Differential Diagnosis for Postpartum Hemorrhage and Sudden Onset of Shortness of Breath and Chest Pain
- Single most likely diagnosis:
- Amniotic fluid embolism (AFE) is less likely given the clinical context, but the most likely diagnosis is severe postpartum hemorrhage (PPH) leading to hypovolemic shock and possibly disseminated intravascular coagulation (DIC). The patient's heavy vaginal bleeding, low blood pressure, tachycardia, and coagulopathy (elevated INR, prolonged prothrombin time, and activated PTT) support this diagnosis. The sudden onset of shortness of breath and chest pain could be related to the hypovolemic shock or a pulmonary embolism, but in this context, it's more likely related to the severe blood loss and potential cardiac strain.
- Other Likely diagnoses:
- Pulmonary embolism: Given the patient's sudden onset of shortness of breath and chest pain, a pulmonary embolism is a possible diagnosis, especially in a patient with a high-risk condition like sickle cell disease and recent childbirth, which increases the risk of thromboembolic events.
- Uterine atony with coagulopathy: The patient's soft and distended uterus, despite uterotonic agents, suggests uterine atony, which is a common cause of PPH. The coagulopathy (as evidenced by the lab results) complicates the management and increases the risk of further bleeding.
- Do Not Miss diagnoses:
- Pulmonary thromboembolism: As mentioned, this is a critical diagnosis to consider due to its high mortality rate if not promptly treated. The symptoms of shortness of breath and chest pain, even in the context of severe PPH, mandate consideration of this diagnosis.
- Cardiac complications (e.g., myocardial infarction, peripartum cardiomyopathy): Although less likely, cardiac complications could present with similar symptoms and are potentially life-threatening if not recognized and treated promptly.
- Rare diagnoses:
- Air embolism: Although rare, it could occur in the setting of significant trauma or invasive procedures and presents with sudden onset of hypotension, shortness of breath, and potentially chest pain.
- Sickle cell crisis: While the patient has sickle cell disease, the acute presentation here is more suggestive of complications related to the postpartum hemorrhage rather than a sickle cell crisis. However, it's a consideration in the broader differential for a patient with this underlying condition.