27.05.2020 Cases I've never seen Part II - Molar Pregnancy

This is a summary of a case I have been following since nearly the beginning of my stay and that finally resolved itself just as I am finishing up my time here.  The patient presented in February with a positive pregnancy test and some light vaginal bleeding.  My initial thought is a bleed in early pregnancy or potentially an early abort.  Upon ultrasound exam I see the image below and note the large myoma which many patients here have and what is often a common cause of bleeding in early pregnancy.  I cannot detect a gestational sac nor can I exclude an abdominal pregnancy as I didn't have any possibility to do lab work at this time (I didn't manage to establish that until much later).  Given she was pain free and there was no free fluid in the abdomen I decided to have her come back in 2 weeks for check up and of course anytime sooner if she has any pain or an increase in bleeding.

February scan

She is back after a few weeks in March and still has bleeding, her pregnancy test is negative at this point so it supports my early diagnosis of an early abortion with known intrauterine myoma.  We discharge the patient and tell her to report back if she has any problems.

March scan with a slight increase in diameter

More weeks pass and it is now April, the patient presents again with vaginal bleeding and a new positive pregnancy test.  This time I even see what I deem a gestational sac, calculating that she is at most 4 weeks since here last visit with negative pregnancy test.  Great!  She's pregnant again and I hope this time it works out, the bleeding is only light after all.  We have her come back in a few weeks in hopes to see an embryo and determine pregnancy age.  

April scan and what looks like an early gestational sac

End of the month the patient returns with more bleeding, I'm less hopeful at this point that the pregnancy is well.  I scan her abdominally this time and for the first time see an image that I find looks quite different than what I have seen before.  I now determine it would be best to order some lab work, beta- HCG, since we are now able to do so.  

April scan - after which I decide to do some lab work

The result is shocking:  500 mIU/ml!!!  This is like 5 times above the norm and indicative of a non-viable molar pregnancy.  We urgently try to get in touch with the patient and schedule her for a dilation and curettage to remove the material and send to histology for confirmation.  We are able to call her a day or so later and schedule her to come in for the following day.  To my surprise I get a call later that night asking to come in to the hospital for a patient with strong vaginal bleeding and loss of this: 

Looks very much like a molar pregnancy to me according to what I know from the books!

Because the patient is hemodynamically a bit unstable, I decide it it best to transfer her to hospital where blood can be given and more hands are available to help.  It was a good decision.  She received two blood bags and gynecologist and anesthesia were very busy stabilizing and performing a curettage to remove the remaining parts of this placenta.  They analyzed the bit they removed and sent us the concluding report from histology:

Again I'm left speechless, apparently it is not a molar pregnancy but given all the other clinical and lab evidence I conclude this is a misdiagnosis. 

The patient was discharged a few days later and has been back to the MHM hospital to monitor her beta HCG levels.  The results at the time have not been reported yet but should be falling to determine further therapy steps.  I'm not sure though that it would be possible, most require Methotrexat and as far as I know that is not available here.  I hope for the best and that all turns out well for her.