Conjoined Twins in a Tertiary Referral Center in Indonesia: A 15-Year Retrospective Descriptive Study and Proposed Management Algorithm for Developing Countries

Abstract

Background:

Conjoined twins are a rare developmental anomaly exhibiting an incidence that ranges from 1 in 50,000 to 1 in 200,000 live births. In low-income nations, insufficient access to advanced prenatal diagnostic technologies, specialized neonatal medical services, and surgical expertise notably affects the management strategies and clinical outcomes for conjoined twins. The accessibility of data from tertiary healthcare facilities in Southeast Asia is significantly constrained, thus impeding the development of management protocols specifically designed for the region.

Objectives:

This study aimed to describe the clinical characteristics, management strategies, and outcomes of all conjoined twin cases managed at Dr. Soetomo General Academic Hospital in Surabaya, Indonesia, over a 15-year period, and to propose a comprehensive management algorithm suitable for implementation in developing nations.

Materials and Methods:

A retrospective descriptive study was performed, involving the review of medical records of all conjoined twin pregnancies managed at Dr. Soetomo General Academic Hospital from January 2010 to December 2025. The data collected encompassed the type of conjoining, gestational age at diagnosis and delivery, mode of delivery, associated congenital anomalies, fetal sex, birth weight, Apgar scores, placentation, assessment of separability, and neonatal outcomes. Descriptive statistical methods were employed to summarize the findings. A management protocol was formulated based on institutional experience and an extensive review of the literature.

Results:

A total of 32 cases of conjoined twins were identified during the study period. The most prevalent type was thoracoabdominopagus (n=19, 59.4%), followed by parapagus dicephalus (n=9, 28.1%), thoracopagus (n=2, 6.3%), and one case each of abdominopagus, cephalothoracoabdominopagus, pyopagus, and parasitic twin (3.1% each). The mean maternal age was 28.5 ± 5.8 years (range 18–40). The mean gestational age at delivery was 27.8 ± 7.8 weeks (range 14–38). Cesarean section was performed in 17 cases (53.1%) at a mean gestational age of 33.7 weeks, hysterotomy in 3 cases (9.4%) at a mean gestational age of 26.7 weeks, and vaginal delivery with misoprostol induction in 12 cases (37.5%) at a mean gestational age of 18.5 weeks. Female predominance was noted (50.0%). Cardiac anomalies were identified in 81.2% of cases, hepatic fusion in 69.7%, and abnormal umbilical cord configuration in 33.3%. All twins were categorized as non-separable. The overall mortality rate was 100%, with 11 cases (34.4%) resulting in stillbirth, and the longest recorded postnatal survival was 4.5 months

Conclusions:

Conjoined twins in this developing-country setting demonstrated persistently adverse outcomes. Early prenatal diagnosis, an organized multidisciplinary evaluation framework, and a standardized management algorithm that emphasizes viability, separability, and timely referral are essential for improving care in resource-limited settings.