An Overview of Intraventricular Hemorrhage (IVH) in Preemies

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An intraventricular hemorrhage, also called IVH, is bleeding into the ventricles of the brain. An IVH can be mild or severe, depending on how much bleeding there is. Some babies who experience an IVH won't have any long-term effects, while babies with more extensive bleeds might have developmental delays or other lasting effects.

If your baby has been diagnosed with an intraventricular hemorrhage, learning as much as you can about this condition can help you to understand what is going on with your baby and how he or she will recover.

Severity of IVH

In infants, intraventricular hemorrhages are categorized by how severe the hemorrhage is.

  • Grade 1: Bleeding is limited to the germinal matrix, a fragile area near the ventricles that contains many small capillaries. Grade 1 IVH is also called germinal matrix hemorrhage.
  • Grade 2: Bleeding is found in the ventricles, but the ventricles remain the same size.
  • Grade 3: Bleeding is found in the ventricles, and the bleeding has caused the ventricles to dilate, or grow larger.
  • Grade 4: Blood is found in the ventricles, which have dilated, and in nearby areas of the brain. Grade 4 IVH is also called intracranial hemorrhage.

Grade 1 and grade 2 hemorrhages are usually considered mild bleeds, while grade 3 and 4 bleeds are more severe, with more serious initial symptoms and more long-term complications.

Causes

Prematurity is the greatest cause of intraventricular hemorrhage, and most cases of IVH occur in babies less than 30 weeks gestation or under 1,500 grams (3 lbs 5 oz).

Intraventricular hemorrhages happen early in a preemie’s life, with 90 percent occurring within the first three days of life. Doctors think that several things combine to make preemies susceptible to IVH. First, the blood vessels in a preemie’s brain are more fragile than those in a term baby. Premature babies also may suffer from repeated episodes of low blood-oxygen levels and are exposed to greater fluctuations in blood pressure.

Symptoms

Babies suffering from mild hemorrhages may not have any symptoms. Symptoms of more severe intraventricular hemorrhages in premature babies include:

  • Increased episodes of apnea and bradycardia
  • Decreased muscle tone
  • Decreased reflexes
  • Weak suck
  • Excessive sleep

Diagnosis

Intraventricular hemorrhages are diagnosed with an ultrasound of the head. Many hospitals routinely screen all premature babies for IVH within the first week of life and again before hospital discharge.

Treatment

Unfortunately, there is no way to stop an intraventricular hemorrhage once it has begun. Treatment for IVH targets symptoms of the bleed and may include increased respiratory support or medications for apnea and bradycardia.

Up to 10 percent of infants who have an intraventricular hemorrhage will develop hydrocephalus, a buildup of cerebrospinal fluid in the ventricles. Hydrocephalus makes an infant’s head grow more quickly than usual to make room for the extra fluid and can put pressure on delicate brain tissue. Hydrocephalus may go away on its own, or surgery may be required. Doctors may decide to insert a ventriculoperitoneal shunt (VP shunt) to drain the fluid and reduce pressure on the brain.

Long-Term Consequences

Long-term consequences may be mild or severe and are usually related to the severity of the hemorrhage.

Infants who have a grade 1 or grade 2 bleed may have no lasting effects or may have subtle consequences that are difficult to measure. 

Many children with serious hemorrhages will have no lasting effects, but children who suffer from grade 3 or grade 4 hemorrhages as infants are at risk for more serious consequences. Developmental delays may be more severe among these babies. Children with a history of severe bleeds may also suffer from poor cognitive functioning and other disorders such as attention deficit-hyperactivity disorder (ADHD).

Prevention

Because IVH can cause severe complications and cannot be stopped once it has begun, doctors and scientists have focused their efforts on prevention.

Preventing preterm delivery is the best way to prevent IVH, so expectant mothers with risks for preterm delivery should talk to their doctors about lowering their risk. Several medications have been studied for their role in preventing IVH. Antenatal steroids in women who are at risk for an early delivery have been shown to give some protection, but must be given in a narrow time window. Another medication, indomethacin, has also been shown to give some protection.

Sources

  • Hansen, Thor Willy Ruud. “Prophylaxis of Intraventricular Hemorrhage in Premature Infants: New Potential Tools, New Potential Challenges.” Pediatric Critical Care Medicine Jan. 2006: 7; 90-92.
  • Gardner, Marsha. “Outcomes in Children Experiencing Neurologic Insults as Preterm Infants” Pediatric Nursing Nov/Dec 2005: 31; 448-457.
  • Sears MD, William, Sears MD, Robert, Sears MD, James, Sears RN, Martha. The Premature Baby Book: Everything You Need to Know About Your Premature Baby from Birth to Age One. Little, Brown and Co., New York, 2004.
  • Medline Plus. “Intraventricular Hemorrhage of the Newborn” Accessed 8-20-09 from the website.

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