Peri-intraventricular haemorrhage (PIVH) is a condition characterised by bleeding in and around the ventricles of the brain, typically occurring in premature infants.
PIVH can lead to significant neurological complications, including hydrocephalus and developmental delays.
Early detection, proper management and strategies to prevent prematurity are crucial for reducing the risk and impact of PIVH.
Epidemiology
Peri-intraventricular haemorrhage (PIVH) primarily affects premature infants born before 33 weeks of gestation, with the highest risk in those born at extremely low birthweights or very low birthweights.
The incidence decreases with increasing gestational age at birth.
Aetiology
The primary cause of PIVH is the fragility of blood vessels of the germinal matrix, usually in those born before 33 weeks’ gestation.
After 33 weeks’ gestation, the germinal matrix involutes and therefore, haemorrhage is less likely.
Other risk factors include fluctuations in cerebral blood flow, oxygen levels and lack of maternal antenatal steroids.
Pathophysiology
Peri-intraventricular haemorrhage (PIVH) results from the rupture of blood vessels in the germinal matrix of the periventricular area, leading to bleeding in the area and into the intraventricular space.
Bleeding is typically classified as grades I to IV, with grades III and IV described as severe:
grade I:
hemorrhage limited to the germinal matrix.
grade II:
IVH without ventricular dilatation.
grade III:
IVH with ventricular dilatation occupying > 50% of the ventricle.
grade IV:
IVH with intraparenchymal hemorrhage
Clinical Presentation
Peri-intraventricular haemorrhage (PIVH) usually occurs in the first few days to weeks of life and is often initially asymptomatic.
It may present later with the following clinical features:
bleeding can lead to anemia and signs of reduced oxygen-carrying capacity.
Differential diagnosis
Infection.
Periventricular leukomalacia.
Metabolic disorders.
Diagnosis
Diagnosis of PIVH involves a combination of clinical evaluation and diagnostic tests, including:
monitoring of head circumference
cranial ultrasound:
a non-invasive imaging modality used to visualise the ventricles and identify haemorrhage
serial screening cranial ultrasounds are performed in those of gestation < 33 weeks and/or low birthweights, including at discharge from Neonatal Units.
coagulation studies:
assessing coagulation parameters to rule out bleeding disorders.
Management
Non-pharmacological
Supportive care:
- monitoring vital signs, neurologic status and oxygen levels.
Delayed cord clamping at birth.
Ventricular drainage:
serial lumbar punctures
in some severe cases, a ventricular drain or ventriculoperitoneal shunt may be placed to relieve pressure.
Pharmacological
Antenatal maternal steroids for those at risk of preterm delivery.
Surgical
Surgical interventions may be considered for severe cases with progressive hydrocephalus, such as ventriculoperitoneal shunt placement.
Prognosis
The prognosis for infants with PIVH varies based on the severity of haemorrhage and any associated complications.
Those with severe IVH are at greater risk of neurological deficits, seizures, developmental delays or cerebral palsy.
Early intervention and neurodevelopmental follow up are essential for optimising outcomes.