This document provides information on intraventricular hemorrhage (IVH), a common complication in preterm infants. It discusses the anatomy of the ventricular system and germinal matrix, where bleeding typically occurs. Risk factors for IVH include lack of blood flow autoregulation and a highly vascular germinal matrix in preterms. Grading systems for IVH are described. Management involves supportive care, monitoring for progression, and addressing complications like posthemorrhagic ventricular dilatation. While grades 1-2 IVH often resolve without sequelae, higher grades carry increased risks of neurodevelopmental impairment or mortality. Preventive strategies discussed include antenatal steroids, avoiding blood pressure fluctuations, and synchronized ventilation.
This set of ppt displays a short description about IVH and Pulmonary hemorrhage its causes, grades, pathophysiology related to it, management and the prognosis in paediatric population.
This set of ppt displays a short description about IVH and Pulmonary hemorrhage its causes, grades, pathophysiology related to it, management and the prognosis in paediatric population.
This presentation aims at discussion of the pathophysiology , clinical presentation and management of the different types of intracranial bleeds in a neonate. Special emphasis has been laid on intraventricular hemorrhage. The germinal matrix bleed in a preterm is discussed in depth along with the various evidence based management protocols available. Radiological diagnosis of IVH in a preterm / term baby will be discussed in the upcoming presentations.
Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathyMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Management of hypoxic ischemic encephalopathy (HIE) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Management of hypoxic ischemic encephalopathy (HIE) . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
intracranial hemorrhage- by KEMISA HASSEN ZAINABU IIHS_jinjaUGANDA (2).pptxHASSENZAINABUKEMISA
By the end of this we shall be able to know the following
definition.of intracranial hemorriage
Classification of intracranial hemorriage
Types of intracranial hemorriage.
Causes of intracranial hemorriage.
Signs and symptoms of intracranial hemorriage
Investigations specific management.
Complication.
Ongoing nursing care.
This presentation aims at discussion of the pathophysiology , clinical presentation and management of the different types of intracranial bleeds in a neonate. Special emphasis has been laid on intraventricular hemorrhage. The germinal matrix bleed in a preterm is discussed in depth along with the various evidence based management protocols available. Radiological diagnosis of IVH in a preterm / term baby will be discussed in the upcoming presentations.
Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathyMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Management of hypoxic ischemic encephalopathy (HIE) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Management of hypoxic ischemic encephalopathy (HIE) . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
intracranial hemorrhage- by KEMISA HASSEN ZAINABU IIHS_jinjaUGANDA (2).pptxHASSENZAINABUKEMISA
By the end of this we shall be able to know the following
definition.of intracranial hemorriage
Classification of intracranial hemorriage
Types of intracranial hemorriage.
Causes of intracranial hemorriage.
Signs and symptoms of intracranial hemorriage
Investigations specific management.
Complication.
Ongoing nursing care.
Birth Injuries are the common complications of Instrumental Delivery. So intrapartum management should be done very carefully in ordered to ensure healthy and good outcome of baby.
definition of hydrocephalus, types of hydrocephalus, communicating and non communicating hydrocephalus, csf, different treatments of the hydrocephalus, different types of shunts, VP shunt, causes of hydrocephalus, normal pressure hydrocephalus NPH, slit ventricle syndrome, ETV
Hydrocephalous is a serious disease of the central nervous system which has both congenital and aquired subtypes. the congenital variety affects the children and is a considerable burden especially is the developing countries. I tleads to long term morbidity and high rates of mortality
Hello Guys,
This presentation talks about diagnosis and management of Antenatally detected hydronephrosis. We have discussed evidence based fetal hydronephrosis management including - antenatal followup schedule, fetal interventions, postnatal screening and follow up proforma, MCU, Functional renal scans, prophylactic antibiotics and available surgical management options.
This presentation is an overview of congenital cyanotic heart diseases, with a special discussion on Tetralogy of Fallot. We discuss the pathophysiology, clinical manifestations as well as the most updated management options for treating this condition. The topic ends with a few important complications seen in TOF patients. Hope you find it useful.
You can follow us on: Facebook page 'Neonatohub' (online academic platform) OR visit our YouTube channel 'Neonatohub' for more paediatric and neonatology presentations.
Hi Guys,
This presentation talks about Tuberculosis diagnosed in mother in the antenatal period, its treatment, implications on mother and fetus, the various protocols available currently regarding the neonatal management . Special focus being in major issues like breastmilk feeding, BCG, AKT prophylaxis, mother-child isolation.
Hope you find it useful.
P.S. - Please checkout my youtube channel - 'NEONATOHUB' & Facebook page 'Neonatohub' for lectures on neonatology.
Hello Guys,
This presentation consists of the updated guidelines under National tuberculosis elimination programme of India (MOHFW). The presentation includes case definitions and diagnostic algorithms for Pulmonary, Extrapulmonary and Drug resistant TB(MDR/ XDR TB) and the tratment protocols in pediatric cases.
Hope you find it useful.
This presentation is a simplified version of the various types of cardiac arrythmias seen in pediatric age groups. We have discussed supraventricular tachycarsias and prolonged QT syndrome in details here. Hope everyone finds it useful.
Hello guys,
Todays presentation aims at discussing the most common syndromic causes of short stature - Turners syndrome and Downs syndrome. We have discussed the Genetics, Phenotype and co-morbidities with their individual management strategies. I hope you find it uselful too.
This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
This presentation is a part 2/4 of series of presentation on Paediatric immunization.This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
This presentation is aimed at giving the basic information of a neonate classification on basis of gestational age and the birth weight. Prematurity has been discussed in details. I have also included the growth charts that can be used for growth monitoring in term as well as preterm babies.
** This presentation is available in a video lecture format at my youtube channel - NeonatoHub. Do watch it for further understanding of the topic & subscribe to the channel.
Hello guys, bringing to you the concept of golden hour of neonatology. As in trauma, the first hour of neonatal life is most precious and this ppt is an attempt to highlight a few key aspects of this resuscitative strategy in premature infants.
Thsi presentation is a sincere attempt to demonstrate the aseptic techniques needed to collect blood culture, urine culture, diagnostic lumbar puncture. Disscussion about the use of there modalities in neonatology practice and the ways to increase their sensitivity and specificity is done.
this presentation is also available in a video lecture format at my Youtube channel - "NeonatoHub". Hope you enjoy it more in that format.
https://www.youtube.com/watch?v=vZ71vymGVC8
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
Respiratory physiology & Respiratory Distress syndrome in a newborn.Sonali Paradhi Mhatre
Hi guys, This ppt shows the pathophysiology of pulmonary surfactant in newborn and respiratory distress syndrome. Main focus is towards management of RDS esp. exogenous surfactant administration. Your comments are welcome. Thank you.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
5. This includes the hemorrhagic oedema that is observed
most commonly after vaginal deliveries.
The edema is soft, superficial and pitting and crosses the
sites of suture lines.
Usual site of caput formation is the vertex and steadily
resolves over the first few days of life.
Compression of the presenting part exerted by the uterus or
the cervix on the is the most common pathogenesis & seen
in 20 – 40% of vaccuum deliveries.
No intervention is needed.
CAPUT SUCCEDANEUM
6. Cephalhematoma refers to a circumscribed region of hemorrhage
overlying the skull ( subperiosteal)and confined by the cranial
sutures.
Highest incidence found with use of vaccum (10.8%) followed
closely by midforcep delivery(9.5%) and less by low forceps(7.2%)
An underlying linear skull fracture is seen in 10 – 20 % cases with
cephalhematoma.
The lesion usually seen increasing in size after birth and presents
as a firm, tense mass that does not transilluminate.
Common complications include severe hyperbilirubinemia,
anaemia, osteomyelitis.
No specific therapy is indicated. Evacuation of the lesion is
contraindicated.
CEPHALHEMATOMA
7. Subgaleal hemorrhage refers to the hemorrhage beneath
the aponeurosis covering the scalp and connecting the
frontal and occipital components of the occipitofrontalis
muscle.
Blood may spread beneath the entire scalp and may even
dissect into the subcutaneous tissues of the neck.
The infants generally present at 1 hr of age and manifests
as a firm, fluctuant mass, increasing in size postnatally,
and may present at the subcut tissue on the posterior part
of neck.
SUBGALEAL HEMATOMA
8. These infants have a relatively high incidence of :
1. Hypovolemic shock (10%)
2. Requirement of volume expansion or ionotropic
support (35%)
3. Need for transfusion for anaemia (35%)
4. Secondary coagulopathy (50 %)
5. Hyperbilirubinemia (35%)
After the acute phase, the lesion usualy resolves in 2
– 3 wks.
SUBGALEAL HEMATOMA
9.
10. INTRACRANIAL HEMORRHAGE
• Intracranial hemorrhage is a collective term
encompassing many different conditions characterised
by the extravascular accumulation of blood within
different intracranial spaces.
Term Infant Preterm Infant
Commonest are subdural,
subarachnoid or
subtentorial.
Mostly related to Birth
trauma, HIE, coagulopathies
and undetermined causes
Commonest is bleeding from
the subependymal germinal
matrix and may result in
intraventricular or
periventricular hemorrhage.
White matter injury due to
hypoxic ischaemia and
infections.
11. An Epidural hemorrhage is a collection of blood between the inner
skull and the dura.
Usually caused by injury to the middle meningeal artery, which is less
susceptible to injury as it is freely movable in the space.
Causes include TRAUMA.
Affected infants usually have a skull fracture and cephalhematoma
and the treatment is supportive with possible surgical / needle
aspirations.
EPIDURAL HEMORRHAGES
12. Subdural hemorrhage refers to the hemorrhage in the plane between
the dura and the arachnoid membrane and involves tears of bridging
veins of the subdural compartment.
Usually follows a traumatic delivery of a near term / term infant.
Signs may include lethargy ± irritability, asymmetric hypotonia,
impaired third cranial nervy function ipsilateral to lesion, focal seizures,
signs of raised icp.
Other clinical clues can be decreased feeding, failure to thrive,
intermittent vomiting – often related to late post SDH neuropathic
effects.
CT / MRI (esp for posterior fossa lesions) are modalities of choice.
Management involoves a proper and repeated neurologic followup and
sos interventions.
SUBDURAL HEMORRHAGE
13. A subarachnoid hemorrhage is an accumulation of blood
between the arachnoid mater and the pia mater.
Infant SAH is venous , as opposed to arterial in adults.
SAH may be primary , coming from the vessels of the
subarachnoid space, or secondary occurring when the blood
extends from existing intraventricular, cerebral or cerebellar
hemorrhages.
Close observation and repeated neurologic assessments are
mainstay of management.
Anticonvulsant medications and IV fluid therapy are needed if
lethargy / seizures are present.
Serum electrolyte and urine output monitoring to be done for
possible SIADH , if significant SAH has been identified.
SUB-ARACHNOID HEMORRHAGES
14. An Intracerebral parenchymal hemorrhage occurs deep within the brain
tissue after venous infarction and is commonly referred as
PERIVENTRICULAR HEMORRHAGIC INFARCTION.
The most common complications of PVHI is Periventricular leukomalacia
in preterm infants and porencephalic cysts in term infants.
Clinical signs of PVHI follow those of severe neonatal encephalopathy
and overlap with clinical signs as seen with SDH, SAH or IVH.
CT is the modality of choice.
Management requires observation and supportive care. If imaging
studies show a midline shift, neurosurgical consultation needed.
Developmental studies of preterm infants with PVHI have shown that
significant cognitive and/or motor delays complicate the overall recovery
in atleast 2/3 rd of the survivors.
Careful follow up is therefore indicated in every case.
CEREBRAL HEMORRHAGE
15. An Intracerebellar parenchymal hemorrhage is most often
seen in preterm infants with complications of labor and
delivery and in whom intense respiratory management is
required.
Incidences have been found approx 10% in preterms
<34wks, by MRI studies & is almost always associated
with birth injury in terms.
Clinically, an ICPH is unique in causing unexplained
motor agitation, in addition to respiratory compromise,
apnea and breathing irregularities. Other general
symptoms of ICH are also present.
CT and MRI are preferable over Ultrasound.
Management is usually conservative.
CEREBELLAR HEMORRHAGE
16. I N T R A V E N T R I C U L A R
H E M O R R H A G E
19. INTRODUCTION
• Intraventricular hemorrhage is the most common CNS complication of a preterm birth.
• The overall incidence of IVH in preterm infants <1500gm is approx 13 – 15 %.
• Because IVH is rarely seen in term infants, their incidence rates are exceptionally low and
associated with birth related injury and / or asphyxia.
• The germinal matrix begins to involute after 34 wks postconceptional age, and thus the
peculiar vulnerability decreases, but is not totally eliminated.
• By 36 wks gestation, the germinal matrix has involuted in most infants, although sopme
residual may persists.
20. WHY PRETERMS….???
1. Lack of cerebral blood flow autoregulation.
Therefore, a PRESSURE PASSIVE state exists.
2. Highly vascularized subependymal germinal matrix, lack of supporting
basement membrane in blood vessels, and increased amount of fibrinolytic
activity in germinal matrix.
3. Pathologic increased fluctuations in the cerebral blood flow velocity.
(Eg. RDS, Pneumothorax, PDA, Hypothermia, hyperosmolarity, etc.)
4. Isolated hypertension associated with seizures, intubations and
suctionings also predisposes these babies to IVH.
21. • The occurrence of preterm IVH is greatly associated with the immaturity of the germinal
matrix of the lateral ventricles
• The cortical neuronal and glial cell precursors develop from the germinal matrix and the
adjacent ventricular germinal zone during the late 2nd and 3rd trimester.
• This ependymal germinal matrix is highly vascularized region with arterial supply from
the anterior and the middle cerebral arteries and the anterior choroidal vessels.
• Bleed in this region, thus may be confined to the germinal matrix or it may rupture into
either lateral ventricles and may thereby become a unilateral or bilateral GM / IVH.
PATHOPHYSIOLOGY
22. Increased cerebral blood flow
Fluctuations in the cerebral blood flow.
Increased Central venous pressure.
Endothelial Injury.
Vulnerable germinal matrix capillaries.
Coagulation disturbances.
Increased Fibrinolysis.
PATHOGENETIC FACTORS LEADING TO IVH.
23. CLINICAL PRESENTATION
• Asymptomatic (sometimes).
• Sudden & catastrophic deterioration in form of
neurologic signs like stupor, coma, seizures, posturing
or apneas.
• Full fontanel with sudden drop in hematocrit.
• Can be accompanied by hyperglycemia, hyperkalemia,
hypotension, bradycardia.
• SIADH may be seen.
• Sometimes, IVH can present as a gradual clinical
deterioration with altered levels of consciousness,
hypotonia, abnormal extremity or eye movements.
25. CRANIAL ULTRASOUND
• Cranial Ultrasound is the procedure of choice for Screening and Diagnosis of Intraventricular
hemorrhage.
• CT and MRI are acceptable alternatives but are more expensive and require transport to the
imaging service.
• 2 systems for classifying GM / IVH have been started for clinical use – Papille & Volpe systems.
• Papille was initially CT based system but was further adapted for the interpretation of USG. Volpe
system is ultrasound based.
• The utility of the classification schema resides in the ability of the clinicians to communicate
degrees of severity and to have a source of information for comparison of lesions as well as
having means to follow progression or regression and recovery of the initial insult of IVH.
26. CRANIAL ULTRASOUND
Grade Papille Grading system Volpe Grading syytem
1 Subependymal hemorrhage
with minimal or no /ivh
Germinal matrix hemorrhage
< 10% IVH
2 IVH without Ventricular
dilatation
IVH 10 – 50 %
3 Enlargement of ventricles
secondary to distension
with blood
IVH > 50 % with lateral
ventricle dilatation
4 Extension of hemorrhage
into the parenchyma along
with IVH and enlargement.
-
There is no Grade 4 in volpe classification. Final stage is Periventricular echodensity signifying parenchymal lesion
27. CRANIAL ULTRASOUND SCREENING
Age USG Indication
1 day Perinatal asphyxia ,
In utero drug
exposure
3 days Unstable clinical
course
7 days All infants ≤32 wks
gestation
36 wks PMA or
before discharge
All NICU babies
• A cranial ultrasound is indicated for screening sick
preterm infants for IVH from the first day of life ,
throughout hospitalization.
• Typically a Neurosonography is done between day 1
and 7, depending on clinical presentation and
institutional protocols.
• Approx 50 % GM/IVH may occur on Day1.
• Approx 90 % GM/IVH have occurred by Day4.
• Of all GM/IVH identified by Day 4 of life, 20 – 40 % will
progress to more extensive hemorrhage.
28. M A N A G E M E N T O F
I N T R A V E N T R I C U L A R
H E M O R R H A G E
29. M A N A G E M E N T O F
I N T R A V E N T R I C U L A R
H E M O R R H A G E
P R E V E N T I O N A C U T E
M A N A G E M E N T
P O S T N A T A L
P R E V E N T I O N
P R E N A T A L
P R E V E N T I O N
F O L L O W U P
30. IVH PREVENTION
Prenatal strategies
• Avoidance of Premature deliveries.
• Transportation in utero.
• Antenatal steroid therapy.
Postnatal strategies
• Avoid Birth asphyxia.
• Avoid blood pressure fluctuations
• Avoid rapid infusions of volume
expanders or hypertonic solutions.
• Prompt & cautious CVS support to
prevent hypotension.
• Correct acid –base abnormalities
• Correct coagulopathies.
• Synchronized mechanical ventilation.
31. ACUTE STAGE MANAGEMENT
• General supportive care to maintain normal blood volume.
• Maintain electrolyte and acid- base status.
• Blood transfusion to maintain hematocrit , in large bleeds.
• Thrombocytopenia or coagulation disturbances should be corrected.
• In case of Posthemorrhagic ventricular dilatation, careful monitoring of ventricular size by serial
ultrasounds and appropriate interventions ( Therapeutic lumbar punctures,VP shunts/ medical
decompressiosn) .
• Follow up serial imaging to detect progression of IVH and later progressive hydrocephalus.
32. OUTCOME
• Grade 1 & 2 IVH - Spontaneous Resolution
• Grade 3 IVH - Evolves over 1 – 3 wks.
After this it produces fibrotic reaction that
obliterates subarachnoid space & leads to
ventricular dilatation and hydrocephalus.
• Intraparenchymal Hemorrhage - Mortality / Followed in 1 – 8
wks by tissue destruction
and formation of
porencephalic cyst.
33. PROGNOSIS
• Grade 1 & 2 IVH – No significant neurologic dysfunction.
• Grade 3 IVH – neurologic abnormality in 35 % of infants.
• Grade 4 IVH – Neurologic abnormality in 55 % of infants.
• Mortality seen in approximately 50 % of neonates with hemorrhagic infarct.
2008, Browser et al.
34. EVIDENCES
• 1. Metaanalysis performed in 1996 by P. crowley ,regarding the benefits of antenatal steroid use in preterm delivery
have concluded that Corticosteroid treatment is associated with a substantial reduction in the risk of intraventricular
haemorrhage, regardless of the criteria used for diagnosis.
• 2. A metaanalysis performed by smit,od,whitlaw in 2013 had concluded that Postnatal administration of
phenobarbital cannot be recommended as prophylaxis to prevent IVH in preterm infants and is associated with an
increased need for mechanical ventilation.
• 3. A metaanalysis performed by Peter w. fowlie (1996, 2003) have concluded that prophylactic indomethacin has a
number of short term benefits for the preterm infant but there is no evidence to suggest that it results in an
improvement in the rate of survival free of disability
• 4. Jeffrey M. Perlman, M.B., Steven Goodman, M.D., Katherine L. Kreusser, M.D., and Joseph J. Volpe, M.D;
Reduction in Intraventricular Hemorrhage by Elimination of Fluctuating Cerebral Blood-Flow Velocity in Preterm
Infants with Respiratory Distress Syndrome; N Engl J Med 1985; 312:1353-1357 which concluded that elimination of
fluctuating cerebral blood-flow velocity in preterm infants with respiratory distress syndrome markedly reduces the
incidence and severity of intraventricular hemorrhage.
35. EVIDENCES
5 . The other preventive strategies studied and found not to be useful are vitamin A, ethanmsylate, antenatal vitamin
k administration to mother for imminent preterm delivery.
6. Lynn J. Groome, PhD, MD1, , Robert L. Goldenberg, MD1, Suzanne P. Cliver, BA1, Richard O. Davis, MD1,
Rachel L. Copper, RN1,March of Dimes Multicenter Study Group; Neonatal periventricular-intraventricular
hemorrhage after maternal β-sympathomimetic tocolysis concluded that β-Sympathomimetic tocolytic therapy
may be associated with a more than two fold increase in the incidence of neonatal periventricular-intraventricular
hemorrhage.
7. Caldas JP, Braghini CA, Mazzola TN, Vilela MM, Marba ST. Peri-intraventricular hemorrhage and oxidative and inflammatory stress
markers in very-low birth weight newborns. J Pediatr (Rio J). 2015;91:373---9
This study has not found any association between ROI, GSH, and IL‐6 levels with the occurrence of PIVH in very‐low birth weight
infants.
36. EVIDENCES
5. Studies regarding the neurodevelopmental outcomes:
Allison H. Payne, MD, MS; Susan R. Hintz, MD, MS; Anna Maria Hibbs, MD, MS; Michele C. Walsh, MD,
MS; Betty R. Vohr, MD; Carla M. Bann, PhD; Deanne E. Wilson-Costello, MD ; for the Eunice Kennedy
Shriver National Institute of Child Health and Human Development Neonatal Research Network ;
Neurodevelopmental Outcomes of Extremely Low-Gestational-Age Neonates With Low-Grade
Periventricular-Intraventricular Hemorrhage; JAMA Pediatr. 2013;167(5):451-459.
doi:10.1001/jamapediatrics.2013.866.
• Results = Low-grade hemorrhage was not associated with significant differences in unadjusted or adjusted risk of
any adverse neurodevelopmental outcome compared with infants without hemorrhage. Compared with low-grade
hemorrhage, severe hemorrhage was associated with decreased adjusted continuous cognitive (β, −3.91 [95% CI,
−6.41 to −1.42]) and language (β, −3.19 [−6.19 to −0.19]) scores as well as increased odds of each adjusted
categorical outcome except severe cognitive impairment (odds ratio [OR], 1.46 [0.74 to 2.88]) and mild language
impairment (OR, 1.35 [0.88 to 2.06]).
• Conclusion = The authors concluded that at 18 to 22 months, the neurodevelopmental outcomes of extremely low-
gestational-age infants with low-grade periventricular-intraventricular hemorrhage are not significantly different
from those without hemorrhage. Additional study at school age and beyond would be informative.
37. TO
CONCLUDE………. Cranial hemorrhage in infants can be 1. Extracranial 2. Intracranial
The extracranial hemorrhages include – caput, cephalhematoma & subgaleal
hematoma.
The intracranial hemorrhages can further be – Extradural, subdural, subarachnoid,
cerebral, intracerebellar, intraventricular hemorrhage.
Vaccum delivery has been implicated in etiogenesis of ICH .esp term neonates, closely
followed by high and mid forceps followed by low forceps extraction.
Intraventricular hemorrhage is the most common CNS complication of a preterm birth.
38. Germinal matrix bleed and resulting intraventricular hemorrhage is more commonly
seen with preterm babies & is greatly associated with the immaturity of the germinal
matrix.
A cranial ultrasound is indicated for screening sick preterm infants for IVH from the first
day of life throughout hospitalization.
IVH grading is performed as per the Papille & Volpe grading systems. ( Cranial ultrasound
based)
Prognosis of Grade 1 & 2 IVH has been found the best and nearly equivalent to a normal
neonate.
Strict neurologic follow up is a must in all the cases of IVH for long term morbidity
corrections.
TO
CONCLUDE……….