S

1. IVH
Done by :Dr Rimaa M LAfi
Supervisor : Dr Samer Abdelrazeq

2. Introduction:
• IVH, the most common type of neonatal intracranial hemorrhage,
occurs mainly in preterm infants ≤32 weeks of gestation. The
incidence ranges from 13-65% in different centers, decreases with
advancing gestational age and is influenced by certain perinatal risk
factors (see below).

4. Pathogenesis is related to
• (1) Intra-vascular factors:
• Impaired cerebral autoregulation.
• Fluctuating cerebral blood flow (related to fluctuating arterial blood pressure).
• ↑ Cerebral blood flow (e.g., due to hypercarbia, excess volume expansion).
• ↑ Cerebral venous pressure (e.g., with pneumothorax, asphyxial heart failure).
• Hypotension and reperfusion.
• Coagulation abnormalities.
• (2) Vascular factors:
• Germinal matrix, a highly vascular structure with poor capillary support, is
present 50% of ventricular area or distends ventricle).
• Intra-parenchymal echodensity (IPE) represents periventricular hemorrhagic
infarction and is often referred to as Grade IV IVH.

5. severity and grading of IVH by head ultrasound:
• The following grading system is used:
• Grade I – Bleeding is confined to the germinal matrix*GM.
• Grade II – GMH and IVH occupies between 10 to 50 percent of the
lateral ventricle volume.
• Grade III – GMH and IVH occupies more than 50 percent of the
lateral ventricle volume and is associated with acute ventricular
distension.

6. Management General measures include the following:
• Maintenance of arterial perfusion to avoid hypotension or
hypertension and preserve cerebral blood flow
• Adequate oxygenation and ventilation with specific avoidance of
hypocarbia, hypercarbia, and acidosis.
• Provision of appropriate fluid, metabolic, and nutritional support.
• Seizures should be treated
• Detection of posthemorrhagic ventricular dilatation, which is the
major complication of severe IVH.

7. • Other than early diagnosis and careful supportive care
For progressive ventricular dilatation (post-hemorrhagic
hydrocephalus), the essential point is early recognition.
• do serial head U/S examinations in infants with IVH ≥grade II. Some
cases of ventricular dilatation will respond to serial lumbar punctures
and/or acetazolamide or other diuretics (to decrease CSF production).
Persistent, progressive ventricular dilatation requires a ventricular
reservoir or v-p shunt by a neurosurgeon.

8. Intraventricular Hemorrhage Prevention in preterm
Guidelines (IVH PREVENTION BUNDLE)
• Equipment
• • Cardio-respiratory monitor
• • Isolette and Isolette cover
• “IVH Bundle” sign
• • “Minimal Handling” sign

9. Implementation
• • Place the infant into the isolette bed
• • Confirm the infant weight and gestational age to determine eligibility for
IVH Prevention Guidelines.
##An infant only needs to meet one of the two criteria for guideline
implementation: less than 32 weeks gestation and/or less than 1500 grams.
o Guideline interventions should be implemented soooon as possible!!
.If it is known in advance that the infant will meet the criteria for IVH
Guidelines, neutral head positioning should be implemented and maintained
in the delivery room with Delayed Cord Clamping (DCC)

10. • A. Midline Positioning of the head
• o Rationale:
• Midline Positioning of the head Prevent cerebral blood flow
fluctuations and maintaining jugular venous flow

11. • B. Elevate Hed of Bed
• 1. Elevate the head of the bed 15-30° during the first 5-7 DAYS.
• 2. May briefly to placed flat during X-rays or procedures as needed
• 3. Avoid Trendelenburg position. and Avoid raising feet and legs
above head

12. • C. Minimal Handling and stimulation
• Rationale: Minimizing handling will prevent disturbances in cerebral
blood flow; reducing stimulation and gentle care taking decrease
incidence of IVH

13. • D. Minimize pain and stress
• 1. Use swaddling and other non-pharmacologic interventions
(boundaries; shield eyes from light) when performing mild painful
procedures.
• 2. Consider pain medication for painful procedures and intubated
infant who are agitated and/or fighting the ventilator, continues
infusion is preferred over bolus administration
• 3. Suction (ETT, deep nasal/oral) only when clinically indicated
• E. Maintain normothermia (36.5-37 °c)

14. • F. Slow increase intravascular volume
• o Rationale rapid increase intravascular volume leading to impaired cerebral
autoregulation
• 1. Limit infusion rate of blood products 3 hours
• 2. Limit infusion rate of bolus saline 30 minutes or more except in arrest situation
• 3. DW10%, 2ml/kg for hypoglycemia boluses should be given over 5 minutes
• 4. Avoid use of sodium bicarbonate. If needed give 1-2 mEq/kg over at least 30
minutes
• 5. Avoid hypovolemia ,hypotension keep MAP within normal range

15. • G. Slow withdrawal/flushing of UAC
• H. Respiratory intervention
• I. Reduce fluctuations in blood pressure

16. • Patient Teaching
• • Explain the procedure to the infant’s family and adverse reactions
and discuss any other concerns.
• Complications
• • IVH causes brain injury in premature infants and is directly
associated with negative neurodevelopmental outcomes.
interventions are aimed at decreasing dramatic shifts in cerebral
perfusion

17. References:
• 1. Hansen AR, Cloherty and Stark's Manual of Neonatal Care, 8th edition, 2017.
• 2. Gleason CA, Devaskar SU (Ed.), Avery’s Diseases of the Newborn, 9th edition, 2012.
• 3. Gomella TL et al., Neonatology: Management, Procedures, On-Call Problems, Diseases and Drugs, 7th edition, 2013.
• 4. Auckland District Health Board, Newborn Services Clinical Guideline, NZ, 2018 Update.
• 5. Bedside Clinical Guidelines Partnership, Neonatal Guidelines 2017-19, Staffordshire, Shropshire and Black Country Neonatal Operational Delivery Network and Southern West
Midlands Neonatal Operational Delivery Network.
• 1- Implementing a Neuro-Bundle in a Level III Neonatal Intensive Care Unit, University of Maryland ,
• Baltimore , May 2019. http://hdl.handle.net/10713/9637
• 2- Chiriboga, N., Cortez, J., Pena-Ariet, A., Makker, K., Smotherman, C., Gautam, S.Hudak,M.L. (2019).
• Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing sever ICH: a quality
• improvement project. Journal of Perinatology, 39, 143-151.2019
• 3- Romantsik, O., Calevo, M.G., & Bruschettini, M. (2017). Head midline position for preventing the
• occurrence or extension of germinal matrix-intraventricular hemorrhage in preterm infants (review).
• Cochrane Database of Systematic Reviews, 7CD012362.doi:10.1002/14651858.CD012362.pub2
• 4- Neonatal Neuro-protective Best Practice Guidelines NICU Brain Sensitive Care Committee Swedish Medical
• Center-2015
• 5- REDUCING INTRAVENTRICULARHEMORRHAGE IN A LEVEL III NEONATAL INTENSIVE CARE UNIT, 1Hospital
• of the University of Pennsylvania, United States 2015, 10.1136/bmjqs-2015-IHIabstracts.17