A pregnant client at 32 weeks gestation is admitted with severe preeclampsia and develops disseminated intravascular coagulation (DIC). Laboratory results show: platelets 45,000/mm³, fibrinogen 80 mg/dL, PT 18 seconds, PTT 65 seconds, and D-dimer elevated. Which nursing intervention should be the priority?
1Administer fresh frozen plasma as ordered
2Apply pressure to all bleeding sites
3Monitor for signs of intracranial hemorrhage✓ 정답
4Prepare for immediate cesarean delivery
해설
Monitoring for intracranial hemorrhage is the priority because it is the most life-threatening complication of DIC in pregnancy. Other interventions like administering FFP or applying pressure are supportive but secondary.
Clinical Context
This client is in the third trimester with severe preeclampsia, now complicated by disseminated intravascular coagulation (DIC). The laboratory profile reveals a classic consumption coagulopathy: severe thrombocytopenia (platelets 45,000/mm³), hypofibrinogenemia (fibrinogen 80 mg/dL), prolonged coagulation times (PT 18 seconds, PTT 65 seconds), and elevated D-dimer, indicating massive clot formation and breakdown. In DIC, microthrombi and consumption of clotting factors paradoxically lead to a high risk of both thrombosis and hemorrhage.
Why Monitoring for Intracranial Hemorrhage is the Priority
The priority nursing intervention is to monitor for signs of intracranial hemorrhage (ICH). While administering blood products and preparing for delivery are critical components of care, the immediate nursing priority is assessment to detect the most life-threatening complication. In the context of DIC and severe preeclampsia, spontaneous bleeding into the brain is a catastrophic event that requires rapid identification to prevent irreversible neurological damage or death. Evidence from maternal mortality reviews identifies intracranial hemorrhage as a leading cause of death in obstetric populations, second only to obstetric hemorrhage [1]. A case report of intracerebral hemorrhage in a pregnancy complicated by hypertensive disease further illustrates the devastating and rapid nature of this complication, underscoring the need for vigilant neurological surveillance [4].
Pathophysiological Basis for the Risk
Severe preeclampsia causes endothelial dysfunction and vasospasm, which can damage the integrity of cerebral blood vessels. When DIC develops, the already compromised vasculature is exposed to a system with depleted clotting factors and platelets. The combination of vascular injury and a profound coagulopathy creates an environment where a vessel rupture cannot be effectively tamponaded by clot formation, drastically increasing the risk of a fatal intracranial bleed. The platelet count of 45,000/mm³ is well below the threshold where spontaneous intracranial hemorrhage becomes a significant concern, making continuous neurological assessment a non-negotiable aspect of care.
Analysis of Other Interventions
Administering fresh frozen plasma (Option 1) is an essential medical intervention to replace consumed clotting factors, but it is a physician-ordered treatment that follows the nurse's initial and ongoing assessment. Applying pressure to all bleeding sites (Option 2) is a standard supportive measure for external hemorrhage, yet it does not address the invisible, life-threatening risk of internal bleeding in the brain. Preparing for immediate cesarean delivery (Option 4) is the definitive treatment for preeclampsia, as delivery of the placenta is the cure. However, performing major surgery on a patient with active, uncontrolled DIC and a platelet count of 45,000/mm³ carries an extreme risk of surgical hemorrhage. Stabilization of the coagulopathy with blood products is typically required before proceeding to the operating room unless there is an immediate fetal or maternal indication that outweighs the bleeding risk. The nurse's priority remains the continuous assessment for the most immediate threat to the client's life, which is an intracranial hemorrhage, a complication that has been identified as a significant cause of maternal near-miss and mortality events in tertiary care settings .
References (research sources)
[1]
Proposals for Improving Maternal Safety (2024 Edition): Insights From the Analysis of Maternal Deaths in Japan.Research articleJapan Maternal Death Exploratory Committee. (2026) · DOI: 10.1111/jog.70302
[4]
Extensive Intracerebral Hemorrhage Involving Basal Ganglia and Frontal Lobe With Intraventricular and Subarachnoid Extension in a Triplet Pregnancy Following In Vitro Fertilization: A Case Report and Review.Case reportGoit R, Gupta P, Nguyen L, Patel S, Rana KK, Jaiswal S, Bekoju P, Shrestha R, Nguyen D. (2026) · DOI: 10.1002/ccr3.71911
Clinical Management of DIC in Severe Preeclampsia
Pathophysiology
Severe preeclampsia causes endothelial injury, releasing thromboplastin and activating the coagulation cascade. This leads to disseminated intravascular coagulation (DIC), a consumption coagulopathy where microthrombi deplete platelets and clotting factors, paradoxically increasing the risk for life-threatening hemorrhage such as intracranial bleeding.
Priority Nursing Assessment
The highest priority is continuous neurological surveillance to detect intracranial hemorrhage. Monitor for sudden severe headache, altered level of consciousness, pupillary changes, new-onset seizures, or focal motor deficits. Any change in neurological status requires immediate escalation to the provider for potential CT imaging and neurosurgical intervention.
Collaborative Interventions
Administer blood products (fresh frozen plasma, cryoprecipitate, platelets) as ordered to correct the coagulopathy.
Prepare for urgent delivery, as placental delivery is the definitive treatment for preeclampsia. Cesarean delivery is often indicated if the maternal condition is unstable.
Apply pressure to venipuncture sites and avoid intramuscular injections to minimize external bleeding.
Maintain strict intake and output, monitor for signs of placental abruption, and manage hypertension with prescribed agents.
Disseminated Intravascular Coagulation (DIC) — A serious disorder in which the proteins that control blood clotting become overactive, leading to both widespread clotting and severe bleeding due to consumption of clotting factors.
Intracranial Hemorrhage — Bleeding within the skull, a life-threatening complication of severe bleeding disorders that requires immediate detection to prevent irreversible brain damage.
Severe Preeclampsia — A pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys, which can progress to eclampsia and DIC.
Consumption Coagulopathy — The pathological process in DIC where clotting factors and platelets are used up by widespread microthrombi, resulting in a high risk of hemorrhage.