From the Guidelines
For high INR in DIC with intrauterine fetal demise, prothrombin complex concentrate (PCC) is the primary treatment recommendation, as it offers a faster and more effective correction of coagulopathy compared to fresh frozen plasma (FFP) 1. Administer 25-50 U/kg of 4-factor PCC to correct coagulopathy, which may need to be repeated based on ongoing clinical assessment and laboratory values. Additionally, cryoprecipitate (10 units) should be given if fibrinogen levels are below 100 mg/dL. Platelet transfusion (1 unit per 10 kg body weight) is indicated for platelet counts below 50,000/μL. Prompt delivery of the fetus is essential to remove the source of thromboplastin that's driving the DIC. While administering these blood products, closely monitor hemoglobin, platelet count, fibrinogen, PT/INR, and aPTT every 4-6 hours. The rationale for this approach is that DIC in intrauterine fetal demise results from release of tissue factor from the dead fetus, triggering widespread coagulation that depletes clotting factors and platelets. PCC replaces these depleted factors, while cryoprecipitate specifically addresses hypofibrinogenemia, and platelet transfusion corrects thrombocytopenia to reduce bleeding risk during delivery. It is worth noting that the use of PCC has been shown to be more effective and safer than FFP in correcting coagulopathy in patients with warfarin-associated bleeding 1. Furthermore, the American, British, and European clinical practice guidelines recommend PCCs over FFP for warfarin-associated major bleeding or urgent procedure 1. In cases where PCC is not available, FFP can be used as an alternative, but it is essential to be aware of the potential risks and limitations associated with its use, such as volume overload and transfusion-related complications 1. Vitamin K can be administered as an adjunct treatment to help replete stores of clotting factors and reduce the INR, but it should not be used as a sole reversal agent in emergency settings due to its delayed onset of action 1. The decision to restart anticoagulation after an episode of acute bleed should be made on a case-by-case basis, taking into account the individual patient's risk of thromboembolic events and the need for ongoing anticoagulation therapy 1. Overall, the use of PCC in the management of high INR in DIC with intrauterine fetal demise offers a rapid and effective correction of coagulopathy, which can help reduce the risk of bleeding complications and improve patient outcomes 1.
From the Research
Product Options for High INR, DIC, and Intrauterine Fetal Demise
When dealing with high INR, DIC, and intrauterine fetal demise, the following product options can be considered:
- Prothrombin Complex Concentrate (PCC)
- Fresh-Frozen Plasma (FFP)
Rationale for Product Choice
The choice between PCC and FFP depends on various factors, including the severity of the condition and the patient's overall health.
- PCC has been shown to rapidly correct INR in patients with coagulopathy of trauma 2 and warfarin reversal 3, 4.
- FFP is also effective in correcting coagulopathy, but its use may be associated with a higher risk of volume overload and transfusion-related complications 2, 4.
Key Considerations
When selecting a product, the following considerations should be taken into account:
- The need for rapid correction of INR
- The risk of volume overload and transfusion-related complications
- The availability of the product and the patient's overall health status
- The underlying cause of the high INR, DIC, and intrauterine fetal demise, such as placental abruption or amniotic fluid embolism 5, 6.
Management of DIC and Intrauterine Fetal Demise
In addition to product selection, the management of DIC and intrauterine fetal demise should include:
- Early diagnosis and treatment of the underlying condition
- Replacement of volume, blood products, and coagulation components
- Cardiovascular and respiratory support
- Elimination of the underlying triggering mechanism 6.