A Double-Hit Placental Catastrophe: Spontaneous Expulsion of a Placenta Praevia Followed by Acute Co-Twin Placental Abruption in a Dichorionic Twin Pregnancy-A Case Report
Sujnanendra Mishra* and Swadhin Kumar Mishra
ABSTRACT
Background: Placenta praevia and placental abruption are leading causes of antepartum haemorrhage. Their sequential occurrence within a single dichorionic twin pregnancy praevia of one placenta followed by acute abruption of the other is exceptionally rare and life-threatening for both the mother and the surviving fetus.
Case: A 26-year-old woman, gravida 2 para 1 with one previous caesarean delivery, presented at 28 weeks and 4 days of a dichorionic diamniotic twin pregnancy with painless vaginal bleeding followed by uterine contractions. Moments after arrival in the labour room, she spontaneously expelled the intact placenta of Twin 1, which showed features of lower-segment (praevia) implantation. Bedside ultrasound confirmed intrauterine death of Twin 1 and a retroplacental hypoechoic area behind the placenta of Twin 2. Within five minutes, Twin 2 developed severe bradycardia (60 bpm) and the mother became hypotensive (85/50 mmHg). A category 1 caesarean section under general anaesthesia revealed a Couvelaire uterus and a retroplacental clot involving approximately 40% of the placental surface of Twin 2. Twin 2 (1100 g) was delivered by breech extraction with Apgar scores of 1 and 3 and an umbilical arterial pH of 7.01. The mother developed uterine atony, a 2000 mL haemorrhage and disseminated intravascular coagulation (DIC; INR 1.8, fibrinogen
90 mg/dL), managed with a massive transfusion protocol, uterotonics, tranexamic acid and B-Lynch compression sutures, with preservation of the uterus. Mother and surviving twin were discharged in stable condition.
Conclusion: This “double-hit” placental emergency suggests that sudden uterine decompression after expulsion of one placenta may precipitate abruption of the co-twin’s placenta. Rapid recognition of both pathologies, immediate operative delivery, early activation of a massive transfusion protocol and skilled neonatal resuscitation allowed survival of both mother and co-twin. To our knowledge, this sequence with survival of both has not been previously reported.
