Differential Diagnosis
- Single most likely diagnosis
- Postpartum hematoma: The patient's symptoms of sharp lower midline abdominal pain radiating down her legs while ambulating, focal tenderness to palpation just inferior to the bladder, and a history of a complicated vaginal delivery with shoulder dystocia suggest a postpartum hematoma. The fact that she has no pain while lying down and the pain is exacerbated by ambulation also supports this diagnosis.
- Other Likely diagnoses
- Uterine dehiscence or rupture: Although less likely given the patient's stable vital signs and lack of severe abdominal pain, uterine dehiscence or rupture is a possible complication of a vaginal delivery, especially with a history of shoulder dystocia.
- Endometritis: The patient's symptoms of lower abdominal pain and focal tenderness could also be consistent with endometritis, although the lack of fever and uterine tenderness makes this diagnosis less likely.
- Urinary retention: The patient's difficulty ambulating and sharp lower midline abdominal pain could be related to urinary retention, although she has voided twice without difficulty and has no dysuria.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Pulmonary embolism: Although the patient has no symptoms of shortness of breath or chest pain, pulmonary embolism is a potentially life-threatening condition that must be considered in any postpartum patient with sudden onset of pain or difficulty ambulating.
- Spinal epidural hematoma: Given the patient's history of epidural analgesia during labor, spinal epidural hematoma is a rare but potentially devastating complication that must be considered, especially if the patient develops numbness, weakness, or bowel/bladder dysfunction.
- Rare diagnoses
- Ovarian torsion: Although rare in the postpartum period, ovarian torsion could present with sudden onset of severe abdominal pain and should be considered if other diagnoses are ruled out.
- Deep vein thrombosis: The patient's moderate edema in the lower extremities could be consistent with deep vein thrombosis, although this diagnosis is less likely given the lack of pain or erythema in the affected areas.