Intraventricular Hemorrhage

This month, let’s review a common morbidity among premature babies that we all actively work to prevent: intraventricular hemorrhage (IVH).

What is IVH?

Intraventricular hemorrhage occurs due to bleeding in the brain, typically originating in the fragile germinal matrix and extending into the ventricles. IVH is a significant risk factor for brain injury and subsequent neurodevelopmental impairment in preterm infants. This is an essential topic for NICU nurses to stay informed about the latest evidence-based care, ensuring the best outcomes for their patients.

Who is Most at Risk of IVH?

Premature infants born at less than 32 weeks of gestation are at the highest risk for IVH. The more premature the infant, the greater the risk. Extremely low birth weight babies (<750g) have a 10-fold higher likelihood of severe IVH compared to infants weighing >1250g at birth.

Additional risk factors include:

• Chorioamnionitis

• Perinatal hypoxic-ischemic events

• Use of sodium bicarbonate

• Significant delivery room resuscitation

• Neonatal transport

How Does IVH Happen?

The germinal matrix, located just below the ventricles, is a highly vascular structure involved in angiogenesis (blood vessel development) and producing neuronal and glial progenitors. This matrix gradually decreases in size and typically involutes (disappears) by 34-36 weeks of gestation. Therefore in premature infants less than 32 weeks, the germinal matrix remains present and is extremely fragile and at risk for bleeding. The blood vessels within the germinal matrix have a “U-turn”, making it extremely vulnerable to fluctuations in blood flow and pressure.

IVH often occurs due to increased venous pressure or cerebral blood flow fluctuations. Unlike term infants, the preterm brain is “pressure-passive” and lacks the ability to autoregulate blood pressure effectively. This makes it particularly sensitive to:

• Hypotension followed by reperfusion

• Isolated hypertension or increased cerebral blood flow caused by events like seizures, intubation, suctioning, or surfactant administration

The highest risk of IVH is within the first three days of life, with approximately half of neonatal hemorrhages occurring within the first six hours. Small nuances in care, such as rapid bolus infusion or lifting the hips during a diaper change, can influence IVH risk, highlighting the critical role of NICU nurses in prevention.

Luo, 2019

Grades of IVH

The severity of IVH is categorized into four grades based on the extent of hemorrhage:

• Grade 1: Germinal matrix hemorrhage (<10% of ventricular volume).

• Grade 2: Hemorrhage involving 10-50% of the ventricular volume.

• Grade 3: Hemorrhage involving >50% of ventricular volume, often causing lateral ventricle distension.

• Periventricular Hemorrhagic Infarction: Echodensity in the periventricular region.

Historically, “Grade IV” referred to hemorrhage extending from the ventricle into the parenchyma. However, experts now view this as a distinct process (parenchymal venous infarction) rather than an extension of IVH.

IVH may also disrupt cerebellar development due to its high population of progenitor cells, which are vulnerable to blood products. Advanced MRI techniques have identified primary hemorrhages in the cerebellar germinal matrix.

Signs of IVH

Clinical signs of IVH vary widely, from asymptomatic presentations to sudden, severe deterioration. Symptoms may include:

• Apnea

• Tense, full fontanelle

• Drop in hematocrit

• Widened sutures

• Increasing head circumference

• Seizures

• Posturing

• Hypotension

Diagnosis is made through routine cranial ultrasounds.

Management of IVH

Management of IVH is primarily supportive and includes:

• Serial ultrasounds to monitor for complications (e.g., post-hemorrhagic ventricular dilation).

• Blood transfusions for significant drops in hemoglobin or hematocrit.

• EEG or aEEG monitoring to detect seizure activity.

• Surgical interventions, such as ventricular reservoirs or ventriculoperitoneal (VP) shunts, in cases of posthemorrhagic hydrocephalus.

Outcomes of IVH

• Grades 1 and 2: These typically resolve over time, though inflammation and neurotoxic effects may disrupt white matter, impair myelination, and lead to cortical and thalamic dysmaturation. Long-term sequelae remain uncertain, emphasizing the need for follow-up care.

• Grade 3: Associated with increased risk of periventricular white matter injury. Neurodevelopmental outcomes may depend on the timing of interventions for posthemorrhagic ventricular dilation.

• Periventricular Hemorrhagic Infarction: A significant predictor of neurodevelopmental impairment, commonly causing unilateral spastic hemiplegia (cerebral palsy) contralateral to the hemorrhage.

How Can We Prevent IVH?

Since IVH treatment is primarily supportive, prevention is critical. Preventative strategies include:

• Prenatal care: Maternal steroids and management of chorioamnionitis.

• Antenatal interventions: Delayed cord clamping, ensuring thermoregulation/preventing hypothermia, and experienced resuscitation teams.

• NICU care: Measures to reduce cerebral blood flow fluctuations and stress, such as gentle two-person care, positive sensory experiences, ensuring that boluses are given slowly and the legs/hips are never lifted above the head. 

Let’s review the evidence for a few specific interventions:

• Head positioning: Evidence is mixed. Some studies suggest elevated head positioning may benefit survival and reduce severe IVH, a Cochrane review in 2020 found there is no strong evidence that a specific head position significantly reduces IVH.

• Ventilation management: Complications of over or under ventilation result in fluctuations in cerebral blood flow and elevated central venous pressure.

  • Hypocarbia is associated with hypotension and increased risk of IVH and white matter injury.

  • Hypercardia results in vasodilation leading to increased cerebral blood flow.

  • Delivering high tidal volumes (>6mL/kg) during the positive pressure ventilation in the delivery room was shown to increase the rate of severe IVH.

• Avoiding harmful medications: Sodium bicarbonate is associated with increased IVH risk, potentially due to hyperosmolarity, sodium fluctuations, and hypernatremia.

• Prophylactic indomethacin: Some centers administer indomethacin prophylactically to reduce IVH. Studies have shown prophylactic indomethacin reduces severe IVH and the incidence of symptomatic PDA but did not seem to impact long term outcomes.

  • One study examined a cohort of NICUs over a ten year period and found indomethacin prophylaxis decreased over the ten year period among most NICUs in the cohort with no change in IVH. 

• NIRS Monitoring: Some NICUs utilize Near Infrared Spectroscopy during the first 72 hours of life. NIRS provides non-invasive measurements of changes in cerebral perfusion and oxygenation. It has the potential of providing real time information on cerebral blood flow.

  • A Phase 3 randomized control trial conducted at 70 sites looking at 1601 infants did not find a lower incidence of death or severe brain injury at 36 weeks in extremely preterm infants guided by NIRS monitoring for the first 72 hours compared to usual care.

Does your NICU have an IVH prevention bundle? What is included? Email me and let me know if you do something I didn't mention. I'd love to hear about your practices in your NICU and how you are working with your team to prevent IVH!

Stay curious,
Amanda

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References:

• Riddle, A., Miller, S., & Back, S. (2024). Brain injury in the preterm infant in AVery’s Diseases of the Newborn. Elsevier

• Cizmeci, M & Vries, L. (2025). Intracranial Hemorrhage and Stroke in the Neonate in Fanaroff and Martin’s Neonatal Perinatal Medicine (12th Ed). Elsevier

• Kolnik, S. E., Upadhyay, K., Wood, T. R., Juul, S. E., & Valentine, G. C. (2023). Reducing Severe Intraventricular Hemorrhage in Preterm Infants With Improved Care Bundle Adherence. Pediatrics, 152(3), e2021056104.

• Garvey, A. A., Walsh, B. H., & Inder, T. E. (2022). Pathogenesis and prevention of intraventricular hemorrhage. Seminars in perinatology, 46(5), 151592. 

• Matlock D. N., Jr (2019). Does an elevated midline head position prevent periventricular-intraventricular haemorrhage in extremely low birth weight neonates?. Acta paediatrica (Oslo, Norway : 1992), 108(10), 1925. 

• Romantsik, O., Calevo, M. G., & Bruschettini, M. (2020). Head midline position for preventing the occurrence or extension of germinal matrix-intraventricular haemorrhage in preterm infants. The Cochrane database of systematic reviews, 7(7), CD012362. 

• Al-Matary, A., Abu Shaheen, A., & Abozaid, S. (2022). Use of Prophylactic Indomethacin in Preterm Infants: A Systematic Review and Meta-Analysis. Frontiers in pediatrics, 10, 760029. 

• Curtis, S. F., Cotten, C. M., Laughon, M., Younge, N., Peterson, J., Clark, R. H., & Greenberg, R. G. (2024). Indomethacin Prophylaxis in Preterm Infants: Changes over Time. American journal of perinatology, 41(S 01), e680–e688.

• Hansen, M. L., Pellicer, A., Hyttel-Sørensen, S., Ergenekon, E., Szczapa, T., Hagmann, C., Naulaers, G., Mintzer, J., Fumagalli, M., Dimitriou, G., Dempsey, E., Tkaczyk, J., Cheng, G., Fredly, S., Heuchan, A. M., Pichler, G., Fuchs, H., Nesargi, S., Hahn, G. H., Piris-Borregas, S., … Greisen, G. (2023). Cerebral Oximetry Monitoring in Extremely Preterm Infants. The New England journal of medicine, 388(16), 1501–1511.

• Luo, J., Luo, Y., Zeng, H., Reis, C., & Chen, S. (2019). Research Advances of Germinal Matrix Hemorrhage: An Update Review. Cellular and molecular neurobiology, 39(1), 1–10. https://doi.org/10.1007/s10571-018-0630-5