A 32 week pregnant lady presents in emergency room with continuous bleeding per vaginum. The uterus is painful and tender. Most likely diagnosis is:
**Core Concept:** Antepartum hemorrhage (APH), also known as threatened abortion or threatened preterm labor, is a significant obstetric emergency characterized by bleeding during pregnancy. It can be classified as either secondary to placental abruption or as primary APH due to uterine causes.
**Why the Correct Answer is Right:** The correct answer, **C. Intrauterine infection (Pyometra)**, is the most likely diagnosis in a 32-week pregnant female with continuous bleeding per vaginum and tender uterus. This condition results from the accumulation of purulent secretions within the uterine cavity due to occlusion of the cervix, leading to an increased risk of infection and inflammation.
**Why Each Wrong Option is Incorrect:**
A. **Cervical incompetence (Cervical erosion)**: This is a less likely cause in a 32-week pregnant patient, as it usually presents earlier in pregnancy with vaginal bleeding. In addition, the cervix may not be tender in this scenario.
B. **Placental abruption**: While this can cause bleeding per vaginum, the persistent pain and tenderness of the uterus are less common in placental abruption cases.
D. **Pyosalpinx (Inflammatory Process)**: This refers to an inflamed fallopian tube, which is unrelated to the clinical picture described in the question. The focus is on the uterus and its tenderness rather than the fallopian tube.
**Clinical Pearl:** In cases of suspected APH, a thorough physical examination is essential to evaluate for uterine tenderness, which can aid in narrowing down the differential diagnosis. Pyometra is a common cause of APH in postpartum women, but its presentation in a pregnant patient is a clue to consider this diagnosis.
**Correct Answer Explanation:** Uterine tenderness in a 32-week pregnant patient indicates that the source of bleeding is likely within the uterus. Pyometra, being an intrauterine infection, presents with signs of uterine inflammation and tenderness, making it the most probable diagnosis in this scenario. Additionally, the patient is already pregnant, making other causes like placental abruption less likely.
**Why the Other Options are Incorrect:**
- Cervical incompetence (cervical erosion): This condition is typically seen in the first trimester and is not associated with uterine tenderness.
- Pyosalpinx (Inflammatory Process): This refers to an inflamed fallopian tube and is not directly associated with uterine tenderness in a pregnant patient.
- Placental abruption: Although possible, the persistent uterine tenderness and pain are less common in placental abruption cases. The patient's advanced pregnancy stage also makes it less likely.