Abstract / Summary
Abstract Background Conjoined twins represent one of the rarest and most physiologically complex presentations in pediatric patients, with omphalopagus fusion involving the anterior abdominal wall from the xiphisternum to the umbilicus occurring in approximately 18–28% of all conjoined twin cases. The perioperative management of such neonates, particularly in the setting of prematurity, demands an individualized approach that integrates shared anatomy, immature organ physiology, and specific challenges imposed by the magnetic resonance imaging (MRI) environment. Case Presentation: We report a case of premature female omphalopagus conjoined twins (Twins B and C) born at 34 weeks of gestation as part of a triplet pregnancy complicated by preterm premature rupture of membranes (PPROM). At 43 2/7 weeks post-conceptual age (PCA), two months and seven days of chronological life, the twins were referred to King Faisal Hospital, Kigali, Rwanda, for diagnostic abdominal-pelvic MRI under sedation before elective surgical separation. Management: Anesthesia management was conducted by a multidisciplinary team with one anesthesiologist assigned to each twin. Pre-procedural optimization included glycemic control with dextrose 10% infusion and a six-hour fasting period. An atropine circulation test confirmed a hemodynamically separate circulation. Induction was achieved using concurrent intravenous ketamine (0.5 mg/kg) and propofol (1 mg/kg) per twin, supplemented with 100% oxygen via a facial mask. Twin B developed post-induction apnea that required bag-mask ventilation for five minutes before spontaneous breathing resumed. A top-up dose of propofol (1 mg/kg) was required for the Twin C midway procedure, which precipitated a brief apneic episode that required bag-mask ventilation for two minutes. Outcome: Abdominal-pelvic MRI was completed within 15 minutes. Both twins were monitored in the recovery unit for six hours, tolerated oxygen weaning and uneventfully resumed trophic feeds. No further sedation-related complications were noted. Conclusion This case highlights the critical importance of individualized drug dosing, anticipation of apnea risk in premature post-conceptual neonates, confirmatory testing of a separate circulatory system, anesthesiologist allocation per twin during MRI sedation, and multidisciplinary collaboration for safe outcomes in such rare presentations.