We report the case of a 27-year-old pregnant woman, gravida 3 para 2, who was presented to the maternity emergency unit of Princess Christian Maternity Hospital (PCMH) in Freetown at term in labor. The patient was referred from a health center for prolonged labor and arrest of descent at complete cervical dilatation despite being in active labor for the past 9 hours. She was an illiterate street trader. In terms of past obstetric history, there was a spontaneous vaginal delivery (SVD) at term of a healthy live born boy and a fresh stillbirth at term for an unknown reason. During this present pregnancy, she did not make any antenatal care visit. Therefore, blood pressure levels during pregnancy were undocumented and no obstetric ultrasound examination was performed. Her last menstrual date was unknown. Other relevant risk factors, such as gestational diabetes and infectious diseases, were also not known or documented.
Upon admission, the patient was awake and orientated and presented the following vital signs: blood pressure of 180/120 mmHg and a protein value of 3+ on urine dipstick test. Clinical examination revealed anasarca and hyperreflexia and a gravid abdomen with assumed term pregnancy and assumed singleton. The cervix was fully dilated with dystocia of labor; the presentation was cephalic. On auscultation with Pinard stethoscope, fetal heartbeat was absent. Ultrasound was not available. The findings led to the admission diagnosis of "obstructed labor with intrauterine fetal death (IUFD) and preeclampsia."
The patient was admitted to the eclamptic ward to be stabilized, and application of Hydralazine 5 mg (i.v.) every 20 minutes under close blood pressure monitoring was performed.
Under spontaneous progression of labor (no application of oxytocin), the patient was transferred to the labor ward, where one head of the yet unknown conjoined twin was born. Even though blood pressure was controlled (140/95 mmHg), the patient developed eclamptic fits. Ceasing of seizures was achieved after implementing the loading dose of the MgSO4 protocol.
The consultant obstetrician was now involved, and a new clinical assessment revealed a somnolent patient that was now stable, reflexes were low, and the blood pressure was controlled: 140/95 mmHg. The fundal height corresponded to term; there were no adequate contractions, and the fetal heart was absent. On vaginal examination, the presentation was left occiput posterior with stuck fetal head and a turtleneck phenomenon. With regard to the unknown presence of conjoined twins, the diagnosis of obstructed labor (suspicion of shoulder dystocia) and IUFD was confirmed and eclampsia was added. In an attempt to deliver the shoulders, manual extraction of both arms was performed as follows: reaching up along the dorsal shoulder blade, sweeping the humerus down, and thereby bringing the left arm out of the vagina. The same procedure was performed at the anterior shoulder for the right arm (Figure 1). Since shoulders were still not following and due to the unordinary presentation of the fetus, a second deep vaginal examination along the fetus' back was done, and further membranes were discovered. This led to the sudden and unexpected diagnosis of conjoined twins.
An emergency cesarean section under general anesthesia via a longitudinal midline incision was performed immediately. The fetus was extracted by breech, whilst the born head was repositioned vaginally by a midwife (Figure 2). External inspection of the conjoined twins after surgery revealed a female thoracopagus type that seemed to involve the heart (Figure 3). Apgar score (Appearance, Pulse, Grimace, Activity, and Respiration) was 0/0/0, and pH was generally not available. The gestational age was estimated to be about 37-39 weeks of gestation.
The MgSO4 protocol was maintained further for 48 hours, and the antihypertensive therapy was continued with Hydralazine and later changed to 3 x 20 mg Nifedipine orally. The patient was kept under close monitoring of blood pressure, reflexes, respiration rate, and input-output evaluation.
During the postpartum period, there was no reappearance of seizures, and the anasarca disappeared fully. In the absence of proper laboratory facilities, no parameters concerning the hepatic or renal status could be done. Oral antihypertensive therapy was maintained for 6 weeks. On the control visit after 8 weeks, the patient was clinically fully recovered.