Why does hemorrhage occur in premature babies?
The germinal matrix is a temporary structure near the lateral ventricles from which future brain cells migrate during pregnancy. Its capillaries are thin and almost devoid of supporting tissue. In a premature baby, the system for regulating cerebral blood flow is immature, so any sudden changes - a drop or jump in pressure, fluctuations in carbon dioxide levels, rapid administration of solutions, severe respiratory distress - are directly reflected in the blood vessels. By the end of pregnancy, the germinal matrix practically disappears, so such hemorrhage is rare in full-term children.
- Source: fragile vessels of the germinal matrix
- The risk is higher the shorter the gestational age
- Provoke fluctuations in blood pressure and gases
- Most often in the first 72 hours of life
- Rarely occurs in full-term infants
Degrees and what they mean
The assessment is carried out using neurosonography data. In the first degree, the blood is limited to the zone of the germinal matrix; in the second, it enters the ventricle without expanding it. The third degree means that there is a lot of blood and the ventricle is dilated. Separately, damage to the substance of the brain near the ventricle is described - this is the most severe option associated with a violation of the venous outflow. It is the degree, together with the child’s condition, that determines the prognosis, so it is important for parents to check with the doctor not only the fact of hemorrhage itself, but also its characteristics.
- I degree - blood within the germinal matrix
- II degree - blood in the ventricle without its expansion
- III degree - dilation of the ventricle with blood
- Parenchymal lesion - brain matter involved
- The lower the degree, the better the prognosis
Symptoms
Minor hemorrhages often occur hidden and are detected only during a routine ultrasound - this is why it is done to all premature babies without waiting for complaints. With a significant volume of blood, the condition changes noticeably: the child becomes lethargic, sucks worse, episodes of respiratory arrest, a drop in pressure, pallor, decreased muscle tone, and sometimes convulsions appear. The fontanel bulges and tenses. Later, after weeks, the development of hydrocephalus is indicated by an accelerated increase in head circumference.
- Often asymptomatic with mild degrees
- Lethargy, decreased tone, weak sucking
- Episodes of apnea and bradycardia
- Pallor, drop in hematocrit
- Protruding fontanelle
- Convulsions in severe forms
Diagnosis and observation
The main method is neurosonography through the large fontanel. It is performed on all children born significantly prematurely, in the first days of life, and then repeated according to a schedule in order to track blood resorption and notice the expansion of the ventricles in time. MRI of the brain is usually done closer to the expected due date: it more accurately shows the state of the white matter and helps to clarify the prognosis. Additionally, hematocrit and coagulation parameters are monitored. After discharge, head circumference is continued to be measured and development assessed by age.
- Neurosonography in the first days and over time
- Regular head circumference measurement
- MRI of the brain at term
- Hematocrit and coagulogram
- Examination by a neurologist and assessment of skills by age
- Hearing and vision testing
Treatment and risk reduction
It is impossible to stop a hemorrhage that has already occurred with drugs, so treatment is aimed at stability: careful nursing, maintaining pressure, breathing and temperature, and a minimum of sharp manipulations. The blood in the ventricles gradually dissolves on its own. If posthemorrhagic hydrocephalus develops, the neurosurgeon may perform unloading punctures, place a temporary reservoir, and then a shunt. Measures taken before birth significantly reduce the risk: a course of corticosteroids for the mother if there is a threat of premature birth, birth in a center with a prematurity unit, delayed clamping of the umbilical cord.
- Careful security regime in the department
- Maintaining stable blood pressure and breathing
- Monitoring the size of the ventricles
- Unloading punctures and shunting for hydrocephalus
- Antenatal corticosteroids for threatened preterm birth
- Delayed cord clamping
- Early rehabilitation and developmental care