What is the diagnosis for a 32-year-old woman, gravida (number of times pregnant) 3, para (number of viable births) 2, at 38 weeks gestation, with a history of previous cesarean delivery, now presenting with sudden restlessness, intense lower abdominal pain, moderate vaginal bleeding, and fetal heart rate tracing showing recurrent late decelerations?

Differential Diagnosis

• Single most likely diagnosis:
  • Uterine rupture: This is the most likely diagnosis given the patient's history of a previous cesarean delivery, sudden onset of intense lower abdominal pain, and the presence of recurrent late decelerations on fetal heart monitoring. The fact that the cervix is not progressing and the fetal vertex is at a higher station (-3) also suggests a possible uterine rupture.
• Other Likely diagnoses:
  • Placental abruption: This condition is characterized by moderate vaginal bleeding, intense abdominal pain, and fetal distress (recurrent late decelerations). Although the patient's symptoms and fetal heart rate tracing are more suggestive of uterine rupture, placental abruption is still a possible diagnosis.
  • Uterine dehiscence: This is a partial separation of the uterine scar, which can cause abdominal pain, vaginal bleeding, and fetal distress. However, it is less likely than uterine rupture given the severity of the patient's symptoms.
• Do Not Miss diagnoses:
  • Amniotic fluid embolism: Although this condition is rare, it can be life-threatening for both the mother and the fetus. The sudden onset of intense abdominal pain, fetal distress, and maternal restlessness could be indicative of an amniotic fluid embolism.
  • Placenta previa: This condition can cause vaginal bleeding and fetal distress. Although the patient's symptoms are more suggestive of uterine rupture or placental abruption, placenta previa should not be missed as it can be life-threatening.
• Rare diagnoses:
  • Uterine inversion: This is a rare condition where the uterus turns inside out, either partially or completely. It can cause abdominal pain, vaginal bleeding, and fetal distress. However, it is less likely given the patient's symptoms and history.
  • Vasa previa: This condition occurs when the fetal blood vessels are located in the membranes covering the cervix. It can cause vaginal bleeding and fetal distress. Although it is rare, it should be considered in the differential diagnosis, especially if the patient has a history of multiple pregnancies or a previous uterine surgery.