Intraventricular Hemorrhage / IVH

The medical malpractice lawyers at Hixson & Brown, P.C. have experience representing babies and infants who have been diagnosed with an intraventricular hemorrhage. Sometimes the parents of these children are told by physicians that the IVH occurred prior to birth and had nothing to do with labor and delivery. Although this does happen, our attorneys see cases where the IVH was caused by negligent care and treatment provided by doctors, nurses and hospitals either during the birthing process or shortly after birth. Parents of infants suffering from intraventricular hemorrhage and cerebral palsy should investigate the matter further to see if the IVH was caused by medical negligence.

Although frequently referred to as IVH, intraventricular hemorrhage is also referred to as germinal matrix hemorrhage. IVH is an important cause or factor in the development of Cerebral Palsy in babies who have suffered prolonged periods of hypoxia and in premature infants who are more susceptible to brain injury. The bleeding (hemorrhage) in the brain that leads to a diagnosis of IVH usually occurs in the subependymal germinal matrix. Although the hemorrhage usually occurs in the capillary network, it can also occur from the arteries in the brain.

Causes or Risk Factors for IVH:

Risk factors for intraventricular hemorrhage include prenatal conditions, complications of labor and delivery, and post-birth conditions or complications. They are often related to fluctuations in cerebral blood flow during IV fluid boluses, or increases in cerebral venous pressure from compression of the baby’s head from forceps or during labor and delivery. For example, babies born prematurely and without steroid therapy to mature their fetal lungs are at greater risk for IVH. These infants often develop respiratory distress syndrome (RDS) and have difficulty breathing. This stress to the body can cause an increase in blood pressure and hemorrhage or bleeding in the brain. This respiratory distress can also lead to a respiratory acidosis (high CO2 levels) that can affect the autoregulatory function that control blood flow to the brain. In addition, babies suffering from hypotension (low blood pressure) or decreased oxygen delivery to the brain for whatever reason (i.e.: a failure to timely intubate a child or to properly ventilate a child with bag and mask), can be at increased risk for bleeding in the brain.

Although there are a number of suspected causes or risk factors for intraventricular hemorrhage, those we see in medical malpractice cases include the following:

  1. Intra-vascular risks/factors:
    1. Premature infants often have impaired cerebral autoregulation
    2. Neonates often have fluctuating cerebral blood flow (related to arterial blood pressures that fluctuate)
    3. Increased cerebral blood flow ( e.g., due to hypercarbia (high CO2), excess volume expansion (too much IV fluids given at one time)
    4. Hypotension and reperfusion
  2. Vascular risks/factors:
    1. The germinal matrix is a highly vascular structure with poor capillary support and is at increased risk for brain injury and IVH in babies less than 35 weeks gestation.
    2. Germinal matrix capillaries are highly susceptible to hypoxic or ischemic injury.
  3. Extra-vascular risks/factors: Preterm infants:
    1. Have poor vascular support in the tissues of their brain.
    2. Are at increased risk of hypoxia, hypercarbia and acidosis (low pH) due to immature lungs.

Preterm Babies

— IVH occurs most frequently in babies born before 32 weeks gestation or who weigh less than 3.3 pounds at birth. The occurrence of IVH increases with decreasing gestational age. It has been reported that the occurrence rate of intraventricular hemorrhage decreases 3.5% with each added week of gestation. Thus, this highlights the need for early diagnosis and treatment to stop preterm labor or to extend gestation for as long as possible.

As pointed out in the above risk factors, fluctuations of cerebral blood flow in babies born prematurely are associated with the development of intraventricular hemorrhage. This is because babies born prematurely are vulnerable to changes in cerebral blood flow as a result of impaired autoregulation. This impaired blood flow results in a pressure-passive circulation, where the baby cannot sustain constant blood flow to the brain with changes in systemic blood pressure. As a result, increases or decreases in blood pressure can cause changes in blood flow to the brain, leading to injury to the baby’s germinal matrix. Thus, abrupt increases in a baby’s blood pressure that may contribute to IVH include noxious stimuli, rapid volume expansion with fluid boluses, tracheal suctioning, and seizures.

This is why, whenever possible, premature babies should be born in tertiary care centers with neonatal intensive care units. Such centers are equipped to care for premature babies in a way that minimizes the risk for IVH. In fact, the transport of premature babies after birth to a higher level of care is a risk for developing IVH due to the increase stress caused by the transport.

Term infants — Severe IVH occurs less frequently in babies born at term, although Grade I hemorrhages are not uncommon. In babies born at term, IVH may be caused by trauma (eg, abdominal compression), a hypoxic ischemic injury or increased intracranial pressure with a large IVH which deceases cerebral perfusion.

Preventing Intraventricular Hemorrhage in Babies:

In many instances, IVH can be prevented or the severity of the IVH lessened. The following goals for medical care and treatment are critical:

Prior to Birth:

  • Prevent or delay preterm labor and birth
  • Improved perinatal management, including:

- Transportation of a pregnant mother who is at risk for preterm labor to a regional or tertiary care center prior to delivery
- Administration of glucocorticoids (Betamethasone or Dexamethasone) to accelerate fetal lung maturity and decrease IVH

After Baby is Born:

  • Appropriate resuscitation by neonatal experts to avoid hypoxia and hypercarbia
  • Provide circulatory support to avoid hypotensive episodes and to avoid fluctuating blood pressures

Relationship to Periventricular Leukomalacia / PVL --

It has been reported that many babies who die more than one week after suffering an intraventricular hemorrhage also have evidence of periventricular leukomalacia (PVL) or necrosis in parts of the brain. This could be the result of hypoxia occurring due to the hemorrhaging of blood into other parts of the fetal brain.

Diagnosis and Timing of IVH:

An immediate recognition that a baby has suffered a brain bleed at birth rarely occurs. Clinical evidence of intraventricular hemorrhage reveals itself in one of three ways:

  1. Presents Silently – A clinically silent intraventricular hemorrhage can occur without signs or symptoms. This occurs in 25 to 50 percent of cases. Many times the IVH is inadvertently discovered by a screening ultrasound of the brain.
  2. Slow Progression – The most common presentation of IVH is that it evolves over hours to several days. There are nonspecific findings such as an altered level of consciousness, decreased tone in the muscles, decreased movements by the baby, and subtle changes in eye position or movement. Lung functioning may also be disturbed.
  3. Rapid Deterioration – This is the least common presentation and occurs over minutes to hours. Clinical findings can include:
    • Seizure type episodes
    • Irregular respirations, periods of apnea or decreased ventilation
    • Irregular posturing of the body
    • Stupor or coma
    • Hypotension (low blood pressure)
    • Decreased red blood cell evidenced by a decreased hemoglobin or hematocrit
    • Flaccid weakness
    • Bradycardia (low heart rate)
    • Nerve abnormalities such as pupils being fixed to light
    • Bulging anterior fontanelle
    • Metabolic acidosis evidenced by decreased pH

Timing

— Most instances of IVH in premature infants occurs within the first 5 days of birth. Once it occurs, it can progressively worsen over the next 3 – 5 days.

Diagnosis of IVH

— An ultrasound of the brain is used to diagnosis IVH. It is highly sensitivity when it comes to detecting acute bleeding and it is portable. Two different views are taken by the radiologist to identify blood in the germinal matrix, parenchyma and/or ventricles. Due to the sensitivity of US, it can detect the location of the bleeding as well as the extent of the blood pooling. This information is useful in grading the severity of the IVH

The Different Severity Ratings for IVH:

The grading system utilized for intraventricular hemorrhage is based on the amount of bleeding as well as the area or areas of the brain affected. The grading system is as follows:

  • Grade I – Bleeding only in the germinal matrix.
  • Grade II – Intraventricular bleeding occupies 50 percent or less of the lateral ventricle volume.
  • Grade III – Intraventricular bleeding occupies more than 50 percent of the lateral ventricle volume.
  • Grade IV – Intra-parenchymal echodensity (IPE) / Hemorrhagic infarction in periventricular white matter.

Grade I corresponds to mild, grade II to moderate, and grades III and IV to severe IVH. Each grade of IVH may be either on one side of the brain or both sides.

Prognosis Based on Grade of IVH Suffered:

Severity of IVHMortality (%)Progressive Ventricular Dilatation (%)Neurological Damage or Problems (%)
Grade I

5

5

5

Grade II

10

20

15

Grade III

20

55

35

Grade IV

50

80

90

Many times infants with a diagnosis of Grade I IVH will go on to have normal productive lives. However, those infants with a diagnosis of Grade 3 or Grade 4 intraventricular hemorrhage likely will have profound injuries that will affect almost every aspect of their life.

If your child was diagnosed with an intraventricular hemorrhage, you should have the medical records reviewed by an attorney handling cases involving cerebral palsy and IVH. Such a review may reveal that medical malpractice was the cause of the IVH and that the brain damage suffered by your child could have been averted by proper medical care.