What is the diagnosis for a 39-year-old gravida 4, para 0, aborta 3 woman at 35 weeks gestation, with a history of uterine leiomyoma and abdominal myomectomy, presenting with intense lower abdominal pain, tachycardia, and fetal heart rate tracing showing moderate variability and persistent variable decelerations?

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Differential Diagnosis

  • Single most likely diagnosis
    • Placental abruption: The patient's presentation of intense, constant lower abdominal pain, persistent variable decelerations on the fetal heart rate tracing, and a history of uterine leiomyoma and myomectomy are all consistent with placental abruption. The variable decelerations suggest fetal distress, which is a common finding in placental abruption.
  • Other Likely diagnoses
    • Uterine rupture: Given the patient's history of abdominal myomectomy, where the uterine cavity was entered, there is an increased risk of uterine rupture. The patient's symptoms of intense abdominal pain and the presence of contractions could be indicative of uterine rupture.
    • Preterm labor: The patient is at 35 weeks gestation and presents with contractions, cervical dilation, and effacement, which could suggest preterm labor. However, the presence of intense abdominal pain and fetal distress suggests that there may be an underlying complication.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
    • Uterine dehiscence: Similar to uterine rupture, uterine dehiscence is a life-threatening condition that can occur in patients with a history of uterine surgery. It is essential to consider this diagnosis, especially given the patient's history of myomectomy.
    • Placenta previa: Although the patient's symptoms do not classically suggest placenta previa, it is essential to consider this diagnosis, especially given the patient's history of uterine leiomyoma and myomectomy. Placenta previa can cause severe bleeding and fetal distress.
  • Rare diagnoses
    • Vasa previa: This is a rare condition where the fetal blood vessels are located in the membranes covering the cervix. The patient's symptoms of intense abdominal pain and fetal distress could be suggestive of vasa previa, although it is a less likely diagnosis.
    • Amniotic fluid embolism: This is a rare but life-threatening condition that can occur during pregnancy. The patient's symptoms of intense abdominal pain and fetal distress could be suggestive of amniotic fluid embolism, although it is a less likely diagnosis.

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