Differential Diagnosis
- Single most likely diagnosis
- Postpartum hematoma: The patient's symptoms of sharp lower midline abdominal pain radiating down her legs while ambulating, focal tenderness to palpation just inferior to the bladder, and a history of a complicated vaginal delivery with shoulder dystocia suggest a postpartum hematoma. The fact that she has no pain while lying down and the pain is exacerbated by ambulation also supports this diagnosis.
- Other Likely diagnoses
- Uterine dehiscence or rupture: Although less likely given the patient's stable vital signs and lack of severe abdominal pain, uterine dehiscence or rupture could still be considered, especially given the history of a complicated delivery with shoulder dystocia.
- Endometritis: The patient's symptoms of lower abdominal pain and focal tenderness could also be consistent with endometritis, although the lack of fever and uterine tenderness makes this diagnosis less likely.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Pulmonary embolism: Although the patient's symptoms do not strongly suggest pulmonary embolism, it is a potentially life-threatening condition that must be considered in any postpartum patient with acute onset of pain, especially if the pain is severe or accompanied by respiratory symptoms.
- Ureteral injury or obstruction: The patient's symptoms of sharp lower midline abdominal pain radiating down her legs could also be consistent with a ureteral injury or obstruction, which would require prompt diagnosis and treatment to prevent long-term complications.
- Rare diagnoses
- Ovarian torsion: Although rare in the postpartum period, ovarian torsion could present with acute onset of lower abdominal pain and should be considered if other diagnoses are ruled out.
- Postpartum preeclampsia: The patient's symptoms of lower abdominal pain and edema could also be consistent with postpartum preeclampsia, although the lack of hypertension and other symptoms makes this diagnosis less likely.