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: Although less likely than severe PPH, the sudden onset of shortness of breath and chest pain could suggest a pulmonary embolism, especially in a patient with sickle cell disease who may have an increased 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) could be contributing to the ongoing bleeding.
- Do Not Miss diagnoses:
- Amniotic fluid embolism (AFE): Although the presentation is not classic (no mention of fetal distress or meconium-stained fluid), AFE is a catastrophic condition that can cause sudden onset of hypotension, hypoxia, and coagulopathy. It's essential to consider AFE in any case of sudden cardiovascular collapse during pregnancy or postpartum.
- Sepsis: The patient's tachycardia, tachypnea, and hypotension could also suggest sepsis, particularly if there was chorioamnionitis or another infection. However, there's no clear indication of infection in the provided information.
- Rare diagnoses:
- Peripartum cardiomyopathy: This is a rare condition characterized by heart failure in the last month of pregnancy or within 5 months postpartum, without any other identifiable cause. The patient's shortness of breath, chest pain, and hypotension could be suggestive of cardiomyopathy, but it's less likely given the context of severe PPH.
- Placenta accreta spectrum (PAS) disorders: Although the patient had a spontaneous vaginal delivery, PAS disorders can cause severe PPH. However, there's no indication of abnormal placental attachment in the provided information.