Unexpected clinical diagnosis of thoracopagus-type conjoined twins during labor associated with eclampsia: A case report from Sub-Saharan Africa

Background:

Conjoined twins represent one of the rarest forms of twin gestation with incidences from 1/50 000 to 1/250 000. Even in high-resource settings, conjoined conditions present an enormous challenge of a catastrophic obstetric event.

Severe preeclampsia and eclampsia constitute a significant public health threat in both developed and developing countries, accountable for 12% of all maternal deaths and for considerable adverse impacts on maternal and fetal health.

Here, we describe a patient in whom these two pathologies arose concomitantly and assess the impact of the conditions in a low-resource setting.

Methods:

The patient, 27 years, G3P2, at term was referred on full cervical dilatation for prolonged labor to the maternity emergency unit of Princess Christian Maternity Hospital in Freetown, Sierra Leone. She presented more over with severe preeclampsia and IUFD due to late referral. After application of Hydralazine iv and under spontaneous progression of labor one of the babies heads was born. The patient then developed eclamptic fits. Ceasing of seizures was achieved after implementing the loading dose of the MgSO4-protocol. In the absence of an early as well as intrapartum ultrasound, the diagnosis of conjoined twins was unknown. Because of the arrested descent of the shoulders and the stuck fetal head only now the surprising and unexpected diagnosis of conjoined twins could be made clinically by deep vaginal examination. The emergency cesarean section was performed immediately. External Inspection of the conjoined twins after surgery revealed a female thoracopagus-type. In the absence of proper laboratory facilities, no parameters concerning the hepatic or renal status could be done. Though, during the postpartum period the patient clinically fully recovered.

Findings:

The role of early diagnosis and management of pregnancy-associated conditions with emphasis on first trimester screening and ultrasound has been numerously published.

In developing countries medical conditions during pregnancy commonly advance to more complicated stages of disease due to non-attendance of antenatal care, late presentation, lack of equipment such as laboratory facilities and ultrasound or lack of trained medical personnel. The impact can clearly be seen in our presented case: non-attendance to antenatal clinic, delay in the referral leading to an undetected preeclampsia and unknown conjoined twins. As a consequence the patient developed avoidable and life-threatening complications.

Interpretation:

The impact of early diagnosis and management for conjoined twins and preeclampsia respectively is crucial. The occurrence of both conditions in a low-resource setting is demonstrated here to be the main complicating factor for the fetal and maternal outcomes.

Inaccessibility to quality healthcare is a major barrier resulting in morbidity and mortality.

To improve maternal and child health worldwide, barriers that limit access must be addressed at all levels.