Intraventricular hemorrhage of the newborn

Definition

Intraventricular hemorrhage (IVH) of the newborn is bleeding into the fluid-filled areas (ventricles) surrounded by the brain. The condition is most often seen in premature babies.

Alternative Names

IVH - newborn

Causes, incidence, and risk factors

Infants born before 30 weeks of pregnancy are at highest risk for such bleeding. The smaller and more premature the infant, the higher the risk for IVH. This is because blood vessels in the brain of premature infants are not yet fully developed and are extremely fragile. The blood vessels grow stronger after 30 weeks of pregnancy.

IVH is more common in premature babies who have had physical stress, such as respiratory distress syndrome, pneumothorax, or high blood pressure. The condition may also occur in healthy premature babies who were born without injury. IVH may develop in full-term babies, but this is very uncommon.

IVH is rarely present at birth. If it occurs, it will usually be in the first several days of life. The condition is quite rare after 1 month of age, no matter how early the baby was born.

IVH falls into four groups, called grades. The higher the grade, the more severe the bleeding.

Grades 1 and 2 involve a small amount of bleeding and do not usually cause long-term problems.

Grades 3 and 4 involve more severe bleeding, which presses on or leaks into brain tissue. Blood clots can form and block the flow of cerebrospinal fluid, leading to increased fluid in the brain (hydrocephalus).

Symptoms

There may be no symptoms. The most common symptoms seen in premature infants may include:

• Breathing pauses (apnea)
• Decreased muscle tone
• Decreased reflexes
• Excessive sleep
• Lethargy
• Weak suck

Signs and tests

A routine head ultrasound is recommended for all babies born before 30 weeks to screen for IVH. The test is done once between 7 and 14 days of age. A second routine ultrasound is suggested close to the time the baby was originally expected to be born. About 25 percent of babies born before 30 weeks will have a problem detected that should at least be followed with additional ultrasounds.

An ultrasound might also be ordered if a premature baby has new signs or symptoms. IVH should be considered whenever the baby's health worsens suddenly, especially in the first week of life. Worrisome signs might include breathing pauses, pale or blue coloring, abnormal eye movements, shrill cry, seizures, poor suck, and decreased muscle tone. The blood count may have fallen. A physical exam may reveal a bulging fontanel.

A head CT is recommended if a term baby has symptoms after a difficult birth, low blood count, or other signs of bleeding problems.

Treatment

There is no current therapy to stop the bleeding. Talk to your doctor about care decisions. The health care team will keep the infant as stable as possible, and treat symptoms as appropriate. For example, a blood transfusion may be given to improve blood pressure and blood count.

If hydrocephalus develops, a spinal tap may be done to relieve pressure. If the condition cannot be treated with a spinal tap, surgery may be needed to place a tube or shunt in the brain to drain fluid.

Expectations (prognosis)

How well the infant does depends on the severity of bleeding and whether hydrocephalus developed. Infants with grade I or II bleeding have outcomes similiar to premature babies who do not have IVH.

More severe IVH may lead to developmental delays and problems controlling movement.

Calling your health care provider

Regular doctor's visits are recommended for several years after being diagnosed with an IVH. The doctor will check the child's developmental progress and make sure the bleeding has not damaged the brain.

Prevention

Pregnant women who are high risk of delivering early may be given medicines called corticosteroids to help reduce the baby's risk for IVH.

In certain women who are on medications that affect bleeding risks, vitamin K should be given before delivery.

References

Hansen TW. Prophylaxis of intraventricular hemorrhage in premature infants: new potential tools, new potential challenges. Pediatr Crit Care Med. Jan 2006; 7(1): 90-2.

Futagi Y. Neurodevelopmental outcome in children with intraventricular hemorrhage. Pediatr Neurol. Mar 2006; 34(3): 219-24.44

Gabbe SG, Niebyl JR, Simpson JL. Obstetrics - Normal and Problem Pregnancies. 4th ed. New York, NY: Churchill Livingstone; 2002:974-983.

Ment LR. Practice parameter: neuroimaging of the neonate: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. Jun 2002; 58(12): 1726-38.