Complex Case of Persistent Positive Pregnancy Test Following Confirmed Miscarriage

Case at a Glance

A 25-year-old woman presents with persistently positive pregnancy tests and rising hCG levels six weeks after a confirmed complete miscarriage, despite having what appeared to be a normal menstrual period and negative ultrasound findings.

Patient's Story

The patient, a 25-year-old female (height 5'3", weight 57kg), experienced a miscarriage at approximately 6-8 weeks gestation. The miscarriage began on June 10th with heavy bleeding lasting one week. Follow-up ultrasound on June 17th confirmed complete passage of products of conception with only minimal clots remaining, which passed naturally. She subsequently had what she believed to be a normal menstrual period on July 3rd-8th, which was heavier and more painful than usual but consistent with post-miscarriage expectations. The patient had protected intercourse once on June 27th. On July 10th, a routine pregnancy test was unexpectedly positive, prompting urgent gynecological evaluation.

Initial Assessment

Patient presented with positive home pregnancy tests showing progressively darker lines, lower abdominal pain (intermittent), and light spotting with bright red blood (different from normal menstrual flow). Physical examination revealed no obvious abnormalities. Patient denied typical pregnancy symptoms that were present during her previous pregnancy.

The Diagnostic Journey

Transvaginal ultrasound revealed thin endometrial lining, a small ovarian cyst, and no visible intrauterine or ectopic pregnancy. No retained products of conception were identified. Urine pregnancy test confirmed positive result. Serial hCG levels were ordered to determine if levels were rising, falling, or plateauing. The patient's hCG had been appropriately declining following the initial miscarriage, making the current positive tests concerning for either new pregnancy, retained tissue, or gestational trophoblastic disease.

Final Diagnosis

Pending - Differential diagnosis includes: 1) New early pregnancy (less likely given timing and ultrasound findings), 2) Retained products of conception not visible on ultrasound, 3) Gestational trophoblastic disease, 4) Persistent trophoblastic tissue. The case was complicated by the timing of apparent menstruation and negative imaging despite positive pregnancy tests.

Treatment Plan

Serial quantitative beta-hCG monitoring every 48-72 hours to determine trend. Complete blood count and comprehensive metabolic panel. Continued pelvic rest and monitoring of symptoms. Patient counseled on warning signs requiring immediate medical attention including severe abdominal pain, heavy bleeding, or systemic symptoms. Follow-up scheduled within one week or sooner if symptoms worsen.

Outcome and Follow-up

Results pending at time of case documentation. Patient and partner experiencing significant anxiety due to diagnostic uncertainty. Multidisciplinary consultation with gynecologic oncology considered if hCG levels remain elevated or rise, given concern for gestational trophoblastic disease. Patient referred to pregnancy loss support resources for emotional support during diagnostic workup.