Anesthesia Management of Premature Omphalopagus Conjoined Twins Undergoing Sedation for Abdominal-Pelvic Magnetic Resonance Imaging: A Case Report and Literature Review

Conjoined twins are a rare occurrence where two babies are physically connected at birth, a result of an embryo that did not fully separate during the first few weeks of development. While the idea of two people sharing one body is startling, the medical reality is even more complex. These twins often share vital organs, such as the liver or parts of the digestive system, which means their bodies are not just touching but functionally linked. This connection creates a unique challenge for doctors: when one twin needs medicine or surgery, the other is affected too. The situation becomes even more delicate when the twins are born prematurely, as their organs are still developing and their bodies are less able to handle stress, cold, or the drugs used to keep them still during medical procedures.

In a recent report from Rwanda, a team of doctors faced this exact challenge with a pair of premature conjoined twins who needed a special type of medical scan. The twins, born at thirty-four weeks of pregnancy, were joined at the front of their abdomens, a specific type of connection known as omphalopagus. This configuration meant they shared a liver but likely had separate hearts. Before the surgeons could plan to separate them, they needed a detailed map of the twins' internal anatomy, which required a magnetic resonance imaging, or MRI, scan. However, an MRI machine is a loud, narrow tube that requires the patient to lie perfectly still for a long time. For newborns, especially those born early, this means they must be sedated, or put into a deep sleep, without the use of general anesthesia machines that are too large or magnetic for the room. The doctors had to figure out how to safely put two connected, premature babies to sleep at the same time, monitor them closely, and wake them up without causing harm.

The twins, referred to as Twin B and Twin C, were born as part of a triplet pregnancy that was complicated by the early rupture of the water bag, leading to their premature arrival. By the time they were two months and seven days old, they had grown strong enough to be considered for the scan, weighing a combined five kilograms. The medical team at King Faisal Hospital in Kigali knew that the biggest risks were not just the twins' shared anatomy, but their immaturity. Because they were born early, their brains were not yet fully developed to control their breathing automatically, a condition that makes them prone to stopping breathing after receiving sedative drugs. Furthermore, because they shared a liver, the team worried that drugs given to one twin might travel to the other, or that their livers might not be able to break down the medicine fast enough.

To prepare for the procedure, the doctors took a series of careful steps. They first confirmed that the twins had separate blood circulations, meaning a drug given to one would not immediately affect the other. They did this by giving a small amount of a heart-stimulating drug to Twin B and watching Twin C's heart rate; since Twin C's heart did not speed up, the team knew they could treat each baby as an individual patient. They also ensured the twins were well-fed and warm, as premature babies are very sensitive to low blood sugar and cold temperatures. Most importantly, they assigned one anesthesiologist, a doctor specialized in sedation, to each twin. This ensured that if one baby had a problem, a dedicated expert was right there to fix it immediately, rather than one doctor trying to manage two patients at once.

When it was time for the scan, the team used a combination of two sedative drugs, ketamine and propofol, given through IV lines placed in each twin's arm or leg. They chose these specific drugs because they work quickly and wear off fast, which is ideal for a short procedure. However, the plan did not go perfectly smoothly, and the doctors were prepared for this. Shortly after the drugs were given, Twin B stopped breathing and her oxygen levels dropped dangerously low. The anesthesiologist assigned to her immediately began helping her breathe with a mask and bag, a process that took five minutes until she started breathing on her own again. At the same time, Twin C remained stable, proving that the two babies were indeed independent. Later, during the scan itself, Twin C began to move, which would have ruined the images. The team gave her a small extra dose of the sedative to keep her still, but this caused her to stop breathing briefly as well. Again, the team responded quickly, helping her breathe for two minutes until she recovered.

The scan was completed successfully in fifteen minutes, providing the surgeons with the clear images they needed to plan the separation. The twins were then moved to a recovery area where they were watched closely for six hours. During this time, their breathing remained steady, their oxygen levels stayed normal, and they were able to start eating again without any issues. The doctors noted that the apnea, or stopping of breathing, was not a surprise but a predictable reaction for babies born this early. The fact that the team was ready with masks and oxygen allowed them to manage the situation without any long-term harm.

This case highlights that while the situation is incredibly rare and complex, it can be managed with careful planning and a team that treats each twin as a separate individual. The doctors learned that even with separate hearts, the shared liver and the immaturity of the babies' bodies require very low doses of medicine and constant vigilance. They also confirmed that a simple test to check if the twins share blood flow is essential before giving any drugs. The report serves as a guide for other medical teams, showing that with the right preparation, even the most fragile patients can undergo necessary medical procedures safely. The success of this procedure in a resource-limited setting also demonstrates that high-quality care for such rare conditions is possible anywhere, provided the right expertise and teamwork are in place.