What is the treatment approach for Disseminated Intravascular Coagulation (DIC) in a newborn?

Treatment of Disseminated Intravascular Coagulation (DIC) in Newborns

The primary treatment of neonatal DIC is aggressive management of the underlying disorder (sepsis, asphyxia, or other triggers) combined with supportive blood product replacement, while avoiding routine anticoagulation unless specific thrombotic complications develop. 1, 2

Immediate Priorities

Identify and Treat the Underlying Cause

• Sepsis is the most common trigger in neonates, requiring immediate broad-spectrum antibiotics and hemodynamic support 1, 3
• Neonatal asphyxia is the second most common cause, associated with 17% mortality compared to 10% in non-asphyxia DIC 2
• Other triggers include necrotizing enterocolitis, respiratory distress syndrome, and severe hypoxia—all require disease-specific interventions 1, 4

Laboratory Monitoring

• Obtain baseline platelet count, PT/APTT, fibrinogen, and D-dimer immediately 5, 3
• Monitor coagulation parameters every 6-12 hours in acute bleeding DIC to guide blood product replacement 5
• A ≥30% drop in platelet count is diagnostic even without clinical bleeding 6

Blood Product Replacement Strategy

Fresh Frozen Plasma (FFP)

• Administer 10-20 mL/kg every 12 hours when PT/APTT is prolonged AND active bleeding is present 7, 8
• Do not transfuse FFP based solely on laboratory values without clinical bleeding 7, 5
• FFP provides all coagulation factors but may require large volumes 7

Cryoprecipitate

• Give cryoprecipitate (usual dose 1 unit/5 kg or 5-10 mL/kg) when fibrinogen falls below 1.0 g/L 7
• Cryoprecipitate is more concentrated than FFP for fibrinogen replacement and avoids volume overload 7

Platelet Transfusion

• Transfuse platelets to maintain count >50 × 10⁹/L in actively bleeding neonates 5
• Consider prophylactic transfusion at lower thresholds (>20-30 × 10⁹/L) in high-risk situations like concurrent intracranial hemorrhage 7

Red Blood Cell Transfusion

• Replace blood loss to maintain adequate oxygen delivery and hemodynamic stability 7
• Monitor hematocrit frequently in bleeding neonates 8

Anticoagulation: When and How

Heparin Use in Neonatal DIC

• Do NOT use routine anticoagulation in bleeding-predominant DIC 5, 8
• Consider low-dose unfractionated heparin (UFH) only if thrombotic complications develop (e.g., renal vein thrombosis, cerebral sinovenous thrombosis, or limb-threatening arterial thrombosis) 7
• If anticoagulation is indicated: Start UFH at therapeutic doses (initial bolus 75 units/kg IV, then 28 units/kg/hour for term infants, 28 units/kg/hour for preterm infants) 7, 8
• Use preservative-free heparin formulations in neonates to avoid benzyl alcohol toxicity 8

Specific Thrombotic Scenarios

• Renal vein thrombosis with IVC extension: Anticoagulate with UFH or LMWH for 6 weeks to 3 months 7
• Cerebral sinovenous thrombosis without significant hemorrhage: Anticoagulate with UFH or LMWH for 6 weeks to 3 months 7
• Limb-threatening arterial thrombosis: Start therapeutic UFH immediately; consider thrombolysis if no response within hours 7

Agents to AVOID

• Do NOT use tranexamic acid or recombinant Factor VIIa in neonatal DIC due to increased thrombotic risk and lack of evidence 5, 6
• Avoid antithrombin III concentrate—evidence is lacking and it is not recommended in neonatal DIC 3
• Do not use activated protein C—its value is doubtful and not validated in neonates 3

Special Considerations in Neonatal DIC

Developmental Coagulopathy

• Neonates have physiologically lower levels of vitamin K-dependent factors (II, VII, IX, X) and contact factors (XI, XII), making them more susceptible to DIC 1, 4
• This "developmental coagulopathy" means laboratory values must be interpreted using neonatal-specific reference ranges 1

Asphyxia-Associated DIC

• Neonates with asphyxia-related DIC have higher mortality (17% vs 10%), more severe bleeding (11% vs 6.8%), and require more aggressive therapy 2
• These patients more commonly receive antithrombin (43% vs 38%), recombinant thrombomodulin (28% vs 20%), and FFP transfusion (68% vs 51%) compared to non-asphyxia DIC 2
• Severe asphyxia correlates with worse outcomes: 19% mortality versus 11% in mild asphyxia 2

Bleeding Risk with Procedures

• Correct thrombocytopenia and coagulopathy BEFORE invasive procedures (lumbar puncture, central line placement, intubation) 7
• Preterm infants have 13.8% risk of intracranial hemorrhage with thrombolytic therapy versus 1.2% in term infants—avoid thrombolytics in preterm neonates unless absolutely necessary 7

Clinical Pitfalls to Avoid

• Do not delay treatment of the underlying disorder while waiting for coagulation studies—begin empiric antibiotics for suspected sepsis immediately 1, 3
• Do not transfuse blood products prophylactically based on laboratory values alone without bleeding or planned procedures 7, 5
• Do not use low-dose "prophylactic" heparin in bleeding-predominant DIC—it provides no benefit and increases bleeding risk 5
• Avoid benzyl alcohol-containing heparin preparations in neonates due to risk of gasping syndrome and neurologic toxicity 8

Prognosis and Monitoring

• In-hospital mortality ranges from 10-17% depending on underlying cause, with asphyxia-related DIC having the worst outcomes 2
• Continue frequent laboratory monitoring (every 6-24 hours) until coagulation parameters normalize 5
• Monitor for complications including intracranial hemorrhage, renal failure, and multiorgan dysfunction 1, 4
• Long-term neurodevelopmental follow-up is essential in survivors of severe neonatal DIC with asphyxia 2