Infant Brain Bleeds: Intraventricular Hemorrhages (IVH)
An intraventricular hemorrhage (IVH) is a serious type of infant brain bleed that occurs when there is bleeding within the brain’s ventricular system. The ventricular system is where spinal fluid is produced. Intraventricular hemorrhages can result from hypoxia (oxygen deprivation) or from physical trauma during birth. Premature and low birth weight infants are particularly susceptible because blood vessels in their brains are not fully developed and are therefore weak. Improper management of birth and neonatal care can result in intraventricular hemorrhages, which can cause permanent brain damage and conditions such as hydrocephalus, cerebral palsy (CP), periventricular leukomalacia (PVL), seizure disorders, and intellectual/developmental disabilities.
Risk Factors for Intraventricular Hemorrhages
Intraventricular hemorrhages (IVH) occur most frequently in babies who are born at less than 32 weeks of gestation or have a birth weight of less than 1500 grams and are not properly managed. Other risk factors for IVH include hypoxic-ischemic encephalopathy (HIE), birth trauma, lack of prenatal steroid (betamethasone) therapy in babies who are about to be born preterm, prolonged neonatal resuscitation, and respiratory distress.
Causes of Intraventricular Hemorrhages
Intraventricular hemorrhage (brain bleed) can be caused by a lack of oxygen to the baby’s brain and brain trauma. Oxygen deprivation can cause bleeding because when the brain receives insufficient oxygen, cells start to degrade. When the cells that make up the blood vessel walls start to break down, the vessels become fragile and can rupture very easily.
Traumatic head injury can also result in ruptured blood vessels. Head trauma is often caused by the use of forceps and vacuum extractors. These devices are placed directly on the baby’s head to help ease them out of the birth canal. Unfortunately, physicians often apply excessive pressure or misuse these devices, resulting in a brain bleed. Other causes of IVH are discussed below.
- Abnormal changes in blood pressure
- Prolonged labor. The stresses and forces of labor are traumatic for a baby, and physicians often fail to move on to C-section delivery when it is medically necessary. During an extended attempt at vaginal delivery, the baby may become oxygen deprived or experience head trauma.
- Labor-enhancing drugs such as Pitocin or Cytotec. These drugs may lead to uterine tachysystole, a condition in which contractions are too strong, frequent, or long. Uterine tachysystole can cause a baby to become oxygen deprived and/or experience head trauma, both of which can result in brain bleeds.
- Macrosomia (a condition in which the baby is large for gestational age and cannot easily fit through the birth canal) or cephalopelvic disproportion (when there is a size mismatch between the baby’s head and the mother’s pelvis).
- Abnormal fetal presentation, such as a breech or face presentation, that can cause head trauma.
Signs of Intraventricular Hemorrhages
Listed below are some signs that the baby may have IVH:
- An altered level of consciousness
- The baby is limp (hypotonia) and/or weak
- The baby has decreased movement
- The baby’s breathing is abnormal – in severe cases, the baby is not breathing enough, has irregular breathing, and/or has periods in which they stop breathing (apnea)
- The baby has seizures, especially tonic seizures
- The baby is showing neurological signs, such as pupils being fixed to light
- The baby’s heart rate is slow and/or their blood pressure is low
- The baby has a bulging soft spot
- The baby’s red blood cell count (hematocrit) is decreasing
- The baby’s blood is acidic (acidosis)
- The baby is in a coma
Diagnosis and Treatment of Intraventricular Hemorrhages
Intraventricular hemorrhages are diagnosed with a head (cranial) ultrasound. Physicians use the ultrasound to determine the location and extent of the IVH.
Grading of the severity of the IVH is as follows:
- Grade I IVH – Bleeding is confined to the germinal matrix, which is very important in brain development; cells migrate out of this area during brain development and the germinal matrix is most active between 8 and 28 weeks of gestation
- Grade II IVH – Bleeding is occurring inside the ventricles, but they are not enlarged
- Grade III IVH – Bleeding has caused the ventricles to become enlarged
- Grade IV IVH – Bleeding extends into the brain tissue around the ventricles; there is some tissue death in the periventricular white matter next to the IVH
Since IVH occurs most frequently in babies who are less than 32 weeks of gestation or have a birth weight of less than 1500 grams, these infants should have ultrasounds to screen for IVH.
Treatment for blood loss includes giving the baby blood and other therapies to increase blood volume and blood pressure. This includes packed red blood cells, fresh frozen plasma, and normal saline.
Initial management of IVH requires ongoing monitoring with weekly ultrasounds, daily recording of head size, and clinical assessment for signs of increased pressure in the brain. Additional management typically includes lumbar punctures to drain cerebrospinal fluid. If this is not effective, the baby may need to have ventricular drainage or shunting.
Long-Term Effects of Intraventricular Hemorrhage
As with any brain bleed, an intraventricular hemorrhage can damage the brain by causing a decreased amount of oxygen-rich blood in certain areas. If recognized right away and properly managed, IVH may cause no permanent injury in the baby. If mismanaged, however, the hemorrhage can extend into other areas of the brain. Specifically, the ventricles can swell due to too much cerebrospinal fluid, which is called hydrocephalus. Hydrocephalus can lead to damaged blood vessels and white matter damage (periventricular leukomalacia), and an important part of the brain, called the cerebral cortex, may not develop properly.
White matter is important because it regulates the electrical signals between cells of the nervous system. White matter is responsible for transmitting information throughout the brain, to the spinal cord, and outside the brain to the rest of the body. These signals control our bodily functions; nerve cells that transmit signals to the brain and cells that regulate breathing or heart rate would be unable to perform their tasks without white matter.
Ultimately, IVH can cause a child to develop lifelong conditions such as seizures, cerebral palsy, and developmental delays.
Reiter & Walsh ABC Law Centers: Legal Help for Intraventricular Hemorrhages
If you are seeking legal help for a baby that had an intraventricular hemorrhage, it is very important to choose a lawyer and firm that focus solely on birth injury cases. Reiter & Walsh ABC Law Centers is a birth injury firm that has been helping children throughout the nation for over three decades.
We have helped children throughout the country obtain compensation for lifelong treatment, therapy, and a secure future, and we give personal attention to each child and family we represent. Our firm has numerous multi-million dollar verdicts and settlements that attest to our success, and clients pay nothing until we win their case. Please reach out today for a free case evaluation.
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Video: Intraventricular Hemorrhages and Brain Injury
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