Case Study

I thought I'd post an interesting case here and see what you midwives, midwives-to-be and medical detective/mystery junkies think.

S:  A 28 year old G3P2002 presents to the community care clinic stating that she is 22 weeks pregnant with a certain last menstrual period (LMP) of 3/17/2011.  Patient states her abdomen has grown larger as it did with previous pregnancies and that she can feel her baby move.  The problem lies in that she has taken numerous HPTs (home pregnancy tests), and they have all been negative.  She has presented to the ER at 8 weeks with spotting where a urine pregnancy and a B-hCG were completed and both were negative.  The ER physician told her she was not pregnant and did not exam her further (no ultrasound or other assays).  The patient is uninsured and so she does not have a primary care provider.  The patient has no other complaints.  Denies problems with bowel or bladder, no nausea or vomiting, no pain and spotting has ceased since ER visit.  Patient is stressed because she says she is sure she is pregnant, but no one believes her.

O:  T 36.4, BP 128/76, P 100, R 40, weight 138 - up 8# since LMP
Head & Neck - mild exophthalmia, no thyromegaly
Heart - tachycardic, regular rhythm
Lungs - clear to auscultation bilaterally, tachypneic
Abd - appears gravid, soft, nontender, no masses noted
Uterus - consistent with 8 weeks, no fetal parts palpated, no movement noted
FHT - none found by doppler in all 4 quadrants
Urine pregnancy test - negative
No US machine at community clinic

What is your plan of care?

Our plan was to order laboratory assays - CBC, CMP, thyroid panel, LH, FSH and prolactin, quant B-hCG, CA 125, and an ultrasound.  However patient is self-pay and would not be able to afford all of the tests.  The quant B-hCG alone was $127.

We referred her to the high risk resident Women's Clinic and she has an appointment on next Wednesday a.m.

So let's take a poll and see what your differential diagnosis would be.  I will report back next week with lab assays and definitive diagnosis.