What is the diagnosis for a 30-year-old woman, gravida (number of times pregnant) 2, para (number of viable births) 1, at 28 weeks gestation, presenting with severe abdominal pain, nausea, hypertension, and tachycardia, with a history of tobacco use, polysubstance drug use, and peptic ulcer disease?

Differential Diagnosis for Abdominal Pain in a 30-year-old Pregnant Woman

• Single most likely diagnosis:
  • Placental abruption: The patient's severe abdominal pain, hypertension, and uterine tenderness are consistent with placental abruption, a condition where the placenta separates from the uterus. The history of tobacco and substance use increases the risk of this condition.
• Other Likely diagnoses:
  • Preterm labor: The patient's contractions every 1-2 minutes and abdominal pain could indicate preterm labor, especially given her history of prior cesarean delivery.
  • Uterine rupture: Although less likely, the patient's history of prior cesarean delivery and severe abdominal pain raises the possibility of uterine rupture, which is a life-threatening condition.
  • Peptic ulcer disease exacerbation: The patient's history of peptic ulcer disease and current abdominal pain could suggest an exacerbation of this condition, although the location and nature of the pain might not fully align.
• Do Not Miss diagnoses:
  • Eclampsia: Although the patient does not report vision changes or headache, her hypertension and abdominal pain necessitate consideration of eclampsia, a condition that can rapidly progress and is life-threatening.
  • Uterine dehiscence: Similar to uterine rupture, dehiscence (a partial tear) could present with severe abdominal pain and is a critical condition to identify due to its implications for both mother and fetus.
  • Ruptured ectopic pregnancy: Despite the patient being at 28 weeks gestation, a ruptured ectopic pregnancy, although extremely rare at this gestational age, would be catastrophic if missed.
• Rare diagnoses:
  • Hepatic rupture: This is a rare but potentially life-threatening condition that could present with severe abdominal pain and is associated with pregnancy, particularly in the context of preeclampsia or hepatic tumors.
  • Ovarian torsion: Although less common in pregnancy, ovarian torsion could cause severe abdominal pain and must be considered, especially if other diagnoses are ruled out.