Differential Diagnosis for Vaginal Bleeding at 24 Weeks Gestation
- Single most likely diagnosis:
- Placenta previa: This is the most likely diagnosis given the patient's history of vaginal bleeding after intercourse, bright red blood, and a closed cervix with active bleeding from the os. The patient's previous uterine surgeries, including cesarean deliveries and cervical conization, increase her risk for placenta previa.
- Other Likely diagnoses:
- Placental abruption: Although the patient has a closed cervix and no uterine tenderness, placental abruption is still a possible diagnosis, especially given the presence of large clots in the vaginal vault and active bleeding.
- Cervical insufficiency: The patient's history of cervical conization and multiple pregnancies may increase her risk for cervical insufficiency, which could cause vaginal bleeding.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.):
- Uterine rupture: Although the patient is not showing signs of uterine rupture, such as severe abdominal pain or fetal distress, her history of multiple cesarean deliveries increases her risk for this potentially life-threatening condition.
- Vasa previa: This condition, where fetal blood vessels are present in the membranes covering the cervix, can cause severe vaginal bleeding and is often associated with placenta previa or multiple gestations.
- Rare diagnoses:
- Uterine artery pseudoaneurysm: This rare condition can cause vaginal bleeding, especially in patients with a history of uterine surgery or trauma.
- Choriocarcinoma: Although rare, choriocarcinoma can cause vaginal bleeding during pregnancy, especially in patients with a history of abnormal pregnancy or gestational trophoblastic disease.