What is the initial management for a preterm infant diagnosed with Disseminated Intravascular Coagulation (DIC) with prolonged Prothrombin Time (PT) and Partial Thromboplastin Time (PTT) and thrombocytopenia?

Initial Management of DIC in a Preterm Infant

The initial management of a preterm infant with confirmed DIC and prolonged PT/PTT with thrombocytopenia requires immediate treatment of the underlying cause combined with aggressive blood product support: maintain platelets >50×10⁹/L with platelet transfusions, administer fresh frozen plasma at 15-30 mL/kg for the prolonged coagulation times, and give cryoprecipitate if fibrinogen remains <1.5 g/L despite FFP. 1, 2

Immediate Priorities

1. Treat the Underlying Cause

• The cornerstone of DIC management is addressing the primary condition 1, 2, 3
• In preterm infants, common triggers include sepsis, necrotizing enterocolitis, severe hypoxia, hypothermia, or birth trauma 4, 5
• Initiate broad-spectrum antibiotics if sepsis is suspected, as DIC may be an important indicator of infection 6
• Correct hypothermia aggressively, as cold impairs enzymatic coagulation reactions and platelet function 5

2. Blood Product Replacement Strategy

Platelet Transfusion:

• Maintain platelets >50×10⁹/L in the presence of active bleeding 1, 2, 3
• Transfuse at 10 mL/kg of platelet concentrate 7
• Recognize that platelet survival may be very short (hours) in DIC with vigorous coagulation activation, requiring frequent repeat transfusions 1, 5
• For non-bleeding infants at high risk (e.g., post-vaginal delivery with severe thrombocytopenia), consider transfusion if platelets <20-30×10⁹/L 6, 3

Fresh Frozen Plasma (FFP):

• Administer 15-30 mL/kg for active bleeding with prolonged PT/APTT 1, 2, 3
• FFP provides all coagulation factors that are globally deficient in DIC 3
• Do not delay FFP based solely on laboratory turnaround time if bleeding is evident 4

Cryoprecipitate/Fibrinogen:

• If fibrinogen remains <1.5 g/L despite FFP, give cryoprecipitate (two units) or fibrinogen concentrate 1, 2, 3
• Fibrinogen depletes first in massive consumption, reaching critical levels early 5

3. Monitoring Protocol

Frequent laboratory assessment is essential:

• Monitor CBC, PT/APTT, fibrinogen, and D-dimer at least daily in acute DIC 1, 2
• A platelet count decline >30% from baseline suggests subclinical DIC progression 1, 5
• PT/APTT prolongation beyond 1.5× normal correlates with increased clinical bleeding risk 5
• Fibrinogen <1.0 g/L with elevated D-dimers confirms consumptive coagulopathy 4, 5

Critical Pitfalls to Avoid

Do not transfuse prophylactically based on laboratory values alone without bleeding or planned procedures 2, 3

• The evidence shows that prophylactic platelet transfusions in non-bleeding thrombocytopenic preterm infants do not reduce intracranial hemorrhage incidence 7
• However, DIC is fundamentally different from isolated thrombocytopenia due to ongoing consumption 8

Do not use heparin in neonatal DIC with active bleeding or profound thrombocytopenia (<20×10⁹/L) 1, 2

• Heparin is contraindicated in bleeding-predominant DIC and hyperfibrinolytic states 1, 3
• Reserve anticoagulation only for thrombotic-predominant DIC (e.g., purpura fulminans, acral ischemia) 3

Recognize that DIC carries considerable mortality once established and becomes difficult to reverse 4, 5

• Early recognition before microvascular bleeding becomes clinically evident is crucial 4, 5
• Prolonged hypoxia, hypovolemia, and hypothermia accelerate DIC progression in preterm infants 4, 5

Supportive Care Measures

• Maintain normothermia aggressively to preserve enzymatic coagulation function 5
• Ensure adequate oxygenation and perfusion to prevent tissue factor release from endothelial injury 5
• Avoid medications that impair platelet function 4
• Monitor for signs of microvascular thrombosis causing organ dysfunction 5