Key Facts

• 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:
  • abnormal neurological signs: 
    - altered consciousness
    - seizures
    - poor feeding.
  • bulging fontanelle
  • increasing head circumference
  • anemia:
  • 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.