INTRAVENTRICULAR HEMORRHAGE ELBW INFANTS

intraventricular hemorrhage in elbw infants :
A hemorrhage in the brain that begins in the periventricular subependymal germinal matrix can progress into the ventricular system. Both incidence and severity of IVH are inversely related to gestational age. ELBW babies are at particular risk for IVH because development of the germinal matrix typically is incomplete. Any event that results in disruption of vascular autoregulation can cause IVH, including hypoxia, ischemia, rapid fluid changes, and pneumothorax. Presentation can be asymptomatic or catastrophic, depending on the degree of the hemorrhage. Symptoms include apnea, hypertension or hypotension, sudden anemia, acidosis, changes in muscular tone, and seizures.

One commonly used system classifies IVH into 4 grades, as follows:
• Grade I - Germinal matrix hemorrhage

• Grade II - IVH without ventricular dilatation

• Grade III - IVH with ventricular dilatation

• Grade IV - IVH with extension into the parenchyma

IVH is diagnosed using cranial ultrasound, which usually is performed on ELBW infants during the first week after birth, since most IVHs occur within 72 hours of delivery. Use of antenatal steroids decreases incidence of IVH, and treatment consists of supportive care. Early administration of indomethacin also reduces the risk of IVH when used prophylactically in ELBW infants but may affect urine output and platelet function adversely.

Prognosis is correlated with the grade of IVH. The outcome in infants with grades I and II is good; as many as 40% of infants with grade III IVH have significant cognitive impairment, and as many as 90% of infants with grade IV IVH have major neurologic sequelae.

The recent Trial of Indomethacin Prophylaxis in Prematurity (TIPP) demonstrated a decrease in the incidence of severe grades of IVH but no difference in neurodevelopmental outcomes at age 18-24 months. Thus, the question of using such an approach remains unanswered. The use of antenatal steroids has been associated with a decreased incidence of IVH in ELBW infants.