Differential Diagnosis for Postpartum Hemorrhage
The patient's presentation of profuse vaginal bleeding after delivery, unresponsive to uterine massage and uterotonic medications, suggests a complex cause for the postpartum hemorrhage (PPH). The following differential diagnoses are considered:
Single most likely diagnosis
- Uterine inversion or placenta accreta spectrum (PAS) disorders: The history of multiple dilation and curettage procedures increases the risk of placenta accreta spectrum disorders. The avulsion of the umbilical cord from the placenta and the need for manual extraction of the placenta in pieces are highly suggestive of an abnormal placental attachment, such as placenta accreta. Uterine inversion, although less likely given the firm uterus, could also be considered but is less probable without a history of excessive traction on the umbilical cord during delivery.
Other Likely diagnoses
- Retained placental tissue: The placenta was extracted in pieces, which increases the likelihood that some placental tissue may have been retained, leading to continued bleeding.
- Uterine atony: Although the uterus is described as firm, uterine atony cannot be completely ruled out, especially if the firmness is not uniformly maintained throughout the uterus.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Amniotic fluid embolism (AFE): Although AFE typically presents with sudden onset of hypotension, hypoxia, and either cardiac arrest or coagulopathy, it can sometimes manifest with postpartum hemorrhage. Given the severity of AFE, it's crucial to consider it, even if the presentation is atypical.
- Coagulopathy: Pre-existing or acquired coagulopathies can lead to severe postpartum hemorrhage. The patient's lack of prenatal care makes it difficult to assess her coagulation status prior to delivery.
Rare diagnoses
- Uterine rupture: Given the patient's history of multiple uterine procedures (dilation and curettage), there is a small risk of uterine rupture, especially if the previous procedures caused significant uterine scarring.
- Vascular anomalies or lacerations: Although less common, vascular anomalies or lacerations (e.g., uterine artery laceration) could lead to severe, uncontrolled bleeding. These would be rare but important considerations if other causes are ruled out.