We present a 40-year-old Gravida13 Para10 Abortion2 mother who presented with headache, epigastric pain, bilateral leg swelling, epistaxis, and decreased fetal movement for a two-day duration. Her previous pregnancies were uneventful with no prior history of hypertensive diseases in pregnancy or hyperthyroidism reported. Although she had eight home deliveries, there were no twin pregnancies or molar pregnancies. In addition, she had no family history of bleeding diathesis. On the current pregnancy, she had no bleeding, raised blood pressure or any danger signs on the antenatal follow-up she had at 9 weeks. She was referred from a local health center, where the diagnosis of co-existing molar pregnancy was overlooked, with the impression of twin pregnancy and pre-eclampsia.
On admission, her blood pressure was 186/100, her pulse rate was 136 and her respiratory rate was 20. On abdominal examination, she had 36 weeks sized gravid uterus with fetal heartbeat of 136 and grade 2 bilateral pitting edema. On the admission blood tests, hematocrit was 32.8% with O+ blood type. Serum beta-HCG was found to be 215,400 IU/L, thyroid stimulating hormone was 0.05 IU/mL, urinalysis showed +1 proteinuria, other investigations (Renal function test, Liver function test, Complete blood count, and Chest X-ray) were all normal. With the impression of twin pregnancy complicated by pre-eclampsia with severity features and hyperthyroidism, the patient was managed for pre-eclampsia and a biophysical profile was done daily. Ultrasonography revealed two fetal sacs whereby twin A was a breech, alive twin with aggregate gestational age (AGA) of 28+6 weeks with the normal-appearing placenta as seen in (Figure 1). The other sac was filled with cystic spaces and snowstorm appearance, hinting towards a molar pregnancy (Figure 2).
We managed our patient expectantly for a week with daily biophysical profile, dexamethasone injections for fetal lung maturity, magnesium sulphate and anti-hypertensive for pre-eclampsia. After one week, a cesarean section was done for indication of twin pregnancy plus Twin A breech to affect the delivery of a 1.4 kg male neonate with Apgar score of 7 and 9 in the 1st and 5th minute, respectively. The grape-like vesicles, separate from the normal appearing placenta, were evacuated manually (Figure 3). There was intraoperative bleeding while removing the molar tissue. Initial evaluation of the neonate revealed no congenital abnormalities and he was admitted to the neonatal intensive care unit with a diagnosis of very low birth weight and discharged after attaining adequate weight. Although, the histopathology result showed a partial mole with variable-sized dilated chorionic villi with focal trophoblastic proliferation and multiple vascular proliferation seen, there were no malignant features. Post-operative hematocrit was 18.8% for which the patient was transfused with one unit of whole blood. The patient was discharged from our side on the 16th day after advice on subsequent follow-up. The level of beta-HCG was determined to be normal on the 2nd follow-up at 7 weeks as illustrated in (Table 1). On this visit, the mother had no new compliant with normal blood pressure and TSH levels. In addition, the infant's interpretation of growth curves adjusted for gestational age showed adequate growth.