Dicephalus Tetrabrachius Parapagus Conjoined Twins: A Case Report from Orotta National Maternity Referral Hospital, Eritrea

Background: Conjoined twins (CT) are exceptionally rare congenital anomalies, with an estimated incidence of 1 in 50,000 to 200,000 births, and they pose substantial diagnostic and therapeutic challenges. When the condition is not identified before labour, the rigid fetal mass may result in absolute mechanical obstruction, frequently leading to severe maternal complications, including uterine rupture. This risk is particularly pronounced in low-resource settings, where delayed presentation and limited access to timely surgical intervention further increase the likelihood of adverse maternal outcomes. Case Summary: A 26-year-old woman (gravida 4, para 3) was referred to Orotta National Maternity Referral Hospital from a peripheral clinic with features of severe obstructed labour and evolving haemodynamic compromise. Intrapartum assessment confirmed the stillbirth of conjoined twins with dicephalus tetrabrachius parapagus morphology, characterized by fusion at the lower torso and pelvis. Initial laboratory investigations demonstrated significant anaemia. Intervention and Outcome: An emergency laparotomy was performed to relieve the obstruction, and the fetal mass was delivered through a classical uterine incision. Intraoperative findings revealed an extensive uterine rupture, involving approximately half the uterine length and extending into the left broad ligament. Owing to the severity of the rupture and the need for rapid and definitive haemorrhage control, a life-saving subtotal hysterectomy was performed. The patient received blood transfusions and comprehensive postoperative care and was successfully stabilised and recovered from the event. Conclusion: This case illustrates a rare and life-threatening presentation of undiagnosed dicephalus parapagus conjoined twins resulting in obstructed labour and uterine rupture in an unscarred uterus. It highlights the crucial role of early and adequate antenatal screening and emphasizes that prompt, definitive surgical management, such as subtotal hysterectomy, remains central to maternal survival in catastrophic obstetric emergencies, particularly in resource-limited settings complicated by massive haemorrhage. Keywords: conjoined twins, thoracopagus twins, obstructed labour, subtotal hysterectomy, emergency obstetric surgery, Eritrea