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Intraventricular hemorrhage of the newborn

Definition

Intraventricular hemorrhage (IVH) of the newborn is bleeding into the fluid-filled areas (ventricles) inside the brain. The condition occurs most often in babies that are born early (premature).

Alternative Names

IVH - newborn; GMH-IVH

Causes

Infants born more than 10 weeks early are at highest risk for this type of bleeding. The smaller and more premature an infant is, the higher the risk for IVH. This is because blood vessels in the brain of premature infants are not yet fully developed. They are very fragile as a result. The blood vessels grow stronger in the last 10 weeks of pregnancy.

IVH is more common in premature babies with:

• Respiratory distress syndrome
• Unstable blood pressure
• Other medical conditions at birth

The problem may also occur in otherwise healthy babies who were born early. Rarely, IVH may develop in full-term babies.

IVH is rarely present at birth. It occurs most often in the first several days of life. The condition is rare after the first month of age, even if the baby was born early.

There are four types of IVH. These are called "grades" and are based on the degree of bleeding.

• Grades 1 and 2 involve a smaller amount of bleeding. Most of the time, there are no long-term problems as a result of the bleeding. Grade 1 is also referred to as germinal matrix hemorrhage (GMH).
• Grades 3 and 4 involve more severe bleeding. The blood presses on (grade 3) or directly involves (grade 4) brain tissue. Grade 4 is also called an intraparenchymal hemorrhage. Blood clots can form and block the flow of cerebrospinal fluid. This can lead to increased fluid in the brain (hydrocephalus).

Symptoms

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

• Breathing pauses (apnea)
• Changes in blood pressure and heart rate
• Decreased muscle tone
• Decreased reflexes
• Excessive sleep
• Lethargy
• Weak suck
• Seizures and other abnormal movements

Exams and Tests

All babies born before 30 weeks should have an ultrasound of the head to screen for IVH. The test is done in the 1 to 2 days of life. Babies born between 30 to 34 weeks may also have ultrasound screening if they have symptoms of the problem.

A second screening ultrasound may be done around the time the baby was originally expected to be born (the due date).

Treatment

There is no way to stop bleeding associated with IVH. The health care team will try to keep the infant stable and treat any symptoms the baby may be having. For example, a blood transfusion may be given to improve blood pressure and blood count.

If fluid builds up to the point that there is concern about pressure on the brain, a spinal tap may be done to drain fluid and try to relieve pressure. If this helps, surgery may be needed to place a tube (shunt) in the brain to drain fluid.

Outlook (Prognosis)

How well the infant does depends on how premature the baby is and the grade of the hemorrhage. Less than half of babies with lower-grade bleeding have long-term problems. However, severe bleeding often leads to developmental delays and problems controlling movement. Up to one third of babies with severe bleeding may die.

When to Contact a Medical Professional

Neurological symptoms or fever in a baby with a shunt in place may indicate a blockage or infection. The baby needs to get medical care right away if this happens.

Most newborn intensive care units (NICUs) have a follow-up program to closely monitor babies who have had this condition until they are at least 3 years old.

In many states, babies with IVH also qualify for early intervention (EI) services to help with normal development.

Prevention

Pregnant women who are at high risk of delivering early should be given medicines called corticosteroids. These drugs can help reduce the baby's risk for IVH.

Some women who are on medicines that affect bleeding risks should get vitamin K before delivery.

Premature babies whose umbilical cords are not clamped right away have less risk for IVH.

Premature babies who are born in a hospital with a NICU and do not have to be transported after birth also have less risk for IVH.

References

deVries LS. Intracranial hemorrhage and vascular lesions in the neonate. In: Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin's Neonatal-Perinatal Medicine. 11th ed. Philadelphia, PA: Elsevier; 2020:chap 53.

Dlamini N, deVebar GA. Pediatric stroke. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 619.

Garfinkle J, Miller SP. Neurological problems in the newborn. In: Jankovic J, Mazziotta JC, Pomeroy SL, Newman NJ, eds. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 110.

Soul JS, Ment LR. Injury to the developing preterm brain: intraventricular hemorrhage and white matter injury. In: Swaiman KF, Ashwal S, Ferriero DM, et al, eds. Swaiman's Pediatric Neurology. 6th ed. Philadelphia, PA: Elsevier; 2017:chap 22.

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