This voice annotated PowerPoint will be about disseminated intravascular coagulation, or DIC, in pregnancy. My name is Sara Dotters-Katz, and I am an OB/GYN physician. Because DIC is a complicated pathophysiologic process, we will start by simply explaining the pathophysiology of this condition. Then we will discuss the causes of DIC in pregnancy. And finally, we will review the diagnosis and management of DIC in pregnancy. DIC is a secondary process, a syndrome produced due to an underlying disease that leads to the initiation of the clotting cascade. Interestingly, it’s actually a physiologic response to a pathophysiologic stimulation of the coagulation system. In other words, the overproduction of thrombin leads to fiber in deposition and clots. These microthrombi not only cause organ dysfunction but as a result of a massive clotting action, the body actually becomes depleted of platelets and clotting factors, which leads to hemorrhage. In some ways, it’s easy to think of DIC in two phases– the clotting phase and the bleeding phase. In pregnancy, we see DIC associated with abruption, preeclampsia, including clampsia and HELLP syndrome, acute fatty liver of pregnancy, and amniotic fluid embolism. Approximately 50% of patients with an amniotic fluid embolism will develop DIC. Septic abortion and IUFD are also associated with DIC. Finally, any condition causing massive hemorrhage antepartum, such as placenta previa or placental abruption, intrapartum, such as uterine rupture, accreta, or postpartum hemorrhage can trigger DIC. It is important to note that by far, the most common cause of DIC in pregnancy is placental abruption. In a pregnant woman, one should suspect DIC if the pregnancy is complicated by abruption, amniotic fluid embolism, large postpartum hemorrhage, severe pre-eclampsia, or HELLP syndrome, intrauterine fetal demise, septic abortion, or acute fatty liver of pregnancy, or in any patient that develops severe bleeding– vaginal, abdominal, or intrauterine. Some women present oozing from the skin or mucosa surfaces. Any signs of shock, including tachycardia, low blood pressure, or altered mental status, also merit a thorough workout. The obstetric provider should have low threshold to check for DIC in patients that have any of the above conditions. DIC is a combination of a clinical and laboratory diagnosis. Lab data suggestive of coagulopathy is very concerning for DIC. And low fibrinogen is the least sensitive test and usually a late finding. Though there are multiple scoring criteria in the literature, these are not usually necessary to make the diagnosis of DIC. The key first step in the management of DIC is to identify and correct the underlying cause. Correction could include delivery of the infant, uterine evacuation, or treating sepsis. At the same time, steps should be taken to stabilize the patient. Two large bore IVs, active fluid resuscitation, and oxygen are important early steps. Frequent evaluations with vital signs and monitoring of urine output are also important. Additionally, the anesthesia team needs to be aware. They can better assist with delivery, IV access, as well as airway management if needed. If the fetus is viable, the pediatric team should also be involved. Finally, laboratory studies should be sent including a complete blood count, or CBC, a type and screen or type and cross, as well as coagulation studies, including a PT, PTT, fibrinogen and D-dimer. In the septic patient, cultures should also be sent. The blood bank is another crucial member of the resuscitation team. If your hospital has a massive transfusion protocol, activate it. If not, make the blood bank aware of the situation. The patient should be typed and crossed for 6 units of packed red blood cells, 2 units of fresh frozen plasma, 10 bags of cryoprecipitate, and 1 six-pack of platelets. Therapeutic goals include maintaining platelets above 50,000, fibrinogen above 100 milligrams per desolator, and a PTT less than 1.5 times the normal ranges. If the fetus is previable or no longer living, expedited delivery should occur. This can either be via induction of labor or dilation and evacuation of the uterine cavity. Operative delivery should be avoided if possible. Generally, delivery removes the trigger for DIC. It also helps to involute the source of hemorrhage, the uterus. A C-section is only indicated to save woman’s life in this instance. When there is a viable fetus involved, the situation is more complicated. If the fetal status is reassuring, stabilize the patient, i.e. the mother first, then assess the fetus. Generally, the cause of DIC is one in which delivery is indicated. And in these cases, induction should be started as soon as possible and actively managed with all attempts made to achieve vaginal delivery. However, if there is a non-reassuring fetal status or a vaginal delivery is unsafe– for example, in the case of a placental previa– it is prudent to proceed with Cesarean section. Though, prior to this, every attempt should be made to correct the bleeding and improve the clotting. Hysterectomy is the last option for these patients. Though, it should be done to save the mother’s life. In addition, patients in DIC often need multiple units of product, as well as ICU care. In summary, DIC is an acquired consumptive coagulopathy caused by multiple pregnancy-related conditions. It is life threatening and should be suspected in a woman who presents with symptoms of shock and hemorrhage. Treatment requires a multidisciplinary approach with early activation of the massive transfusion protocol, as well as correction of the underlying cause. Though very dangerous, with early recognition and active management, mortality is low.