Disseminated Intravascular Coagulation (DIC)

Pathophysiology & Triggers

• DIC is never a primary disease; it is the uncontrolled systemic activation of coagulation leading to simultaneous microvascular thrombosis and profound consumption of platelets/clotting factors, resulting in rampant hemorrhage.
• Major Triggers: Severe Neonatal Sepsis (especially Gram-negative endotoxemia), profound Perinatal Asphyxia (HIE / Acidosis), Necrotizing Enterocolitis (NEC), massive Abruptio Placentae, Kasabach-Merritt phenomenon.

Clinical Presentation & Strict Lab Criteria

• Bleeding from multiple unrelated puncture sites (IV lines, heelsticks), spontaneous bruising/petechiae, pulmonary hemorrhage, severe GI bleeding.
• Labs showing profound consumption: Thrombocytopenia (Platelets often < 50k), markedly decreased Fibrinogen (< 100 mg/dL).
• Labs showing halted coagulation cascade: Prolonged PT and aPTT.
• Labs showing clot breakdown (fibrinolysis): Elevated D-Dimer or Fibrin Degradation Products (FDPs).
• Peripheral smear confirms Microangiopathic Hemolytic Anemia: Prominent schistocytes (fragmented RBCs sheared by micro-clots).

Targeted Blood Product Resuscitation

• The ONLY definitive treatment is aggressive reversal of the underlying trigger (e.g., antibiotics for sepsis, cooling for HIE, surgical resection for ischemic NEC).
• Cryoprecipitate: Treatment of choice for profound hypofibrinogenemia. Dose: 1-2 units/kg (or 10 mL/kg) specifically targetting Fibrinogen levels strictly > 100-150 mg/dL.
• Fresh Frozen Plasma (FFP): Dose 10-15 mL/kg. Indicated strictly for prolonged PT/aPTT (>1.5x normal limit) coupled with active severe bleeding.
• Platelet Transfusion: Dose 10-15 mL/kg. Threshold depends on bleeding severity. Maintain platelets > 50,000/mcL if bleeding, or > 100,000/mcL for major surgery/neurosurgery.
• Do NOT use standard Unfractionated Heparin sequentially; paradoxical worsening of hemorrhage without correcting the consumption cycle.

Diagnostic & Management Algorithm

• DIC Reversal: [START] Oozing + Plt < 50k + PT/PTT prolonged -> [ACTION] Treat underlying trigger (sepsis/asphyxia) -> [DECISION] Bleeding? -> [YES] Cryoprecipitate + FFP + Platelets -> [NO] Observe

References

1. Sola-Visner M, et al. Approach to the neonatal bleeding patient. Clin Perinatol.
2. Kling PJ, et al. Disseminated intravascular coagulation. Neoreviews.