Cephalic replacement in conjoined twins

The Zavanelli manoeuvre revisited: A review of the literature and a guide to performing cephalic replacement for severe shoulder dystocia

The Zavanelli manoeuvre is often the final resort of the clinician facing undeliverable shoulder dystocia and we present retrospective pooled data comprising 110 shoulder dystocia cases, 11 impacted breech and 11 locked twin deliveries assessed from ten case series and 38 individual case reports. Although recommended when other external and internal manipulations have failed, we suspect that many clinicians have not had formal training on how to conduct the manoeuvre and may be unfamiliar with the steps involved, leading to a reluctance and delay in initiating this. We describe original descriptions of the manoeuvre, examine its use in intractable shoulder dystocia and illustrate stepwise the cephalic replacement technique. For this review, we have concentrated mainly on the outcomes of the Zavanelli manoeuvre in shoulder dystocia but have also touched on its role in impacted breech and locked twin deliveries. Lastly, we discuss the cognitive load an obstetrician faces when having to make time critical decisions in severe shoulder dystocia and share how other disciplines train and prepare their personnel to manage similar rare and unexpected scenarios.

[Diagnosis of conjoined twins in a pregnant woman at term]

Les jumeaux conjoints sont une malformation rare des grossesses gémellaires monozygotes et mono-amniotiques. Nous rapportons la découverte anténatale de jumeaux conjoints dicéphale à 37 SA. Le pronostic fœtal de cette malformation reste très sombre, nécessitant un recours à une interruption de la grossesse si le diagnostic est posé précocement. A partir de cette observation et une brève discussion, nous faisons un rappel sur cette pathologie rarissime, sur son diagnostic échographique essentiel pour établir une stratégie de prise en charge post natale. Son pronostic reste le plus souvent très réservé.

Conjoined twins, conception, pregnancy, and delivery: a reproductive history of the pygopagus Blazek sisters (1878-1922)

Conjoined twins represent the most uncommon twinning mechanism in humans, with an incidence approaching 1:100,000 deliveries. Although several conjoined male twins have occasionally been reported, for unexplained reasons most cases of conjoined twins are female. Of all the female conjoined twin sets either documented by medical authorities or referenced in ancient literary sources, in only one case were pregnancy and delivery successfully achieved by the conjoined twins themselves. We describe the highly unusual circumstance of the Blazek sisters, an extreme developmental example of the terminal monogenital pygopagus type of conjoined twins in which one of the joined sisters conceived and underwent labor and childbirth. Although little information is known about their own birth, these conjoined twins paradoxically hold a unique place in the history of obstetrics. Information from formal anatomic examinations of the sisters and their exploitative circus exhibitions is outlined with a view to explain relevant reproductive events. We present the sensational conception, pregnancy course, and subsequent vaginal delivery of a healthy male infant as summarized from contemporary sources. Additionally, the significance of pygopagus twins is discussed with regard to other types of monozygous twinning. Although modern operative techniques have been a welcome advance in the science of conjoined twin separation, the Blazek case is another reminder that, even in the era before complex surgery, conjoined twins were not necessarily consigned to an incomplete reproductive career.

[Prenatal diagnosis of omphalopagus conjoined twins at 13 weeks of amenorrhea]

Conjoined twins are a rare occurrence. We present a case of conjoined twins at 13 weeks' gestation. This case demonstrated the possibility of making an accurate diagnosis of conjoined twins and delineating the extent of organ sharing in the first trimester. This analysis and the discover of another anomalies can help the parents with the option for pregnancy termination. Early diagnosis and precise delineation of the shared organs of conjoined twins are essential for optimal obstetric and postnatal management.

The Zavanelli manoeuvre in shoulder dystocia: case report and review of published cases

A case of severe shoulder dystocia is reported in which, after other methods had failed, cephalic replacement succeeded but was very difficult. The infant suffered severe damage. A review of methods to relieve shoulder dystocia is given, with special attention to published cases of the Zavanelli manoeuvre. It could only be used when all other methods fail.