Twin Pregnancy with a live fetus
&  Hydatidiform Mole

OBJECTIVE: Twin molar pregnancy is a rare obstetric event, characterized by the co-existence of a Hydatidiform mole and a potentially live fetus with a normal placenta with an estimated incidence of 1in 20,000 to 1 in 100,000

CASE REOPRT:

 37 y/o, G6p5 GA: 8 weeks pregnant, came to the E&D with c/o vaginal bleeding and abdominal pain, she had this bleeding from the start of her pregnancy with passage of clots. She was otherwise medically and surgically free with history of uncomplicated vaginal deliveries .

On arrival she was vitally stable and  had profuse fresh bleeding around 500 ml, on vaginal  examination os was closed. bedside US : SVF CRL : 8 wks. with ?retro placental Hemorrhage, that was confirmed latter by an

official scan,  FHR = 164bpm There is an irregular hypoechoic area with no vascularity noted right lateral to the gestational sac, measuring 6.8 x 0.9 x 1.4 cm. Suggestive of bleeding. thickened endometrium, Ovaries, normal, No obvious adnexal masses

Her Hemoglobin dropped from 124 to 85gm/dl, BHCG- 1125000.0

MRI DONE Confirmed that twin pregnancy with Hydatidiform mole pregnancy and coexisting alive fetus. Admitted for work up , blood transfusion and MRI to confirm a molar pregnancy vs twin pregnancy

Because of the continuous bleeding and drop of Hemoglobin we decide to terminate pregnancy with patient and partner informed consent. She Discharge next day in good condition with 1 week BHCG follow up in the clinic.

Histopathology: confirmed complete Hydatidiform mole which was confirmed by P57 immunohistochemistry

DISCUSSION:

The diagnosis of twin molar pregnancy is challenging , this condition needs to be differentiated from a partial Hydatidiform mole. MRI is essential to differentiate a twin pregnancy and co existing live fetus from a placenta mesenchymal dysplasia. Cytogenetic analysis is crucial to diagnose twin molar pregnancy (CVC, amniocentesis, RPOC)- complete mole do not express P57 kip2 confirming single parent origin, diploid by karyotype, and a clear case of complete mole. Management options are elective termination or comprehensive prenatal care in a tertiary center as there is a risk of Hemorrhage , pre eclampsia and Hyperthyroidism. Occurrence of post molar GTN risk is not clear.