Intraventricular haemorrhage (neonates)

Intraventricular haemorrhage (IVH) is the most common type of intracranial haemorrhage in the neonate. It occurs primarily in preterm infants but is occasionally seen in the near term and term infants.

About

• Intraventricular haemorrhage (IVH) into the ventricles in the brain.
• Severe damage to cells can lead to brain injury.

Aetiology

• It is most likely to occur in premature babies.
• The incidence of IVH is falling
• It is due to hypoxic ischaemic reperfusion injury of the germinal matrix

Higher Risks

• Premature babies
• Very-low-birth-weight babies (weighing less than 3 pounds, 5 ounces)
• Babies with breathing problems, such as hyaline membrane disease
• Babies who have other complications of being premature
• Labor and delivery problems
• Genetic background
• Shaken baby
• Head Injury
• Infection in the mother
• High blood pressure in the mother
• Blood-clotting problems

Clinical

• Apneoic episodes, Bradycardia, cyanosis, weak suck
• High-pitched cry, Lethargy, stupor, or coma
• Swelling or bulging of the soft spots (fontanelles) - tense anterior fontanelle
• Decreased reflexes, muscle tone, tonic fits with decerebrate posturing
• Abnormal eye movement

Investigations

• Low red blood cell count (anemia)
• A head ultrasound can diagnose the condition.

Severity

• Grade 1. Bleeding occurs just in a small area of the ventricles.
• Grade 2. Bleeding also occurs inside the ventricles.
• Grade 3. Ventricles are enlarged by the blood.
• Grade 4. Bleeding occurs in the brain tissues around the ventricles.

Severity

• Grade I. Isolated germinal matrix haemorrhage 6% Mortality
• Grade II. IVH with normal ventricle size 33% Mortality
• Grade III IVH of sufficient severity to dilate the ventricles with blood 60% Mortality
• Grade IV Intraparenchymal haemorrhage 93% Mortality

Grade IV haemorrhage is usually associated with extensive intraventricular haemorrhage. It is postulated that large blood clots in the germinal matrix and ventricles impair the flow of blood from the medullary veins, which drain the cerebral white matter, into the terminal vein. This impairment of blood flow may lead to venous infarction and, like other venous infarctions, this infarction may be haemorrhagic.

Management

• Prevention: Steroids given 48 hrs prior to delivery lower the risk for IVH in the baby. Given to women between 24 and 34 weeks during pregnancy if they are at risk for early delivery.
• Monitoring: All premature babies less than 32 weeks have head scans in the first few weeks of life
• Treatment: Usually supportive, monitoring. May need ICP monitoring.
• Grades 1 and 2 are most common. Often the baby has no other complications.
• Grades 3 and 4 are the most serious. They may result in long-term brain injury to the baby. Other complications include development problems, hydrocephalus, ong-term brain injury and death

References

• RPA Newborn Care Guidelines