Differential Diagnosis for Postpartum Hemorrhage
- Single most likely diagnosis:
- Laceration: The presence of a right vaginal sidewall defect and profuse vaginal bleeding after delivery, despite a firm and nontender uterus, suggests a laceration as the most likely cause of the hemorrhage. The fact that there is minimal bleeding from the cervical os and the perineum is intact points towards a lateral vaginal wall injury.
- Other Likely diagnoses:
- Uterine atony: Although the uterus is described as firm and nontender, uterine atony cannot be completely ruled out, especially given the recent use of magnesium sulfate, which can relax the uterus. However, the presence of a firm uterus makes this less likely.
- Retained placental tissue: Although the placenta was delivered, there's always a possibility of retained placental tissue, especially if the delivery was complicated. However, the description provided does not strongly support this diagnosis.
- Do Not Miss diagnoses:
- Uterine rupture: Although less likely given the description of a firm uterus and the absence of severe abdominal pain, uterine rupture is a potentially catastrophic condition that must be considered, especially in a patient with a history of cesarean delivery.
- Coagulopathy: Given the patient's diagnosis of preeclampsia with severe features and the potential for disseminated intravascular coagulation (DIC), coagulopathy must be considered as a possible cause of the bleeding.
- Rare diagnoses:
- Vascular injury: Injury to major pelvic vessels, although rare, could present with sudden onset of severe bleeding. The presence of a vaginal sidewall defect might suggest a possible vascular injury, but this would be less common.
- Placenta accreta spectrum (PAS) disorders: Although the placenta was delivered, and there's no mention of placental invasion into the uterine wall, PAS disorders can cause severe bleeding. However, the clinical presentation and the fact that the placenta delivered with gentle traction make this less likely.