Differential Diagnosis for Postpartum Vaginal Bleeding
- Single most likely diagnosis
- Uterine atony: This is the most common cause of postpartum hemorrhage, especially given the patient's history of multiple vaginal deliveries, which increases the risk of uterine atony. The soft uterine fundus on examination supports this diagnosis.
- Other Likely diagnoses
- Retained placental tissue: The presence of large clots and the distended lower uterine segment could indicate that parts of the placenta were not fully expelled during delivery, leading to bleeding.
- Lacerations or trauma: Although the delivery was described as uncomplicated, the possibility of internal lacerations or trauma that were not immediately apparent cannot be ruled out, especially with the significant bleeding.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed)
- Uterine rupture: Although rare, especially in the absence of a previous uterine scar, the severe bleeding and distension of the lower uterine segment necessitate consideration of this life-threatening condition.
- Amniotic fluid embolism: This is a rare but potentially fatal condition that could present with sudden onset of bleeding, hypotension, and other systemic symptoms.
- Coagulopathy: The patient's chronic hypertension and history of pregnancy could predispose her to a coagulopathy, such as disseminated intravascular coagulation (DIC), which would require immediate attention.
- Rare diagnoses
- Placenta accreta spectrum disorders: Given the patient's history of a previous dilation and curettage, there is a slight increased risk of placenta accreta, although this would typically be identified during pregnancy or immediately postpartum.
- Uterine inversion: This is a rare complication where the uterus turns inside out, which could cause severe bleeding and is a medical emergency.