A case of conjoined foetus

The patient, a woman of 32 years, had already given birth to a healthy infant. In this, her second pregnancy, she had attended the aatenatal clinic. At the first visit in the early weeks, the blood pressure had been 170/110 ; during the remainder of pregnancy, it had ranged from 150/100 to 170/120. A trace of albumin had appeared in the urine for the first time at 38 weeks when she was admitted to hospital. In hospital, the following were the significant findings: blood pressure I50/118; albuminuria, trace ; very slight ankle oedema ; blood urea, 23 mg. per cent. ; hmmoglobin, 70 per cent. ; Group IV(O), Rhesus positive. Twin breeches were suspected on palpation, but only one foetal heart could be heard. Radiological examination was not performed. She was treated by bed rest, sedation and restriction of salt and fluids with satisfactory response. One week after admission, the membranes ruptured and labour commenced. The first stage lasted 11~ hours. Before apparent full dilatation of the cervix, the foetal heart ceased to beat. There was no advance in the second stage, and vaginal examination revealed a footting presentation, consisting of three legs and feet. With traction, these three limbs were seen and felt to arise from a single trunk ; the nature of the deformity was therefore recognised. Under general anmsthesia the foetal trunk was delivered by traction on the legs ; the 2 single arms, which were extended, were next taken down in the usual way ; finally, the foetus was elevated by traction on the fused arm and the two heads delivered without difficulty, one after the other, by mouth flexion and suprapubic pressure. The third stage was normal. The single placenta appeared normal ; it weighed 31 oz. The weight of the combined foetus was 8 lb. 4 oz. The episiotomy wound did not heal by first intention ; otherwise the puerperium was normal. On the patient's discharge on the 13th day, the blood pressure was 160/90. The urine was clear. Examination af Conjoined Fcetus This specimen consists of a single trunk with two heads, three upper and three lower extremities. The trunk is cuneiform with a single ventral and ~wo dorso-lateral surfaces, thus indicating separate vertebral columns. The third upper and third lower extremities, which arise from the line of jun.ction of the two dorsal surfaces, show obvious signs of their bilateral origin. The skin on both surfaces of the accessory or fused hand is dorsal in character; there are two thumbs and the tips of the remaining four digits show evidence of duplication. The accessory lower extremity, which is less regular than the upper, has six digits. It is predominantly a left foot wi~h the plantar surface facing to the left and forwards. There are two nails on the distal end of the fused hallux. One of the remaining five digits is doubled. There are two nipples and a single umbilicus on the ventral surface. No external urethral opening can be seen. There are two genital swellings in the perineum, in the righ~ of which is a gonad, presumably testis. The anus ~s single, but imperforate. Radiographic examination clearly distinguishes two separate vertebral columns. Both pelvic and pectoral girdles are also duplicated. Digestive System: The (esophagus, stomach, gall-bladder and duodenum are duplicated. The remainder of the small intestine and the entire large intestine are single. The main liver mass occupies the right hypochondrium and the epigastrium. It has a small cyst on its anterior surface. There is a small accessory liver in the left hypochondrium, lateral ~o which lies the single spleen.