eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Periventricular Hemorrhage-Intraventricular Hemorrhage: Follow-up

Author: David J Annibale, MD, Associate Professor, Director of Neonatology, Director of Fellowship Training Program in Neonatal-Perinatal Medicine, Department of Pediatrics, Medical University of South Carolina
Coauthor(s): Jeanne Hill, MD, Radiology Program Director, Associate Professor, Departments of Radiology and Pediatrics, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Nov 25, 2008

Follow-up

Further Inpatient Care

  • Developmental intervention programs are indicated in individuals with periventricular hemorrhage–intraventricular hemorrhage (PVH-IVH).

Further Outpatient Care

  • Neurological follow-up
  • Developmental follow-up

Deterrence/Prevention

  • Antenatal steroids and the prevention of prematurity are important elements in the prevention of PVH-IVH.
  • Prevention of PVH-IVH begins with avoidance of conditions that do the following:
    • Interfere with autoregulation (eg, hypocarbia, hypercarbia, hypoxia, acidosis)
    • Overwhelm autoregulatory abilities (eg, hypertension)
    • Contribute to rapid fluctuations of cerebral blood flow (eg, ventilatory asynchrony, rapid volume expansion, noxious stimuli, frequent handling)
  • Perform correction of host factors (eg, coagulopathy, acid-base balance, hydration, hypoxia-ischemia).
  • Pharmacological prophylaxis can be accomplished through the use of indomethacin. Although the mechanism of action is currently unknown, indomethacin has been shown to reduce the incidence of PVH-IVH and, specifically, high-grade hemorrhages.9 Follow-up of patients enrolled in a multicenter prophylaxis study conducted by Ment et al was less convincing,8 although sex-related differences favoring treatment in male infants have been postulated. Another large multicenter trial yielded contradictory evidence.14  With such contradictory evidence of benefit, a lack of a definitive demonstration of improvement in developmental outcomes, and a concern for complications, this therapy is not universally accepted and remains controversial.
  • In addition to effects on pulmonary development, prenatal treatment with glucocorticoids has a protective effect with regard to PVH-IVH.
  • The use of other pharmacological modalities to prevent PVH-IVH has been proposed; however, this use is not widely accepted. The other pharmacological modalities include prenatal treatment with vitamin K and phenobarbital and postnatal treatment with ethamsylate, phenobarbital, and vitamin E. Although positive reports concerning the efficacy of these agents are noted, further investigation is required to prove conclusive evidence of benefit.

Complications

  • Obstructive hydrocephalus
  • Nonobstructive hydrocephalus
  • Developmental impairment
  • Cerebral palsy
  • Seizures

Prognosis

  • Grade I and grade II hemorrhage: Neurodevelopmental prognosis is excellent (ie, perhaps slightly worse than infants of similar gestational ages without PVH-IVH).
  • Grade III hemorrhage without white matter disease: Mortality is less than 10%. Of these patients, 30-40% have subsequent cognitive or motor disorders.
  • Grade IV (severe PVH-IVH) IVH with either periventricular hemorrhagic infarction and/or periventricular leukomalacia (PVL): Mortality approaches 80%. A 90% incidence of severe neurological sequelae including cognitive and motor disturbances is noted.

Patient Education

  • Prenatal
    • Specific risks of gestational age
    • Sequelae
  • Postnatal
    • Provide postnatal education (if not provided previously) or reinforce prenatal education.
    • Provide results of sonography and expectations for short-term and long-term care.

Miscellaneous

Medicolegal Pitfalls

  • According to randomized controlled trials, the use of indomethacin appears to be effective in the prevention of periventricular hemorrhage–intraventricular hemorrhage (PVH-IVH). However, this therapy is not universally accepted because of potential complications of treatment and failure to demonstrate significantly improved developmental outcomes after prophylaxis. Whether or not failure to use indomethacin (or the use of the drug with subsequent complications) could result in civil liability is not clear. Complications related to the use of indomethacin (including intestinal perforation) may also present liability. Furthermore, evidence demonstrating improved long-term developmental outcomes is contradictory.
  • Although data are limited, preexisting hemorrhage does not appear to be worsened after indomethacin treatment.15
  • In order to be effective, indomethacin must be administered within hours of birth. The number of at-risk premature patients who could conceivably receive the drug is large. Obtaining a pre-indomethacin echocardiogram to rule out an underlying cardiac condition in which patency of the ductus arteriosus is essential may be considered impractical and not cost effective. Whether or not legal risk is associated with the failure to diagnose a ductal-dependent lesion prior to administering indomethacin is not clear.

Special Concerns

  • In patients with posthemorrhagic ventricular dilation that regresses, provide close follow-up care because hydrocephalus can recur.
 


More on Periventricular Hemorrhage-Intraventricular Hemorrhage

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Follow-up: Periventricular Hemorrhage-Intraventricular Hemorrhage
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References
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References

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Further Reading

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Keywords

periventricular hemorrhage, PVH, intraventricular hemorrhage, IVH, germinal matrix hemorrhage, intraventricular hemorrhage, periventricular hemorrhage, cerebral palsy, developmental delay, hypocarbia, hypercarbia, hypoxemia, acidosis, hydrocephalus, ventricular-peritoneal shunt, mental retardation, seizures, obstructive hydrocephalus, global hypoxic-ischemic injury, periventricular leukomalacia, PVL, nonhemorrhagic ischemic necrosis, anemia, metabolic acidosis, glucose instability, respiratory acidosis, apnea, hypotonia, hypercarbia, hypocarbia pneumothorax, hypoxemia

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Contributor Information and Disclosures

Author

David J Annibale, MD, Associate Professor, Director of Neonatology, Director of Fellowship Training Program in Neonatal-Perinatal Medicine, Department of Pediatrics, Medical University of South Carolina
David J Annibale, MD is a member of the following medical societies: American Academy of Pediatrics and National Perinatal Association
Disclosure: Nothing to disclose.

Coauthor(s)

Jeanne Hill, MD, Radiology Program Director, Associate Professor, Departments of Radiology and Pediatrics, Medical University of South Carolina
Jeanne Hill, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, Association of Program Directors in Radiology, Association of University Radiologists, Radiological Society of North America, and Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Medical Editor

Scott MacGilvray, MD, Clinical Associate Professor of Pediatrics, East Carolina University School of Medicine
Scott MacGilvray, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: MedImmune Speakers Bureau Honoraria Speaking and teaching

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Brian S Carter, MD, FAAP, Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Co-director, Pediatric Advance Comfort Team, Monroe Carell Jr Children's Hospital at Vanderbilt
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, National Hospice and Palliative Care Organization, and National Perinatal Association
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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