Last updated:
April 1, 2026
Periventricular haemorrhage (PVH) is bleeding into the germinal matrix capillary bed – the tissue surrounding the lateral ventricles. It is common in preterm neonates (< 32 weeks gestation), very low birth weight neonates (< 1500 g), and is closely associated with hypoxic-ischaemic encephalopathy (HIE)
Intraventricular haemorrhage (IVH) occurs when bleeding extends into the ventricles.
Periventricular hemorrhagic infarction (PVHI) occurs when bleeding extends into the brain parenchyma.
Definition of terms
| Term | Definition |
|---|---|
| Germinal matrix | Immature tissue containing glial cells. It is immature, very friable, highly metabolic, and heavily reliant on oxygen. |
Antenatal steroids (gexamethasone) greatly reduce the risk of future development of IVH/PVH. Preterm infants should be screened for IVH/PVH through cranial ultrasound. MRI can be ordered to determine the extent of the damage.
Factors associated with PVH/IVH and their treatment/prevention
| Contributing factor | Treatment/Prevention |
|---|---|
| Prematurity | Antenatal steroids, supportive care |
| Perinatal asphyxia or HIE | Resuscitation, Supportive care |
| Neonatal seizures | Phenobarbital, EEG monitor |
| Hypertension | Avoid rapid volume expansion |
| Shock | Fluid replacement, monitor U/O |
| Hypercarbia/hypoxia | Adequate oxygenation |
| Metabolic acidosis | Bicarbonate as per the neonatologist |
| Anaemia | Blood products as needed |
| Coagulopathy | FFP |
| Rapid volume expansion (iatrogenic) | Avoid rapid volume expansion |
| Hydrocephalus | Acetazolamide, neurosurgery |
Classification of intraventricular hemorrhage (Papile)
| Grade | Extent of hemorrhage | |
|---|---|---|
| Grade I | Germinal matrix only | Good |
| Grade II | IVH < 50%, no dilation | Good |
| Grade III | IVH > 50% and ventricular dilation | Mortality <10%. 30-40% have cognitive or motor deficits (blindness or Cerebral Palsy) |
| Grade IV (PVHI) | Parenchymal haemorrhage | Mortality of 80%. 90% will have cognitive or motor deficits. |
- Risk factors
- Maternal
- Lack of antenatal steroids
- Chorioamnionitis
- Maternal bleeding
- Vaginal delivery
- Maternal hypertension
- Hypertension→ elevated blood pressure in the neonate, causing bleeding in the germinal matrix
- Vacuum delivery
- Neonatal
- Prematurity
- Low birth weight
- NRDS
- Pneumothorax
- Sepsis
- Hypotension
- Patent ductus arteriosus
- Frequent handling or suction
- Hypoxic-ischemic encephalopathy
- Mechanical ventilation
- Metabolic acidosis
- Hypercarbia or hypoxia
- Coagulopathy
- Rapid fluid administration
- Maternal
- Pathophysiology of IVH
- Immature and fragile vessels in the germinal matrix: there is poorly developed structural support of blood vessels (immature basal lamina, few pericytes, and decreased glial fibers). Blood vessels are simple, endothelial-lined, and larger than mature capillaries. These capillaries are prone to hemorrhage.
- Impaired cerebral autoregulation: blood pressure fluctuations (hypotension, hypertension, or rapid volume expansion) can lead to sudden changes in cerebral perfusion, increasing the risk of vessel rupture
- Hypoxia-ischemic and reperfusion injury: Hypoxia or ichemia leads to anaerobic metabolism, energy failure, and endothelial injury. When blood flow is restored, reperfusion can trigger oxidative stress and free radical formation, weakening vessel integrity
- Fluctuations in cerebral perfusion: neonatal conditions (such as RDS and PDA), mechanical ventilation, or rapid fluid administration cause fluctuations in cerebral perfusion pressure. These changes increase the risk of hemorrhage into the germinal matrix and ventricles
- Coagulopathy and platelet dysfunction: preterm infants have immature coagulation systems (with decreased clotting factors) and platelet dysfunction. This exacerbates bleeding and limits clot formation after vessels have ruptured
- Hemorrhage expansion and ventricular dilatation: bleeding can extend into the lateral ventricles (grade II – IV). Blood may clot, obstructing CSF drainage, which could lead to post-hemorrhage hydrocephalus. Blood breakdown products (e.g., hemosiderin) may trigger inflammation and fibrosis, further impairing CSF reabsorption at the arachnoid granulations.
- Signs and symptoms
- Investigations
- Cranial ultrasound: This is the best initial test. It can be used to screen neonates born at ≤ 30 weeks of gestation:
- At day 7 – 10
- At 4 – 6 weeks of age
- Before discharge
- MRI for complications
- Complete blood count
- RBS for hypoglycemia
- Arterial blood gas analysis for metabolic acidosis
- Coagulation profile
- Cranial ultrasound: This is the best initial test. It can be used to screen neonates born at ≤ 30 weeks of gestation:
- Treatment
- NICU care
- Umbilical artery catheter placement with X-ray confirmation
- Correct metabolic and fluid disturbances
- Maintain oxygenation and blood pressure
- Treat seizures, anaemia, and coagulopathy
- Indomethacin may be given to reduce the risk of severe IVH
- Surgical treatment of hydrocephalus
- Long-term follow-up
- Prevention
- Antenatal
- Corticosteroids
- Early transfer
- Perinatal
- Delayed cord clamping (30 – 180 seconds)
- Postnatal
- Midline head position
- Minimal handling
- Avoid suctioning
- Stable blood pressure and oxygenation
- Avoid rapid fluids
- Antenatal
- Long-term complications of IVH
- Cerebral palsy
- Post-hemorrhagic ventricular dilatation (PHVD) → Hydrocephalus
- Periventricular leukomalacia (PVL)
- Permanent parenchymal damage is characterized by the presence of periventricular cysts.
- This has a tendency to affect the lower limb and optic nerve fibers the most.
- Seizures
- Developmental delay