Infantile Intraventricular Haemorrhage

This is a significant cause of morbidity and mortality in infants who are born prematurely.

Neurological complications include life-long problems:

• Seizures
• Developmental delay
• Cerebral palsy

Intraventricular Haemorrhage (IVH) is uncommon in term infants, but can be seen in association with trauma and asphyxia. In these cases the bleeding is usually in the choroid plexus.

Incidence

Occurs in 60-70% of neonates weighing 500-750 g and 10-20% of those weighing 1,000-1,500 g.¹ There is an inverse relationship between the severity of the haemorrhage and the likelihood of survival.

Risk factors

• Prematurity - particularly <32 weeks
• Respiratory distress syndrome
• Hypoxia
• Sepsis
• Hypotension
• Hypovolaemia
• Hypertension
• Altered cerebral blood flow

Symptoms

Most cases present by third day of life - 50% on first day. 10-15% may show delayed haemorrhage occurring after first week.
Commonest symptoms are:

• Diminished/absent Moro reflex
• Poor muscle tone
• Sleepiness
• Lethargy
• Apnoea

Premature babies often show sudden deterioration on day 2 or 3 with periods of apnoea, pallor or cyanosis, failure to suck properly, abnormal eye signs, shrill cry, twitching or convulsions, reduced muscle tone or paralysis.

Signs

• Fontanelle may be tense and bulging with severe IVH.
• Neurological depression may progress to coma.
• In mild forms there may be no clinical signs, or there may be alternating symptomatic and asymptomatic periods.

• Apnoea of prematurity
• Neonatal sepsis
• Hypoglycaemia
• Hypermagnesaemia
• Periventricular leukomalacia

• Arterial blood gases show metabolic acidosis.
• Reduced haemoglobin level that may fail to improve on transfusion.
• Transfontanelle ultrasound; this is the diagnostic tool of choice. All premature babies at less than 30 weeks' gestation have cranial ultrasound at 7-14 days of age.

This is mainly supportive and may include the correction of anaemia, acidosis, and hypotension. Ventilatory support may also be required for some who deteriorate acutely.

Fluid/volume replacement

• Packed red blood cells or fresh frozen plasma for anaemia and shock.
• Sodium bicarbonate infusion (carefully) for metabolic acidosis.

Pharmacological

• Anticonvulsants for seizures.
• Acetazolamide can be used to decrease cerebrospinal fluid production.² This limits late, or rapidly progressive hydrocephalus.
• Intraventricular fibrinolytic therapy with streptokinase has been attempted. However a 2007 Cochrane review felt it could not be recommended for neonates following IVH.³

Surgical

• Ventriculoperitoneal and ventriculosubgaleal shunts are the definitive treatments for posthaemorrhagic hydrocephalus.
• Serial lumbar punctures have been used in the management of late or rapidly progressive hydrocephalus; however, this role remains controversial.⁴

• 10-15% have hydrocephalus that may not appear for 2-4 weeks.
• Infants with massive haemorrhage often rapidly deteriorate and die. Mortality from high grade IVH may be 27-50%.⁵
• Significant proportion show motor and cognitive deficits.
• Extremely low birth weight infants with grades I-II IVH have poorer neurodevelopmental outcomes at 20 months than infants with normal cranial ultrasound.⁶

• Antenatal steroids to mother and low dose indomethacin to infant.^7,8 Indomethacin has been shown to decrease the risk of high-grade IVH, without improving developmental outcome.⁹
• The Department of Health "recommends that all newborn babies are given vitamin K in the newborn period". Optimum timing and method of administration are unsure.
• Careful timing and management of delivery to avoid birth trauma and immaturity.¹⁰