X 6 cm mass that 1391
November 1994 Am J Obstet Gynecol
Sanchez-Ramos et al.
likely represented the duplicated uterus described in old records was palpated posterior to the uterus. There were multiple intraabdominal adhesions with peritoneal pseudocyst formation. The sigmoid colon was densely adherent to the left border of the uterus and descended anteriorly to the uterus. Because there was poor access to a very narrow lower uterine segment, a vertical fundal uterine incision was made. Delivery of the fetal head was difficult because it was trapped in a funnel of dense fibrosis that had replaced the pubic bones. The infant weighed 2100 gm and had Apgar scores of 5 and 8 at 1 and 5 minutes, respectively. The postoperative course was complicated by pyelonephritis. Mother and infant were discharged on postoperative day 8.
Comment Conjoined twins is an entity that remains intriguing to physicians and the general public, with separation a challenging problem. It is a true success when these surgically separated twins exhibit long-term survival without major complications and lead functional lives. The patient described here demonstrated this by achieving ultimate reproductive potential, the birth of a normal, healthy child. This case was unique because the
distorted perineal, uterine, and pelvic anatomy complicated our choice of delivery mode. Although cesarean delivery carries risks, especially in a patient with prior surgery, we thought that it was prudent not to disrupt the reconstructed pelvis and extensive perineal reconstruction. In planning for delivery we were fortunate in this case to be able to communicate directly with one of her pediatric surgeons and have her surgical records accessible in spite of the surgery having been performed in another city 18 years before. When pregnancy is undertaken after m~or reconstruction for congenital anomalies involving the abdomen, pelvis, genital tract, or perineum, we recommend careful review of surgical records to detail the reconstructed structures, to best plan for delivery. REFERENCES 1. O'Neill JA, Holcomb GW, Schnaufer L, et al. Surgical experience with thirteen conjoined twins. Ann Surg 1988; 208:299-312. 2. Rosenberg HK, Spackman TJ, Chait A. The Dominican Republic conjoined twins: ischiopagus, tetrapus, omphalopagus. AJR Am J Roentgenol 1978; 130:921-6.
Myocardial infarction during pregnancy: Management with transluminal coronary angioplasty and metallic intracoronary stents Luis Sanchez-Ramos, MD," Youssef G. Chami, MD,b Theodore A. Bass, MD,b Gerardo O. DelValle, MD; and C. David Adair, MD" Jacksonville, Florida A 29-year-old primiparous woman had an inferior myocardial infarction at 26 weeks' gestation. Coronary angiography showed subtotal occlusion of the right coronary artery. Percutaneous transluminal angioplasty and intracoronary urokinase infusion failed to relieve the obstruction. Placement of two Gianturco-Roubin flexible stents created adequate coronary perfusion. (AM J DBsrET GVNECOL ,1994; 171: 1392-3.)
Key words: Myocardial infarction, pregnancy, angioplasty coronary stents We describe a patient who experienced an acute myocardial infarction during pregnancy and underwent
percutaneous transluminal coronary angioplasty and intracoronary stenting.
From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, a and the Section of Cardiology, Department of Internal Mediczne, b Unwersity of Florida Health Science Center. Received for publicatwn January 24, 1994; reVised March 21, 1994; accepted April 12, 1994. Reprznt requests: Luzs Sanchez-Ramos, MD, Department Obstetncs and Gynecology, 653-1 W. 8th St., Jacksonville, FL 32209-6561. Copynght © 1994 by Mosby-Year Book, 1nc. 0002-9378194 $3.00 + 0 6/1/56624
Case report A 29-year-old woman, gravida 2, para 1-0-0-1, was transferred to University of Florida Health Science Center in Jacksonville with the diagnosis of inferior myocardial infarction of 6 hours' duration. During the previous week she had complained of epigastric pain that worsened 1 hour before admission. She was at 26 weeks' gestation, on the basis of early ultrasonography.
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