Barreling down an empty two-lane highway in California's southern Mojave Desert, Cindy Lupica told her husband through gritted teeth that she wasn't going to make it to the closest hospital, more than 20 miles away.
Lupica, then 37, had seen her obstetrician that morning and knew their fourth child would be born soon — but she didn't expect this soon. A little after 6 p.m. on Sept. 30, 2013, the couple was just three miles from home when Michael Lupica pulled his pickup truck to the side of Highway 18 and punched 911 on his cellphone. Minutes later, a firetruck and an ambulance staffed mostly with trainee paramedics roared up beside them. They loaded Cindy into the ambulance before speeding to St. Mary Medical Center in Apple Valley.
Kylie Lupica was born just as they pulled into the parking lot.
Although the baby turned out to be fine, Lupica would not be. She would not learn what was wrong until four months later, after suffering a massive hemorrhage in the restroom of another hospital.
Her last pregnancy and delivery would inextricably link one of life's happiest experiences with one of its most terrifying.
"It took a long time to process," she said. "We're still digesting it."
A chaotic delivery
Lupica was accustomed to being self-sufficient. She lived in the sparsely populated desert community of Lucerne Valley in San Bernardino County and home-schooled her older children. At the time of Kylie’s birth, they were 14, 12 and 4.
During her previous pregnancies, there had been complications involving the placenta, the organ that develops during pregnancy and provides nutrients to the fetus. In 2009, after her third child was born, she underwent a dilation-and-curettage procedure to treat a retained placenta.
Lupica's fourth pregnancy was uneventful until about the 25th week, when she began having regular contractions.
Her obstetrician, Om Prakash, told Lupica that she was probably having normal Braxton Hicks contractions, which are a precursor of labor. When they persisted, Prakash advised her to take it easy and stop exercising.
"These didn't feel like Braxton Hicks," Lupica said, but otherwise she felt well. Her prenatal exams and ultrasounds were normal, Prakash said. He met Lupica at the hospital when the ambulance arrived and delivered the placenta, which looked healthy.
A month after giving birth, Lupica said, she began bleeding.
Medical Mystery illustration for10-31-2017.Cameron Cottrill for The Washington Post (Cameron Cottrill for The Washington Post)
Postpartum vaginal bleeding, Prakash said, is not uncommon. "Ninety-nine percent of the time," he said, "it's normal spotting."
But Lupica said she felt uneasy. A Pap smear was normal, and Lupica said she was relieved when the intermittent bleeding stopped after about a month. A few weeks later, when it recurred, Prakash told her she was probably getting her period.
“I thought, ‘Well, my hormones must really be out of whack,” she recalled.
‘Something suspicious’
About four months after Kylie’s birth, Lupica said, she awoke in the middle of the night to discover that she was drenched in blood.
“I woke up my husband, and I was crying and told him something is really wrong,” she recalled, although the bleeding by then had abated. The next morning, she telephoned Prakash, who told her to come to his office.
Lupica vividly remembers the appointment. Given the quantity of blood she had lost, "I already knew something serious was going on." That ominous feeling was underscored when the obstetrician-gynecologist "took us straight back," escorting her past the other patients in the waiting room.
Prakash performed an ultrasound, which revealed something distinctly alarming: a large growth that resembled a cluster of grapes on the right side of Lupica’s uterus.
“It scared the heck out of me” Prakash recalled. He was fairly certain he knew what it was, having seen a similar case about 30 years earlier.
“There’s something suspicious,” he told the couple. Because he didn’t want to panic them, he said, he didn’t tell them what he suspected. He advised the Lupicas to go toa public hospital several hours from their home first thing the next morning.
Because Lupica had no health insurance at the time, Prakash said, seeking care there would allow her to receive the expensive treatment he suspected she would need without bankrupting her family.
Around 8 a.m. the next morning, the couple arrived at the ER. It would take nearly 12 hours, Lupica said, for doctors to admit her.
“First I was told I was miscarrying, then I was told I was pregnant,” she recalled. “I was tossed from team to team.” No one seemed sure what to do with her, she said. Lupica said she adamantly refused to leave the hospital, fearing that she might bleed to death at home in the middle of the night.
Late in the afternoon, Lupica realized she had begun bleeding again and ducked into a bathroom. She quickly realized she was hemorrhaging and, “terrified and embarrassed,” managed to attract the attention of a passing nurse.
The nurse summoned a doctor, who took one look at her and barked an order for a "STAT beta hCG," an immediate blood test to measure beta human chorionic gonadotropin. The test is used to confirm a pregnancy or to detect certain abnormalities.
“At that point, it was sort of like in the movies where everything goes blurry,” she said, as nurses and doctors rushed in to try to stop the bleeding.
Thirty minutes later, Lupica recalled, a trio of grim-faced doctors trooped into the room where she lay on a gurney.
A shocking diagnosis
“We finally have an answer,” Lupica recalls one doctor saying. “You have choriocarcinoma.”
“It sounds like cancer,” Lupica replied.
"It is," one doctor confirmed. Her postpartum bleeding was the result of a rare and aggressive malignancy that grows in the uterus and is sometimes called placenta cancer. As she and her husband sat in stunned silence, doctors told Lupica that they were admitting her immediately and that she would begin chemotherapy as soon as possible, after testing to determine whether her cancer had spread.
Choriocarcinoma occurs in about 2 to 7 of every 100,000 pregnancies in the United States. It results when a tumor — also known as a mole — develops after conception. Instead of a viable embryo, the result is a molar pregnancy, which can mimic a normal pregnancy.
Most moles are benign, but some become malignant, resulting in a cancer that tends to be fast-growing but curable, especially if caught early. Among the risk factors for malignancy is age: Women younger than 20 and older than 35 are at elevated risk. The most common symptom is vaginal bleeding. Choriocarcinoma can spread to distant parts of the body, usually the brain, liver or lungs.
Although Lupica's liver and brain showed no sign of cancer, a spot was found on her lung. Her bhCG reading was sky-high: 221,000 milli-international units per milliliter of blood. The normal level in pre-menopausal women who are not pregnant should be less than 5.
It is not clear when Lupica's tumor developed. Although some moles form during a pregnancy, about 25 percent occur after a normal delivery, a miscarriage or an abortion. Although the oncologists who treated her cancer could not be reached, Lupica said that they told her she was carrying the tumor during her pregnancy with Kylie. (A healthy birth accompanied by a complete molar pregnancy is an extremely rare event.)
But Prakash said he doubts the tumor was present then: Nothing was ever visible on the ultrasounds performed during her pregnancy, which was otherwise normal. So too, he said, was her delivery, other than the fact that it occurred in an ambulance.
“During her pregnancy, there was nothing to suggest that something was going on,” Prakash said. He suspects the mole developed after Kylie was born. And until the night when she awoke bleeding heavily, Prakash said, her postpartum bleeding did not seem out of the ordinary.
Lupica began chemotherapy soon after she was admitted. Because methotrexate, the standard drug, did not work, she was placed on an aggressive regimen involving five medicines.
“It was very tough,” Lupica recalled.
By July 2014, the date of her final chemo treatment, her bhCG level had dropped to zero and the spot on her lung had disappeared. For patients with metastatic disease, the probability of a cure can exceed 80 percent, according to the American Cancer Society. Three years out, Lupica remains cancer-free.
“I can’t believe I’m a survivor,” she said.
The aftermath
After her recovery — a process that involved dealing with the trauma suffered by her three older children who worried she would die — Lupica decided to raise awareness of her rare disease, one that many people have never heard of.
She has become an advocate for choriocarcinoma patients and those with similar diseases, and she is active on Facebook. From her home in the Mojave, she said, she has sought to raise money for research being conducted at Boston's Brigham and Women's Hospital. Donald Goldstein, an eminent OB/GYN there, pioneered treatment for choriocarcinoma and related cancers.
Lupica said that her oncologists twice consulted with Goldstein about her case.
She credits her faith and her family with helping her endure the ordeal. “I’m still getting little bits of healing,” she said. “Helping other women is helping me.”
Submit your solved medical mystery to sandra.boodman@washpost.com. No unsolved cases, please. Read previous mysteries at wapo.st/medicalmysteries.
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