Delayed Diagnosis of Molar Pregnancy Leads to Uterine Cancer

This case involves a 24-year-old woman who was approximately 6 weeks pregnant after using Bravelle, when she developed cramping and bleeding that prompted her to go to the ER. She was seen by an ER doctor who ordered an abdominal and vaginal ultrasound but never called an Ob/Gyn consultation. She was told that they found no signs of a viable fetus but that a normal heartbeat should not be expected at such an early stage of pregnancy. At the initial visit, she was given Rhogam and discharged home. The patient returned home and continued to bleed substantially to the point where she had no other option but to return to the ER. On this visit the ER, physicians again proceeded without an Ob/Gyn consult and determined that the patient had a miscarriage; no D&C was scheduled or discussed with the patient. One month later the patient began to hemorrhage and again returned to the hospital. An eventual Ob/Gyn consult informed her that she had a complete molar pregnancy and needed an immediate D&C. The patient was referred to an oncologist based on high HCG levels and she was then told she had uterine cancer.

Question(s) For Expert Witness

1. What is the standard of care in identifying and treating molar pregnancy and should this cancer have been identified earlier?

Expert Witness Response E-000051

The ED doctor's management was inadequate, most notably with respect to poor follow-up. Not only molar pregnancy, but ectopic pregnancy as well were possible diagnoses, and only close follow-up and appropriate testing would have revealed the correct diagnosis. A Quantitative Beta Human Chorionic Gonadotropin level (QBHCG) should have been obtained on the first visit, and compared to a repeat level two days later. Likewise serial ultrasounds should have been ordered. This sequence of tests is important to discriminate a viable pregnancy from a miscarriage, from an ectopic pregnancy, from a molar pregnancy. It is likely that such testing would have strongly suggested the diagnosis of molar pregnancy right at the outset. The miscarriage should have been managed, or at the very least followed closely by someone with the capability to manage it. Therefore the failure to obtain Ob/Gyn consultation was below the standard of care. There are several ways to manage a presumed miscarriage, but they are all predicated on favorable test results from the serial testing (QBHCG and ultrasound), and the patient's clinical situation improving. A D & C is the final common pathway of diagnosis and management, and should have been performed much earlier in this patient. It would have stopped the bleeding and confirmed the diagnosis of molar pregnancy.