This case involves a thirty-five year-old female patient with a past medical history of three prior first trimester miscarriages and in-vitro fertilization treatment. The patient began experiencing classic symptoms of early pregnancy including amenorrhea, nausea and vomiting. The patient took a home pregnancy test which was positive and consulted her OBGYN physician shortly thereafter for prenatal care. At around seven weeks gestation the patient presented to the treating OBGYN complaining of a 12 hour history of vaginal bleeding. On examination, the patient’s uterus was found to be large for dates. A pelvic ultrasound was performed which revealed no viable fetal heartbeat and the patient underwent a dilation and curettage procedure to remove the products of conception. After the procedure was performed samples were sent to a pathology lab for testing. The lab erroneously issued a report stating that the cells from the dilation and curettage were “normal product of conception.” After 26 days the pathology lab amended the report to “complete hydatidiform mole.” Conservative treatment failed to treat the mole and the patient required chemotherapy. Literature suggested that the pathology lab’s failure to correctly identify the molar pregnancy at time of the initial biopsy and immediately start the patient on methotrexate allowed metastatic spread of the disease and led to the subsequent need for aggressive chemotherapy.
Question(s) For Expert Witness
- Do you treat hydatidiform moles? Could a delay in initiating methotrexate treatment cause the potential spread of the disease and the subsequent need for more radical treatment?
Expert Witness Response E-007653
As an OBGYN who Is board certified in gynecologic oncology I diagnose and treat hydatidiform moles several times a month. Immediate initiation of methotrexate for “high risk” complete molar pregnancies has been reported but is out of favor and is certainly not standard of care in the United States. If the diagnosis of a complete hydatidiform mole were known after the dilation and curettage (say, in 7 days rather than 26 days), the standard management would be to follow hCG levels weekly and initiate treatment after levels plateau or rise. Identifying a rise in hCG level usually requires three measurements over the course of two weeks (Day 1, Day 8, Day 15). To know the impact of a two week delay in knowing to begin surveillance would require knowing how quickly the patient’s hCG levels rose, when chemotherapy was initiated, and what her risk score (from WHO) was at the time of initiation. In summary, it is unlikely that delay allowed disease to progress to the point that subsequent therapy was impacted.