Which client is at the greatest risk for developing disseminated intravascular coagulation (DIC)?

• A. Primigravida with abruptio placenta
• B. Primigravida who delivered a 10-lb infant 3 hours ago
• C. Gravida 2 who has just been diagnosed with dead fetus syndrome
• D. Gravida 4 who delivered 8 hours ago and has lost 500 mL of blood

Answer: (A)

DIC in pregnancy is a consumptive coagulopathy caused by events that release tissue factor into the maternal circulation, triggering widespread activation of the coagulation cascade. When a large amount of tissue factor enters the bloodstream, clotting factors and platelets are consumed faster than they can be replaced, leading to both widespread microthrombi and a bleeding tendency as the body's clotting system collapses.

Placental abruption provides the strongest trigger because damaged placental tissue and retroplacental hemorrhage release a large amount of tissue thromboplastin quickly. This sets off an intense coagulation response, rapidly consuming platelets and fibrinogen, and increasing the risk of serious bleeding and organ dysfunction. Among the scenarios described, this represents the greatest immediate risk for developing DIC.

A large baby delivered shortly after birth can be associated with hemorrhage, but it does not inherently provide the same explosive release of tissue factor that placental abruption does. Dead fetus syndrome can also provoke DIC due to tissue factor from dead fetal tissue, but the abrupt onset and severity are typically less immediate than with an abruptio placentae. A blood loss of 500 mL postpartum, by itself, is not usually enough to precipitate DIC unless it progresses to massive hemorrhage or is accompanied by another triggering factor.