What is the diagnosis for a 36-year-old woman, gravida (number of times pregnant) 1, para (number of viable births) 0, at 38 weeks gestation, presenting with sudden vaginal bleeding, severe lower abdominal pain, uterine tenderness, moderate vaginal bleeding, and proteinuria (3+ protein), with a history of gestational diabetes mellitus and a 5-pack-year smoking history?

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Differential Diagnosis for Sudden Vaginal Bleeding and Severe Lower Abdominal Pain in a 36-year-old Woman at 38 Weeks Gestation

  • Single most likely diagnosis:
    • Placental abruption: This condition is characterized by the premature separation of the placenta from the uterus, leading to vaginal bleeding and abdominal pain. The patient's symptoms of sudden vaginal bleeding, severe lower abdominal pain, and uterine tenderness, along with the presence of protein in the urine (indicating possible preeclampsia), support this diagnosis. The fact that the placenta was noted to be fundal at 20 weeks reduces the likelihood of placenta previa, making abruption more probable.
  • Other Likely diagnoses:
    • Preeclampsia with severe features: The patient's elevated blood pressure (158/96 mm Hg) and proteinuria (3+ protein on urinalysis) are indicative of preeclampsia. Severe abdominal pain can be a feature of severe preeclampsia, especially if there is associated liver capsule distension (Hellp syndrome).
    • Uterine rupture: Although less common, uterine rupture could present with severe abdominal pain and vaginal bleeding, especially in the context of a prolonged or obstructed labor. However, the patient is not reported to have had a previous uterine scar, which is a significant risk factor.
  • Do Not Miss diagnoses:
    • Placenta previa: Despite the ultrasound at 20 weeks showing a fundal placenta, placenta previa cannot be entirely ruled out without a more recent ultrasound, as the placenta can migrate. However, the presence of severe abdominal pain makes this less likely compared to abruption.
    • Uterine dehiscence: Similar to uterine rupture, dehiscence (a partial tear of the uterine wall) could present with severe pain and some vaginal bleeding. It is less common but critical to diagnose promptly.
    • Amniotic fluid embolism (AFE): AFE is a rare but catastrophic condition that can present with sudden onset of severe abdominal pain, bleeding, and cardiovascular collapse. It's essential to consider AFE in the differential diagnosis due to its high mortality rate.
  • Rare diagnoses:
    • Vasa previa: This condition involves the fetal blood vessels crossing over or near the internal cervical os, unprotected by Wharton's jelly. It can cause severe vaginal bleeding, especially with membrane rupture. However, it is less likely given the absence of reported risk factors (e.g., velamentous cord insertion) and the fact that the initial bleeding was described as moderate.
    • Uterine artery rupture or pseudoaneurysm: These are rare causes of antepartum hemorrhage and abdominal pain but are essential to consider in the differential diagnosis due to their potential severity.

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