Differential Diagnosis for Postpartum Hemorrhage
- Single most likely diagnosis
- B. Retained products of conception: This is the most likely cause given the patient's history of a forceps-assisted vaginal delivery complicated by postpartum bleeding and the presence of active bleeding from the os without any other obvious source. The fact that the uterus is small, firm, and nontender suggests that uterine atony is less likely, and the absence of endometrial masses or increased vascularity on ultrasonography does not completely rule out retained products of conception, especially if they are small or not highly vascular.
- Other Likely diagnoses
- C. Uterine atony: Although the uterus is described as small and firm, which argues against uterine atony, this condition can still occur and is a common cause of postpartum hemorrhage. The history of a previous postpartum hemorrhage and the need for a blood transfusion also keep this diagnosis in consideration.
- E. Von Willebrand disease: The patient's bleeding time is slightly elevated, which could suggest a coagulopathy such as Von Willebrand disease. This condition could contribute to her heavy bleeding, especially given her history of significant bleeding after delivery.
- Do Not Miss diagnoses
- D. Vaginal hematoma: Although the pelvic examination shows a well-approximated vaginal laceration, a vaginal hematoma could still be present and is a potentially life-threatening condition if not recognized and treated promptly. The absence of abdominal pain does not rule out this diagnosis, as hematomas can sometimes be painless.
- A. Gestational trophoblastic disease: While less likely given the clinical presentation and the fact that it's two weeks postpartum, gestational trophoblastic disease can cause bleeding and should be considered, especially if other causes are ruled out.
- Rare diagnoses
- Other coagulopathies or bleeding disorders (e.g., factor deficiencies) could also be considered but are less likely given the information provided. These would typically present with more significant abnormalities in coagulation studies or a personal/family history of bleeding disorders.