The Toll of Separation

Safa and Marwa Bibi, Caters News Agency

This week, 3-year-old twins Safa and Marwa Bibi went back home to Pakistan — having been away since August 2018. As Rachael Buchanan reports for the BBC, this was the time it has taken to separate the twins — who were conjoined at the head.  

Conjoined twins develop from one fertilised egg and so are always identical.

There are two theories about why they are fused together – either the split into two embryos happens later than usual, and the twins only partially divide, or, following the split, parts of the embryos remain in contact and those body parts merge as they grow.

When it occurs, twins are more commonly connected at the chest, abdomen or pelvis. 

Safa and Marwa’s particular commingled physiology presents a unique set of challenges for the GOSH team. The girls are joined at the top of their heads – crown to crown – facing opposite directions.  

They have never seen each other’s faces.

The twins were treated by a team of 100 people at Great Ormond Street Hospital, in England. One of their surgeons, Professor David Dunaway, described their case as the hardest they have ever undertaken, partly because of their distorted brain shape, and partly because of their age — younger twins have a greater chance of success, but due to problems raising funding, Safa and Marwa were 19 months before they were brought to England. This led to some agonizing decisions being made on the operating table, which in turn took an emotional toll on the girls’ doctors.  

That’s when Marwa’s heart rate plummets and they fear she may die on the table.

There is suddenly quiet and stillness around the operating table as all eyes are on the instrument screens. The only sounds are the accelerated beeps of the heart monitors.

The crisis passes, but not without serious consequences.

It is clear to the surgical team that Marwa is the weaker twin. So they decide to give her a key shared vein. It will increase her chances of survival.

It is a hugely difficult decision. Jeelani knows that it may have a serious impact on Safa, until now the stronger twin.

But the team agrees that it is the right thing to do. The operation lasts more than 20 hours. Jeelani is exhausted and hands over to plastic surgeon Juling Ong to close.

“I am relieved. We thought we might lose Marwa at one point,” he says. “But if they wake up as we hope they will, it’s gone well.”

…. In the late afternoon, Jeelani telephones the hospital from home to check on the girls. He is told that Safa is in trouble, making no effort to breathe and her skin is mottled.

“I thought, ‘Safa is dead’,” he says, and recounts how, emotionally exhausted and sleep-deprived, he collapsed on his kitchen floor and started to cry.

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