Differential Diagnosis for Chest Pain in a 37-year-old Pregnant Woman
- Single most likely diagnosis:
- Pulmonary embolism (PE): The patient's presentation of sharp, substernal chest pain that worsens with inspiration and radiates to the right upper quadrant, along with decreased breath sounds over the right lung base and tachycardia, is highly suggestive of a pulmonary embolism. The patient's recent admission for preterm labor and reduced mobility increase her risk for venous thromboembolism, despite receiving heparin for prophylaxis.
- Other Likely diagnoses:
- Pneumonia: Although the patient does not have a fever or cough, pneumonia could still be a consideration, especially with decreased breath sounds over one lung base. However, the lack of typical respiratory symptoms makes this less likely.
- Pleurisy: The sharp chest pain that worsens with inspiration could be indicative of pleurisy, which can occur in pregnancy due to various causes. However, the absence of a fever or other signs of infection makes this less likely.
- Musculoskeletal pain: The patient's reduced activity level and recent hospital admission could contribute to musculoskeletal chest pain, but the severity and radiation of the pain, along with decreased breath sounds, suggest a more serious condition.
- Do Not Miss diagnoses:
- Aortic dissection: Although less common, aortic dissection is a life-threatening condition that can present with severe, tearing chest pain. Pregnancy increases the risk of aortic dissection, particularly in women with pre-existing conditions like hypertension or connective tissue disorders. The patient's blood pressure is within a relatively normal range, but this diagnosis cannot be missed due to its high mortality rate.
- Cardiac ischemia/infarction: Myocardial infarction can occur in pregnancy and may present atypically. The patient's chest pain and tachycardia warrant consideration of cardiac ischemia, especially given the physiological changes of pregnancy that can increase cardiac demand.
- Placental abruption: Although the patient denies vaginal bleeding, placental abruption can sometimes present with abdominal or back pain and should be considered, especially in the context of a twin pregnancy which carries a higher risk of complications.
- Rare diagnoses:
- Amniotic fluid embolism: This is a rare but catastrophic condition that can occur during pregnancy. It typically presents with sudden onset of hypotension, hypoxia, and either cardiac arrest or coagulopathy, which does not match the patient's current presentation but should be kept in mind for any rapid deterioration.
- Spontaneous coronary artery dissection (SCAD): This is a rare cause of myocardial infarction that can occur in pregnancy, often without traditional risk factors for coronary artery disease. The patient's presentation does not strongly suggest SCAD, but it remains a rare consideration in the differential diagnosis of chest pain in pregnancy.