Conjoint twins: “Constant togetherness” a sign of double trouble

Introduction: Conjoint twins are a rare form of twins. Its incidence ranges from 1 in 50,000 to 1 in 100,000 live births. Associated with multiple anomalies, it has very high morbidity and mortality. Ultrasound has not only overcome the diagnostic dilemmas and pitfalls but has helped to characterize the site, extent of conjoining which often decides the prognosis and offers varying outcomes when surgical separation is attempted. Case description: A Gravida 3 Para 1 Living 1 abortion 1 with previous LSCS at 13 weeks presented for the first time to confirm pregnancy. Ultrasound showed monochorionic twin pregnancy. Two cranial vaults, thorax with 2 cardia were seen separately. The abdomen of the twins was not clearly discernible. Twin B had a cystic swelling in the umbilical area and the lumbosacral area. A working diagnosis of conjoint twins with umbilical cord cyst and meningocele was made. The patient was counseled about the prognosis. The patient opted for termination of pregnancy. An autopsy showed an omphalopagus type of conjoint twins with sharing of the intestines from the ileocecal region with omphalocele at the joining site and meningomyelocele in twin B. Conclusion: Diagnosing conjoint twins is a dilemma. Once diagnosed a “Pandora box” is opened. The trouble starts here, with its classification, extent of duplication, and looking for other associated anomalies. When diagnosed, early termination of pregnancy is an option. The late diagnosis makes management difficult with increased risks in preterm labor, intrauterine death, stillbirths, cesarean delivery, and problems of surgical separation with varying prognoses.