Transcervical embryoscopic diagnosis of conjoined twins in a ten-week missed abortion

Embryoscopic diagnosis of conjoined twins presenting with a missed abortion has never been reported. The morphological and pathological examinations, and the exact time of death in the conceptus of a missed abortion are seldom clearly delineated. The newly developed field of embryoscopy has created a new frontier in early embryonic/fetal visualization and is able to confirm the sonographic diagnosis. In this report, we used a transcervical endoscope to verify conjoined twins (thoraco-omphalopagus) in a 10-week missed abortion. Based on the size and the external features of the dead embryo, which exhibited developmental arrest at nine weeks and three days of menstrual age, we estimated that the embryo had died four days before examination. The whole procedure proceeded smoothly without any immediate complications.     

Early diagnosis of conjoined twins using two-dimensional color Doppler and three-dimensional ultrasound

Transvaginal three-dimensional (3-D) and color Doppler ultrasound were used to establish a first-trimester definitive diagnosis and classification of thoracoomphalopagus conjoined twins following two-dimensional (2-D) transabdominal and transvaginal scans that indicated twin gestation of uncertain classification. Color Doppler in combination with 3-D ultrasound can be a useful complement to 2-D ultrasound to confirm early diagnosis and determine the extent of organ sharing and definitive classification of conjoined twins.     

Asplenia syndrome in conjoined twins: a case report

Incomplete fission of the primordial cell mass is generally believed to be the cause of conjoined twinning. It may also explain the tendency towards increased symmetry in these twins. We report a case of the rostral duplication type of conjoined twins with an absence of symmetry; one twin had the asplenia syndrome, whereas the other twin was normal. Local environmental factors acting upon the organ anlage may explain the asymmetric development in these conjoined twins.     

Diamniotic placentation associated with omphalopagus conjoined twins: implications for a contemporary model of conjoined twinning

We have studied omphalopagus conjoined twins with a diamniotic monochorionic placenta. Although conjoined twins usually present in a single amniotic sac, one other example of diamniotic placenta has been reported in omphalopagus twins [Weston et al., 1990: Am J Med Genet 37:558-561]. Most theories concerning the pathogenesis of conjoined twinning exclude the possibility of diamniotic placentation. However, Spencer [1992: Teratology 45:591-602] recently elaborated a model for conjoined twinning based on duplication of organizing centers (primitive streaks) during gastrulation. We have considered the fate of embryonic membranes according to this model of omphalopagus twinning and show that diamniotic placentation is a predictable outcome.     

Neuroradiological findings in adult cranially conjoined twins. Case report

Lactomer and the Polyglactin 910 are coated synthetic braided absorbable sutures commonly used for dermal wound closure. Biomechanical performance tests demonstrated superior performance characteristics of the Lactomer sutures. Using narrow diameter sutures, the Lactomer sutures exhibited superior knot holding forces over the Polyglactin 910 sutures. Moreover, knot security could be reliably achieved with asymmetric and symmetric knots using the Lactomer sutures.     

Successful early separation of a premature xipho-omphalopagus conjoined twins: a case report

Premature xipho-omphalopagus conjoined twins were successfully separated at 7 days of age. The total body weight of the twins before separation was 3502 g. One twin had persistent patent ductus arteriosus and signs of cardiac failure at 4 days of age. This was managed with indomethacin. Thirty-six hours later the second twin became anuric, necessitating early emergency separation. The twins were joined from the lower sternum to the infraumbilical area. The liver was fused, but there was no major vascular connection. There were no other major anomalies. The babies stood the procedure well and were healthy at follow-up 8 months after separation.     

Three-dimensional transvaginal sonography of conjoined twins at 10 weeks: a case report

OBJECTIVE: The aim of this study was to examine two components of psychological well-being--life satisfaction and affective well-being--in community-dwelling elderly with (n = 321) and without chronic headache (n = 4955). METHODS: A checklist of chronic medical conditions was used to determine whether respondents were suffering from headache. Cantril's ladder was employed to measure life satisfaction. The subscale, Mental Health, from the MOS SF-20 was used to assess affective well-being. RESULTS: Headache sufferers reported lower life satisfaction as well as lower affective well-being. However, the difference in life satisfaction between the two groups disappeared after controlling for comorbidity. The difference in affective well-being disappeared after controlling for neuroticism. CONCLUSIONS: Lower life satisfaction in patients with chronic headache is caused by more comorbid diseases in the headache group. Lower affective well-being in headache sufferers is due to higher levels of neuroticism in the headache group.     

Utilization of magnetic resonance imaging in autopsy planning with specimen preservation for thoraco-omphalopagus symmetricus conjoined twins

Conjoined twinning is a rare obstetric event that has fascinated physicians and laypersons alike for centuries. When this event occurs, early diagnosis, close prenatal management, and the proper route of delivery will assure the best possible outcome for mother and affected infants. Magnetic resonance imaging (MRI) is used both as an ancillary technique to the sonography for the antepartum diagnosis and in the preoperative planning for the surgical separation of conjoined twins. This report describes the MRI findings in conjoined twins of the thoraco-omphalopagus symmetricus type, a condition incompatible with extrauterine life. The twins were delivered at 21 weeks gestation. The MRI was used to evaluate the anatomic nature of the internal anomalies. These findings were then used to develop an autopsy approach plan that preserved the external phenotype. After dissection, the specimen was preserved by using polyethylene glycol and ultimately prepared for use as a teaching specimen.     

First-trimester fetal chromosomal diagnosis using endocervical lavage: a negative evaluation

A report in the literature indicated that fetal cells could be obtained by endocervical lavage during the first trimester of pregnancy and successfully cultured. This would allow prenatal diagnosis earlier in pregnancy than is currently possible with second-trimester amniocentesis. Therefore, we attempted to confirm these findings. Our results indicated that the cultural cells were maternal in origin. We disagree with interpretations of the data given in the initial report and conclude that first-trimester prenatal diagnosis is not feasible at this time.     

First-trimester transabdominal fetal echocardiography

BACKGROUND: Fetal echocardiography is usually done during the second trimester of pregnancy, but waiting until that time can lead to anxiety for the parents if the fetus is at high risk of having cardiac abnormalities. We report the feasibility of transabdominal first-trimester fetal echocardiography for early reassurance of normality or a prenatal diagnosis of a cardiac malformation. METHODS: We did first-trimester fetal echocardiography and colour-flow mapping with a 5 MHz curvilinear transducer at 13 weeks' gestation (range 12-13+6 days) in 15 fetuses at risk of cardiac defects. The fetus was judged to be normal if the investigation showed normal visceral situs, four-chamber view, and two normally related great arteries of similar size. We did second-trimester scans and neonatal follow-up for the women who continued with their pregnancies; necropsy was done in two cases of pregnancy termination. FINDINGS: Ten fetuses had normal hearts at the time of the first scan, which was confirmed during second-trimester assessment. In one fetus, the four-chamber view was asymmetrical and a moderate-sized apical muscular ventricular septal defect (VSD) was diagnosed after birth. In another two fetuses we diagnosed small muscular VSD on the second-trimester scans. A complex cardiac malformation was correctly diagnosed in one fetus at 12 weeks of gestation. Thus, in 11 fetuses, the imaging was of sufficient quality to reassure the family or to diagnose an abnormality. In the other four fetuses, the investigation was judged to be incomplete, but no definite cardiac abnormality was identified. INTERPRETATION: Transabdominal fetal echocardiography in the first trimester of pregnancy is feasible. In most patients the resolution of images is sufficient to allow assessment of basic cardiac anatomy, when normal, or detection of complex malformations, when present.     

Successful separation of ischiopagus tripus conjoined twins with comparative analysis of methods for abdominal wall closure and use of the tripus limb

The authors report the successful delivery, preoperative management, and postoperative courses of ischiopagus tripus twin girls successfully separated at 5 months of age. Surgical objectives were predicated on survival and optimum postseparation reconstructive potential for both girls. Each twin has subsequently undergone additional procedures, and both are doing well 2 years after separation. The authors reviewed 17 known cases of ischiopagus tripus separation, comparing anatomic findings, use of the tripus limb, operative strategies, and attainment of abdominal closure. This 18th case includes the first report of splitting the tripus limb and giving each girl a femur. The authors found that detailed systemic investigation, advanced coordinated teamwork with appropriate technical support, applications of new technologies or reapplication of existing technologies, meticulous planning, and favorable anatomy were vital in yielding favorable outcomes.     

Twin reversed arterial perfusion sequence in conjoined, acardiac, acephalic twins associated with a normal triplet. A case report

BACKGROUND: Twin reversed arterial perfusion (TRAP) sequence and development of an acardiac monster is a rare event. Even more rare are conjoined acardiac, acephalic twins complicating a triplet pregnancy with TRAP sequence. The mortality for the acardius is 100%, and morbidity for the normal, pump fetus is 50%. The morbidity of the pump twin or triplet is attributed mostly to in utero congestive heart failure. CASE: A 24-year-old woman, gravida 1, para 0, at 35 weeks' intrauterine pregnancy, gave birth via low transverse cesarean section to a normal female and a pair of conjoined, acardiac, acephalic, pelvipagus twins. CONCLUSION: The diagnosis of acardius in multiple gestation pregnancy, with no fetal heart tone on ultrasound, must be ruled out in every case so that proper counseling, management and avoidance of complications in these patients can be achieved.     

First-trimester neck abnormalities: three-dimensional evaluation

In order to study the first trimester ultrasonographic differences between nuchal translucency and hygroma colli, we rescanned 25 fetuses (13 with nuchal translucency and 12 with hygroma colli) using transvaginal and three-dimensional ultrasonography, after obtaining a fetal karyotype report. Our objective was to test the premise that the different physiopathologic mechanisms of both processes would be reflected in detectable sonographic differences. Our retrospective analysis showed that the most striking ultrasonographic difference was the presence of bullae as well as greater irregularity, extent, and amplitude of the membrane in cases of hygroma colli. Fetuses with simple nuchal translucency had a more homogeneous linear membrane. Although detailed analysis was impossible in 30% of cases, we found three-dimensional ultrasonography to be a useful technique for establishing the differences between these two entities.     

Fetal alcohol syndrome in twins of alcoholic mothers: concordance of diagnosis and IQ

The effects of teratogens can be modified by genetic differences in fetal susceptibility and resistance. Twins of alcoholic mothers provide a unique opportunity to study this phenomenon with respect to alcohol teratogenesis. Sixteen pairs of twins, 5 MZ and 11 DZ, all heavily exposed to alcohol prenatally, were evaluated. They represented all available twins of alcohol-abusing mothers who were on the patient rolls of the authors. The rate of concordance for diagnosis was 5/5 for MZ and 7/11 for DZ twins. In two DZ pairs, one twin had fetal alcohol syndrome (FAS), while the other had fetal alcohol effects (FAE). In 2 other DZ pairs, one twin had no diagnosis while one had FAE. IQ scores were most similar within pairs of MZ twins and least similar within pairs of DZ twins discordant for diagnosis. Despite equivalent alcohol exposure within twin pairs, alcohol teratogenesis appears to be more uniformly expressed in MZ than in DZ twins. These data are interpreted as reflecting the modulating influence of genes in the expression of the teratogenic effects of alcohol.     

Successful pregnancy in a separated conjoined twin

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.     

Delivery of twins

Reconstruction of the nose provides many challenges owing to its differing subunits and varied surfaces. In this article, the nasal anatomy, anesthesia, and some of the reconstructive options available to the dermatologic surgeon are reviewed. These reconstructive options are based on the subunit and depth of the defect. This subunit approach may provide a framework of decision making and options that will help the dermatologic surgeon in reconstruction of defects on this unique anatomic structure.     

First-trimester growth and the risk of low birth weight

BACKGROUND: Previous studies have demonstrated a correlation between first-trimester size and birth weight. It is not known, however, whether low birth weight is related to first-trimester growth. We sought to determine whether the risk of low birth weight and birth weight that was low for gestational age is related to the size of the embryo or the fetus in the first trimester. METHODS: From a data base of ultrasound records of more than 30,000 pregnancies, we identified women who had no important medical problems, a normal menstrual history, and a first-trimester ultrasound scan in which the crown-rump length of the embryo or fetus had been measured. We examined the relation between the outcome of 4229 pregnancies and the difference between the measured and the expected crown-rump length in the first trimester, expressed as equivalent days of growth. RESULTS: A first-trimester crown-rump length that was two to six days smaller than expected was associated with an increased risk (as compared with a normal or slightly larger than expected crown-rump length) of a birth weight below 2500 g (relative risk, 1.8; 95 percent confidence interval, 1.3 to 2.4), a birth weight below 2500 g at term (relative risk, 2.3; 95 percent confidence interval, 1.4 to 3.8), a birth weight below the fifth percentile for gestational age (relative risk, 3.0; 95 percent confidence interval, 2.0 to 4.4), and delivery between 24 and 32 weeks of gestation (relative risk, 2.1; 95 percent confidence interval, 1.1 to 4.0), but not with delivery between 33 and 36 weeks (relative risk, 1.0; 95 percent confidence interval, 0.7 to 1.5). CONCLUSIONS: Suboptimal first-trimester growth may be associated with low birth weight, low birth-weight percentile, and premature delivery.