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

Periventricular Hemorrhage-Intraventricular Hemorrhage: Treatment & Medication

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

Treatment

Medical Care

Supportive care includes the correction of underlying medical disturbances that might be related to the development of periventricular hemorrhage–intraventricular hemorrhage (PVH-IVH) as well as cardiovascular, respiratory, and neurological support.

  • Correction of anemia, acidosis, and hypotension, as well as ventilatory support, might be required in those neonates who present with acute deterioration.
  • Serial lumbar puncture, although once used to prevent progressive hydrocephalus, is not indicated.

Surgical Care

Surgical support for PVH-IVH is limited to intervention for posthemorrhagic hydrocephalus. Because most patients with hydrocephalus following PVH-IVH demonstrate spontaneous resolution within weeks of onset, surgical intervention is usually unnecessary.

  • Serial lumbar punctures have been used to manage early hydrocephalus. However, because spontaneous resolution of hydrocephalus is usually observed, the use of this intervention has been questioned. A multicenter evaluation of serial lumbar punctures demonstrated no benefit when the individual with PVH-IVH is aged 30 months. The role of serial lumbar punctures in the management of late or rapidly progressive hydrocephalus remains controversial.
  • Acetazolamide may be used to diminish CSF production and limit late or rapidly progressive hydrocephalus. Its use in the treatment of early ventricular dilatation is probably limited.
  • Ventriculostomy placement may be required for the management of significant hydrocephalus while awaiting definitive surgical drainage.
  • Ventriculoperitoneal and ventriculosubgaleal shunting remain the definitive treatments for posthemorrhagic hydrocephalus requiring surgical intervention.

Consultations

  • Consult neurosurgery in the event of rapidly progressive ventricular enlargement or prolonged (>4 wk) slowly progressive ventricular enlargement.
  • Neurology consultation might be of value in the event of intractable seizures in an individual with PVH-IVH.
  • A developmental interventionist might be of help with a patient with high-grade hemorrhages.

Medication

Pharmacological intervention in the prevention and treatment of periventricular hemorrhage–intraventricular hemorrhage (PVH-IVH) and posthemorrhagic hydrocephalus remains controversial.

Prostaglandin inhibitors

These agents are postulated to perform prostaglandin synthesis inhibition. They inhibit free radical formation and accelerate maturation of germinal matrix vasculature. Indomethacin has been shown to decrease the risk of high-grade PVH-IVH. However, developmental outcomes have not been shown to be improved with the use of indomethacin prophylaxis. For this reason, the role of indomethacin in the prevention of IVH remains uncertain. Analysis of patients enrolled in a multicenter trial of indomethacin prophylaxis suggests that prophylaxis is effective in male infants and not in female infants. This remains to be confirmed through prospective evaluations.

Other members of this class of drugs have not been demonstrated to be of value in reducing the incidence of PVH-IVH.


Indomethacin (Indocin)

Controversial, but possibly indicated in patients at risk for PVH-IVH, including those <32 weeks' gestation or those who weigh <1250 g at birth. Among its actions, indomethacin inhibits the formation of prostaglandins by decreasing the activity of cyclo-oxygenase. Additionally, through mechanisms poorly understood, indomethacin causes maturation of the germinal matrix microvasculature. It is also associated with decreased cerebral blood flow, cerebral blood flow velocity, and cerebral blood volume, especially when rapidly administered. Alterations of oxidative metabolism are also suggested.

Adult

Pediatric

0.1 mg/kg/dose IV when aged 6 h, then q24h for 2 d for a total of 3 doses

May interfere with renal excretion of drugs (eg, gentamicin); may increase serum potassium levels when administered with potassium-sparing diuretics

Thrombocytopenia or active bleeding; acute renal failure; pulmonary hemorrhage; oliguria; electrolyte disorders; premature infants with or suspected NEC

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pregnancy category D if used for more than 48 h or after 34 weeks' gestation; fluid and electrolyte imbalance including hyperkalemia; possible cerebral hypoperfusion and ischemia; alterations in regional blood flow including GI and renal; acute renal failure; oliguria

Carbonic anhydrase inhibitors

These agents suppress CSF production.


Acetazolamide (Diamox)

The suppression of CSF production in slowly progressive ventricular dilation is controversial. Acetazolamide is a competitive and reversible inhibitor of carbonic anhydrase.

Adult

Pediatric

5 mg/kg/dose PO/IV q6h initially; increase by 25 mg/kg/d; not to exceed 100 mg/kg/d

May increase the excretion of phenobarbital

Patients with hyperchloremic acidosis; decreased serum sodium and/or potassium

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypercalciuria and nephrocalcinosis (especially in combination with furosemide); possible interference with CNS myelination; metabolic acidosis; hypokalemia; hepatic dysfunction

More on Periventricular Hemorrhage-Intraventricular Hemorrhage

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Differential Diagnoses & Workup: Periventricular Hemorrhage-Intraventricular Hemorrhage
Treatment & Medication: Periventricular Hemorrhage-Intraventricular Hemorrhage
Follow-up: Periventricular Hemorrhage-Intraventricular Hemorrhage
Multimedia: Periventricular Hemorrhage-Intraventricular Hemorrhage
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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