A Care-bundle to Prevent Germinal Matrix–Intraventricular Hemorrhage in Neonates

Abstract

Germinal matrix-intraventricular hemorrhages (GM-IVHs) can be seen in up to 25-30% of premature infants. These are associated with a major psychological, social, and financial challenge for care-providers and families caring for premature infants all over the world. The severity is usually classified based on the location and volume vis-à-vis that of the cerebral ventricles, including (A) Grade I GM-IVHs localized in the germinal matrix; (B and C) Grade II and III hemorrhages occupying less than and more than 50% of the ventricular cavities, respectively; and (D) Grade IV IVHs that extend into the surrounding parenchyma with/without a periventricular hemorrhagic infarction (PVH). Germinal matrix-intraventricular hemorrhages have been associated with impaired neurodevelopment (17.5%), static physical disabilities in cerebral palsy (7-63%), deafness (8.6%), and blindness (2.2%). Considering the complex etiopathogenesis of GM-IVH and the fact that most of these events occur within a temporally-delimited period of the first 72 hours after birth, there is increasing interest in the structured application of 3-5 well-accepted preventive measures as a quality improvement (QI) "care bundle" during the high-risk period. In this article, we have described the evidence on which our GM-IVH bundle is based. We have carefully evaluated antenatal factors such as the history of having received steroids and magnesium sulfate, perinatal measures such as delayed cord clamping, management of thrombocytopenia and/or coagulopathy, and postnatal measures such as maintaining a midline head position, cautious endotracheal suctioning and blood withdrawals, and avoidance of routine flushing of intravenous and arterial lines. Based on the strongest evidence and practice consensus, we have adopted a 4-point bundle to prevent GM-IVH in premature infants: (A) Appropriate neonatal resuscitation with, if possible, delayed cord clamping; (B) Golden-hour care; (C) Gentle care of outborn infants including safe transport and avoiding hemodynamic instability; and (D) if needed, management of perinatal thrombocytopenia and coagulopathy. In the next 3-5 years, we will report compliance and changes in the incidence/severity of GM-IVH at our centers.