A twin pregnancy with partial hydatidiform mole, low-lying placenta and coexistent twin pregnancy with fatal obstetrics haemorrhage: a rare catastrophic case report

Abstract

The coexistence of twin gestation and partial hydatidiform mole (PHM) is an exceptionally rare obstetric condition, with fewer than 100 cases documented in world literature. A 28-year-old unbooked G4P3L2 woman presented to our tertiary care centre at 17 weeks and 4 days of gestation with a 15-day history of per vaginal bleeding and features of haemodynamic collapse (pulse rate 140 bpm; blood pressure 80/50 mmHg). Investigations revealed catastrophic anaemia (haemoglobin 3.1 g/dl), markedly elevated serum beta-hCG (>100,000 mIU/ml), coagulopathy (INR 2.83), and acute kidney injury (creatinine 1.31 mg/dl). Thyroid-stimulating hormone was suppressed at 0.005 uIU/ml, consistent with hCG-mediated thyrotoxicosis. Ultrasonography confirmed a diamniotic dichorionic twin gestation with an anterior placenta praevia displaying enlarged, heterogeneous echotexture covering the internal os. Emergency hysterotomy with B-Lynch compression sutures was performed. Intraoperative findings revealed vesicular products of conception alongside both male fetuses (each 182 g; Apgar scores zero). Placental biopsy demonstrated two discrete populations of villi irregularly shaped hydropic villi with cisterns, scalloping, and mild circumferential trophoblastic hyperplasia alongside normal tertiary villi confirming partial hydatidiform mole. No choriocarcinoma was identified. Despite aggressive resuscitation including inotropic support, mechanical ventilation, and multiple blood product transfusions, the patient developed refractory cardiac asystole and died approximately 14 hours postoperatively. This case underscores the lethal potential of PHM with twin gestation and placenta praevia, and highlights critical deficiencies in antenatal surveillance, referral systems, and resource availability that predispose unbooked patients to preventable maternal mortality. Enhanced first-trimester ultrasound protocols and routine beta-hCG measurement in twin pregnancies are urgently needed.