Differential Diagnosis for Severe Pelvic Pain
The patient's presentation of severe pelvic pain, an irregularly enlarged uterus, and a spherical mass visible through the external os, along with her history of heavy menstrual flow and occasional passage of clots, guides the differential diagnosis.
Single Most Likely Diagnosis
- Uterine Rupture due to a Uterine Leiomyoma (Fibroid): The presence of a firm, round mass (likely a fibroid) protruding through the cervix, severe pelvic pain unrelieved by ibuprofen, and the patient's history of heavy menstrual flow and passage of clots, make this a highly plausible diagnosis. The recent menstrual period and the patient's age also support the possibility of a fibroid.
Other Likely Diagnoses
- Ectopic Pregnancy: Given the patient's sexual activity without routine contraception, ectopic pregnancy must be considered, especially with symptoms of severe pelvic pain and a dilated cervix. However, the presence of a visible mass and the timing relative to her menstrual period make this less likely.
- Ovarian Torsion: This condition can cause severe pelvic pain and could be associated with a mass if an ovarian cyst is involved. However, the specific findings of a uterine mass and the patient's menstrual history point more towards a uterine issue.
- Placenta Accreta or Percreta in a Pregnant Uterus: Although less likely given the patient's recent menstrual period, if the patient were pregnant, these conditions could cause severe pain and a uterine mass effect. The history of a dilation and curettage increases the risk of placenta accreta.
Do Not Miss Diagnoses
- Ruptured Ectopic Pregnancy: Although considered in the likely diagnoses, it's crucial to emphasize that missing this diagnosis can be fatal. The patient's presentation of severe pain and tachycardia (elevated pulse rate) necessitates immediate consideration of this life-threatening condition.
- Uterine Rupture due to Other Causes (e.g., Trauma, Previous Uterine Surgery): Any condition leading to uterine rupture is an emergency. The patient's history of a previous dilation and curettage and current symptoms necessitate careful evaluation for uterine integrity.
Rare Diagnoses
- Uterine Sarcoma: Although rare, uterine sarcomas can present with pelvic pain and a uterine mass. The patient's age and symptoms could align with this diagnosis, but it is much less common than uterine fibroids.
- Gestational Trophoblastic Disease (GTD): This includes conditions like hydatidiform mole, which can cause uterine enlargement and bleeding. However, GTD typically presents with abnormal uterine bleeding and is less likely given the patient's recent normal menstrual period and the specific findings on examination.