Differential Diagnosis for Postpartum Bleeding
The patient presents with continuous, dark red vaginal bleeding with small clots following a forceps-assisted vaginal delivery. The following differential diagnoses are considered:
- Single most likely diagnosis
- Retained products of conception (RPOC): This is a common cause of postpartum bleeding, especially after a traumatic delivery like forceps assistance. The presence of a firm, nontender uterine fundus and minimal bleeding suggests that uterine atony is less likely, making RPOC a more probable cause.
- Other Likely diagnoses
- Uterine atony: Although the uterine fundus is firm, uterine atony cannot be completely ruled out, especially in the context of a recent delivery and postpartum bleeding.
- Perineal laceration complications: Despite the perineal laceration repair being intact, there is still a possibility of underlying complications, such as a hematoma or infection, contributing to the bleeding.
- Endometritis: The patient's temperature is slightly elevated, and the presence of leukocytosis (elevated white blood cell count) could indicate an infectious process like endometritis.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Uterine rupture or dehiscence: Although rare, this is a life-threatening condition that requires immediate attention. The patient's history of forceps-assisted delivery and third-degree perineal laceration increases the risk.
- Coagulopathy: The patient's low platelet count and hemoglobin level could indicate a coagulopathy, such as disseminated intravascular coagulation (DIC), which is a serious and potentially life-threatening condition.
- Placenta accreta spectrum (PAS) disorders: Although less likely, PAS disorders can cause severe postpartum bleeding and are often associated with placental invasion into the uterine wall.
- Rare diagnoses
- Uterine artery pseudoaneurysm: This is a rare but potentially life-threatening condition that can cause postpartum bleeding.
- Von Willebrand disease or other bleeding disorders: Although rare, these conditions can increase the risk of postpartum bleeding and should be considered in patients with a history of bleeding disorders or unexplained bleeding.