Differential Diagnosis for a 19-year-old Woman at 38 Weeks Gestation
Single Most Likely Diagnosis
- Placental Abruption: This condition is highly suspected due to the patient's history of a classical cesarean delivery for placental abruption in her previous pregnancy, current symptoms of severe abdominal pain and vaginal bleeding, and the presence of an irregular abdominal mass. The patient's smoking and cocaine use also increase her risk for placental abruption.
Other Likely Diagnoses
- Placenta Previa: Although less likely than placental abruption given the patient's history and symptoms, placenta previa could still be a consideration, especially with vaginal bleeding. However, the presence of an abdominal mass and the nature of the pain might lean more towards abruption.
- Uterine Rupture: Given the patient's history of a classical cesarean section, uterine rupture is a possibility, especially with severe abdominal pain and an irregular mass. However, the absence of contractions and the specific characteristics of the pain and bleeding might make this less likely than abruption.
Do Not Miss Diagnoses
- Uterine Rupture: While mentioned as another likely diagnosis, it's crucial to emphasize that missing a uterine rupture could be catastrophic. The patient's history of a classical cesarean delivery increases this risk, making it imperative to consider, despite its lower likelihood based on the presentation.
- Amniotic Fluid Embolism (AFE): Although less common and not directly suggested by the symptoms provided, AFE is a potentially deadly condition that can occur during late pregnancy and should be considered in the differential diagnosis of any pregnant woman presenting with severe abdominal pain and instability.
Rare Diagnoses
- Vasa Previa: This condition involves the fetal blood vessels crossing over or near the internal cervical os, which can cause significant bleeding if ruptured. It's less likely given the patient's presentation but could be considered if other more common causes are ruled out.
- Uterine Dehiscence: Similar to uterine rupture but involves a partial separation of the uterine scar. It might present with less severe symptoms initially but can progress to rupture, making it a rare but important consideration in someone with a history of uterine surgery.