Children's Hospital Colorado

Conjoined Twins

Conjoined twins are rare and they may be joined at a variety of sites. Conjoined twins face a range of possible health issues, depending on which body parts are joined, or, in some cases, shared. The Colorado Fetal Care Center is at the forefront of determining and providing the best treatments available for each family's specific situation.

For patients

In rare cases, twins develop so closely that their body parts are joined together. Conjoined twins can be connected through a variety of body parts, including the head, chest, abdomen, pelvis and buttocks. Twins joined at the chest or abdomen are the most common type of conjoined twins, comprising 75 percent of all cases.

Common types of conjoined twins

The most common sites for twins to be joined are:

  • Thoracopagus - Joined at the chest and facing each other
  • Omphalopagus - Joined at the abdomen and facing each other
  • Pygopagus - Joined at the buttocks and perineum, and facing away from each other
  • Ischiopagus - Joined with a single bony pelvis and four normal lower extremities
  • Craniopagus - Joined at the skull with or without brain connection

What causes conjoined twins?

Identical twins occur when a single fertilized egg (embryo) splits and develops into two individuals. The dominant theory on the origin of conjoined twins suggests that when the single embryo splits later, separation stops before the process is complete, leaving the babies joined. Alternatively, another theory holds that two separate embryos fuse in early development. What would cause either scenario remains unknown.

The exact rate of conjoined twins is not known, but estimates have varied from 1 in 25,000 to1 in 80,000 births. Maternal age and the number of prior pregnancies do not appear to be factors that influence the occurrence of this type of twins. However, use of assisted reproductive techniques (for example, in vitro fertilization) may result in an increased risk for conjoined twins.

How are conjoined twins diagnosed?

A routine ultrasound is the most common form of diagnosis for conjoined twins. The ultrasound might raise suspicion if the babies appear to be in the same pregnancy sac (meaning no dividing membrane). Then, if there is no dividing membrane, the babies' bodies might not appear to be separate or they might not change position relative to each other as time passes. Prior to 10 weeks of pregnancy, this condition may be diagnosed incorrectly by ultrasound. Multiple organ structures might be involved and/or developing abnormally.

MRI and echocardiogram are used to provide additional details. The more we know about the anatomy and how precisely the two babies are joined, the more accurately our team can assess whether surgically separating the twins is possible, and if so, how best to proceed.

Understandably, this is a very upsetting diagnosis. The fetal care specialists at the Colorado Fetal Care Center can help guide your family through pregnancy, delivery and care for your twins after birth. Successful surgical separation after birth is possible, but the outcomes depend on the type of connection as well as which organs and body structures are shared.

Managing pregnancy with conjoined twins

Conjoined twins can be delivered by cesarean section at our state-of-the-art facility, where our team specializes in managing this condition. Our fetal experts also have experience in procedures to surgically separate the twins after birth. There are no surgical procedures that can be performed while the babies are still in the uterus (referred to as fetal interventions) to separate conjoined twins.

A routine ultrasound is the most common form of diagnosis for conjoined twins. The ultrasound might raise suspicion if the babies appear to be in the same pregnancy sac (meaning no dividing membrane). Then, if there is no dividing membrane, the babies' bodies might not appear to be separate or they might not change position relative to each other as time passes. Prior to 10 weeks of pregnancy, this condition may be diagnosed incorrectly by ultrasound. Multiple organ structures might be involved and/or developing abnormally.

MRI and echocardiogram are used to provide additional details. The more we know about the anatomy and how precisely the two babies are joined, the more accurately our team can assess whether surgically separating the twins is possible, and if so, how best to proceed.

Understandably, this is a very upsetting diagnosis. The fetal care specialists at the Colorado Fetal Care Center can help guide your family through pregnancy, delivery and care for your twins after birth. Successful surgical separation after birth is possible, but the outcomes depend on the type of connection as well as which organs and body structures are shared.

Managing pregnancy with conjoined twins

Conjoined twins can be delivered by cesarean section at our state-of-the-art facility, where our team specializes in managing this condition. Our fetal experts also have experience in procedures to surgically separate the twins after birth. There are no surgical procedures that can be performed while the babies are still in the uterus (referred to as fetal interventions) to separate conjoined twins.

Treatment options for conjoined twins varies from case to case. The Colorado Fetal Care Center works closely with the parents to identify the best treatment plan for their babies.

As a parent, it can feel overwhelming to think about the implications of having conjoined twins. But as one of the nation’s top care centers for conjoined twin treatment, the Colorado Fetal Care Center is uniquely positioned to care for your babies while supporting your family with helpful resources along the way.

Conjoined twin treatment options vary based on where and how the babies are joined. Twins born without immediately life-threatening complications, often those joined at the buttocks or sharing a single pelvis, usually wait several months for surgery. During that time, physicians evaluate organ sharing and plan the surgical approach.

Twins whose lives are immediately threatened, especially those connected at the chest or head, require emergency surgery before extensive diagnostics can be completed. Once the initial surgeries are complete, with or without separation, physicians conduct tests then devise a multi-step approach to each health issue according to its urgency and long-term impact.

Will both babies survive if surgically separated?

Significant ethical considerations arise in cases where it is not possible to achieve separation without sacrificing the life or the quality of the life of one of the two twins. Our surgical team will discuss your options and the survival chances of each twin based on the surgical procedure they choose.

What is the long-term outcome for conjoined twins?

Because there are so many types of conjoined twins and each pair's connection can vary, the outcome depends on a wide range of variables. Your physicians will assess your case with a high degree of detail through multiple diagnostic tests and create a treatment plan aimed at maximizing your children's health and quality of life.

For healthcare professionals

The initial diagnosis of conjoined twins is usually by prenatal ultrasound, but additional detail can be obtained by fetal MRI and fetal echocardiogram. The increased anatomical detail provided by MRI and echocardiogram is important because other anomalies are common even in organs that are not shared. This can affect the potential for separation and the long-term outcomes. In particular, ¾ of conjoined twins who are joined at the chest have a shared heart, making separation impossible.

The history of conjoined twins before birth is not well known due to the fact that these cases are rare and many patients elect termination. However, successful surgical separation after birth is possible, but the prognosis for the conjoined twin surgery depends on the type of connection and shared organs and structures.

Except for life-threatening emergencies that must be treated by immediate separation of the twins, conjoined twin surgery should be delayed until an accurate assessment of shared structures is completed. Of the conjoined twins who are born alive, the potential long-term survivors fall into two groups.

The first group involves children who thrive despite being joined. Pygopagus, ischiopagus and xiphopagus twins usually fall into this category. In this group, there is sufficient time to evaluate organ sharing and to plan operative separation. Separation in these children should probably be delayed several months.

The second group involves twins whose lives are threatened because of the connection or coexistent congenital abnormalities. Emergency surgery with or without separation may be required before appropriate diagnostic studies (tests) can be completed. This type of surgery is indicated when the existence of one twin threatens the life of the other or a potentially correctable life-threatening anomaly is present.

The prognosis for conjoined twin surgery depends on the type of connection:

  • Omphalopagus twins: The results for twins joined at the abdomen (omphalopagus) are particularly good, unless there is a defect in the abdominal wall, which impacts the ability to obtain abdominal closure.
  • Thoracopagus twins: In twins joined at the chest (thoracopagus), a shared heart makes separation impossible. If the heart is not shared, the most common causes of death following separation in thoracopagus twins are cardiac abnormalities, infections and respiratory failure.
  • Pygopagus twins: The prognosis is usually good for pygopagus twins mainly because the joined structures are not essential for life.
  • Ischiopagus twins: The separation of ischiopagus twins is usually difficult because most of the abdominal organs are joined. In addition, there is usually only one pelvis and often only three lower extremities (legs). Significant post-separation orthopedic problems can persist despite a successful separation.
  • Craniopagus twins: The outcome for craniopagus twins relates to whether the brain is connected (total) versus just the skull (partial). For partial connections, a staged approach has better outcomes.

To our knowledge, the recurrence risk is not increased above background for conjoined twins.


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