Differential Diagnosis for Vaginal Bleeding at 38 Weeks' Gestation
The patient presents with vaginal bleeding, severe abdominal pain, and a history of a previous cesarean section. The clinical findings and history guide the differential diagnosis into the following categories:
Single Most Likely Diagnosis
- B. Abruptio placentae: This condition, also known as placental abruption, is characterized by the premature separation of the placenta from the uterus. It is consistent with the patient's symptoms of vaginal bleeding, severe abdominal pain, and the presence of recurrent variable decelerations on the fetal heart rate monitor. The patient's history of contractions preceding the bleeding, which then stopped, also supports this diagnosis, as abruptio placentae can cause uterine contractions to cease due to placental separation.
Other Likely Diagnoses
- D. Uterine rupture: Given the patient's history of a previous lower segment transverse cesarean section and the presentation of severe abdominal pain and vaginal bleeding, uterine rupture is a plausible diagnosis. Uterine rupture can cause cessation of contractions and is a serious complication that requires immediate attention.
- A. Placenta previa: Although less likely given the presence of abdominal pain and the pattern of bleeding, placenta previa cannot be ruled out without further imaging. It typically presents with painless vaginal bleeding, but the clinical picture can vary.
Do Not Miss Diagnoses
- F. Amniotic fluid embolism: Although rare and not directly suggested by the initial presentation of vaginal bleeding and abdominal pain, amniotic fluid embolism is a catastrophic condition that can occur during pregnancy and requires immediate recognition and treatment. The patient's tachycardia and hypotension could be indicative of a severe systemic response.
- C. Vasa previa: This condition involves the fetal blood vessels being present in the membranes covering the cervical os, which can cause significant fetal bleeding if ruptured. It is less likely given the clinical presentation but is critical to diagnose due to its potential for severe fetal morbidity and mortality.
Rare Diagnoses
- E. Uterine inertia: This condition refers to the failure of the uterus to contract sufficiently during labor, which does not directly explain the patient's symptoms of vaginal bleeding and severe abdominal pain. It is less relevant in this acute setting where more emergent conditions are being considered.