What is the most likely cause of postpartum hemorrhage in a patient with a soft uterus and recent expression of clotted blood from the lower uterine segment?

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Differential Diagnosis for Postpartum Hemorrhage

The patient presents with significant bleeding 60 minutes after delivery, with a soft uterus and expression of 1,000 mL of clotted blood from the lower uterine segment. The following differential diagnoses are considered:

  • Single most likely diagnosis

    • Uterine atony: This is the most common cause of postpartum hemorrhage, especially given the patient's soft uterus and the presence of clots. Uterine atony occurs when the uterus fails to contract down effectively after delivery, leading to excessive bleeding.

  • Other Likely diagnoses

    • Retained placental tissue: Although the ultrasound revealed a thin endometrial stripe, it's possible that some placental tissue was retained, especially given the history of placental avulsion and manual extraction. Retained placental tissue can cause bleeding due to incomplete separation of the placenta from the uterus.
    • Laceration or trauma: The patient had a forceps-assisted vaginal delivery and a third-degree perineal laceration, which increases the risk of bleeding from the laceration site or other areas of trauma.

  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

    • Uterine inversion: This is a life-threatening condition where the uterus turns inside out, either partially or completely. It can occur due to excessive traction on the umbilical cord during delivery, as seen in this patient. Uterine inversion can cause severe bleeding and shock.
    • Amniotic fluid embolism: Although less likely, amniotic fluid embolism is a catastrophic condition that can occur during delivery. It's essential to consider this diagnosis, especially if the patient shows signs of cardiovascular collapse or respiratory distress.

  • Rare diagnoses

    • Placenta accreta spectrum (PAS) disorders: These disorders occur when the placenta abnormally adheres to the uterus. Although rare, PAS disorders can cause severe bleeding during delivery, especially if the placenta is manually extracted.
    • Coagulopathy: The patient's history of hypertension and asthma does not suggest a coagulopathy, but it's essential to consider this diagnosis, especially if the patient has a history of bleeding disorders or is taking medications that affect coagulation.

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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