Delivery Room Resuscitation of a Preterm Infant Weighing less than 400 grams and Complete Resolution of Grade 4 Intra Ventricular Hemorrhage (IVH)M
Hussnain Mirza1*, Gregory Logsdon2, Jennifer L Williams2, Kultar Singh1, and Rajan Wadhawan1
1Florida Hospital for Children/UCF College of Medicine, USA
2 Division of Pediatric Radiology, Florida Hospital for Children, USA
Submission: February 05, 2017; Published: March 28, 2017
*Corresponding author: Hussnain Mirza, Center for Neonatal Care, Florida Hospital for Children, Orlando, USA.
How to cite this article: Hussnain M, Gregory L, Jennifer L W, Kultar S, Rajan W. Delivery Room Resuscitation of a Preterm Infant Weighing less
than 400 grams and Complete Resolution of Grade 4 Intra Ventricular Hemorrhage (IVH). Acad J Ped Neonatol. 2017; 3(5): 555679. DOI: 10.19080/AJPN.2017.03.555679
Preterm infants are at risk for Intraventricular Hemorrhage (IVH). Severe IVH (grade 3 or 4) is associated with high mortality, periventricular leukomalacia, post hemorrhagic ventricular dilatation and severe neuro disability. To the best of our knowledge, spontaneous and complete resolution of grade 4 IVH has never been reported. To screen for IVH, head ultrasound is the most common modality. Severe IVH can be well differentiated from other etiologies especially if serial ultrasounds are performed. We are reporting a preterm infant with severe IUGR born at 28 weeks gestation. Usually if the birth weight is less than 400 grams, neonatologist do not recommend neonatal resuscitation due to smaller tracheal size and difficulty in securing endotracheal tube. As this infant was born at 28 weeks, neonatology team has attended the delivery. Endotracheal intubation was successful despite an incredibly low birth weight (288 grams only). We assume that tracheal size is not exclusively associated with birth weight, gestational age is an important variable that shall be considered to make a delivery plan for infants with estimated birth weight <400 grams. This infant also developed grade 4 IVH on day 1 of life. However, this extensive IVH was completely resolved without any significant morbidity. Infant had a normal neurosonogram by 3 months of life. Post hemorrhagic residual white matter injury was evident only on the CT scan and MRI of brain. We propose that MRI of brain should be considered at term equivalent gestation in extremely premature infants with IVH especially if subsequent head ultrasound appears normal.
Abbrevations: IVH: Intra Ventricular Hemorrhage; PVL: Periventricular leukomalacia; PHVD: post hemorrhagic ventricular dilatation; PHH: post hemorrhagic hydrocephalus
Neonatal resuscitation is generally not recommended for preterm infants weighing <400 grams at birth . This threshold is more appropriate for infants born at margin of viability (22-23 weeks gestation). Most clinical outcome studies report data for infants with birth weight 401 grams or higher . However, some infants with disproportionately advanced gestational age may be <400 grams at birth due to the intra uterine growth retardation (IUGR). Szpinda et al.  have reported fetal tracheal size correlates better with the gestational age rather than the fetal weight. Therefore, gestational age of an infant shall be considered in planning to provide life support for infants with estimated fetal weight <400 grams.
Intraventricular hemorrhage (IVH) is a significant complication of prematurity. IVH risk is highest for infants born
near the margins of viability [4,5]. Sever IVH is associated with a
high risk for brain injury . Parental counseling is based upon historical data for severe IVH outcomes including high risk for mortality (up to 60%), cerebral palsy or some other neurodisability (up to 80% of the survivors) [5,7]. Infants with severe IVH may develop periventricular leukomalacia (PVL), progressive post hemorrhagic ventricular dilatation or hydrocephalus requiring neurosurgical intervention . Due to the poor prognosis and the risk for major neurodevelopment disability secondary to severe IVH, many clinicians offer redirection of care and withdrawal of life support. To the best of our knowledge, spontaneous and complete resolution of grade 4 IVH without any significant PVL or PHVD has not been reported so far. We are presenting a preterm infant born at 28 weeks gestation weighing only 288 grams who developed grade 4 IVH that was completely resolved without any residual morbidity.
Baby boy “J” was born at 28weeks gestation. Mother was 25
years old, Caucasian, gravida 3, para 0. Maternal blood type was
O positive, antibody screen negative. She was rubella immune
and all her prenatal labs were negative. There was no history of
maternal herpes, skin rash or febrile illness during the pregnancy.
Mother had no known medical illness. However, she was carrier
for cystic fibrosis but father had no known genetic disease or
carrier state. There was no history of maternal smoking or
hypertension. Severe fetal growth restriction was noted on serial
prenatal ultrasounds along with oligohydramnios since the 18th
week of gestation. No rupture of membrane or loss of amniotic
fluid was noted. Amniocentesis was declined and etiology for
severe IUGR remained unknown. Mother presented in preterm
labor at 28 weeks gestation. Placental Doppler showed absent end
diastolic flow, anhydramnios, and estimated fetal weight was only
280 grams. Two doses of antenatal steroids were administered
and infant was delivered by C section. Apgar scores were 1, 2 and
7 at 1, 5 and 10 minutes respectively. Endotracheal intubation
was successful with a size 2.0 endotracheal tube. Infant was
transferred to neonatal ICU for further management.
Head ultrasound on the day of delivery showed an abnormal
hyperechoic area consistent with grade 4 IVH in the right parietaloccipital
and temporal regions. Next day, the opacity appeared
significantly increased in size, local mass effect on the right lateral
ventricle and brainstem was noted along with 2-3 mm subfalcine
herniation. Left cerebral edema was also noted. Infant required
blood transfusion due to the sudden drop of hematocrit from
45% to 28%. By day 3, there was an extensive echogenic lesion
throughout the right cerebral hemisphere (both intra and extraaxial).
Mild ventriculomegaly was noted on repeated head
ultrasounds over the next week. Ventricle size stabilized by 2
weeks of life. Head ultrasound at 3 weeks of life was stable and the
intracerebral echogenic lesion started to resolve and only slight
lateral ventricular asymmetry was noted by 4 weeks. By 3 months
of age, the intra-parenchymal echogenic lesion was completely
resolved with no ventriculomegaly or any residual PVL. Cranial
ultrasound images from day 3 and 3 months of life are shown in the
Figure 1. Infant’s head circumference followed the 3rd percentile
and no other clinical signs/symptoms of increased intracranial
pressure were noted during the course of hospitalization. Infant
was noted to have recurrent apnea and clinical seizures at 3
months of life that required treatment with phenobarbital. EEG
was remarkable for multifocal seizure activity.
To follow the unusual sonographic resolution of grade 4 IVH,
non-enhanced computerized tomography (NECT) of the brain was
performed at 46 weeks of corrected gestation. There was hypo
attenuation involving the deep white matter of the right occipital
lobe immediately adjacent to the trigone of the right lateral
ventricle extending to the medial parietal cortex. Most likely this
encephelomalacia and ex vacuo dilatation of the trigone of the
right lateral ventricle were related to prior grade 4 hemorrhage.
No acute ischemia, hemorrhage or mass effect was identified. CT
images are shown in the Figure 2.
MRIbrain was performed at 47 weeks of corrected gestation.
Ependymal surface of the ventricles appeared abnormal.
Hemosiderin staining on T2WI and GRE sequences was
reported at the level of trigone/ posterior margin of the right
atrium that correlated with the IVH noted on the initial head
ultrasound. Developing encephelomalacia and gliosis at the right
occipital/parietal lobe junction was also noted. These findings
were consistent with developing subacute stigmata of focal
periventricular leukomalacia (PVL). MRI images are shown in
This extremely premature infant with severe IUGR of unknown
etiology was delivered at 28 weeks gestation. Although estimated
fetal weight was <400 grams, neonatology team decided to attend
the delivery because of the gestational age. Endotracheal tube
(size 2.0) was secured in first attempt indicating an adequate
airway size to provide life support. It is suggested to withhold
resuscitation of preterm infants weighing <400 grams at birth .
This recommendation is based upon assumption that endotracheal
intubation will be difficult for infants weighing <400 grams due to
the smaller airway size. However, tracheal size is a linear function
of gestational age . Decision to provide life support shall not
be exclusively based upon an estimated fetal weight without
considering the gestational age of the infant.
This infant was also diagnosed with grade 4 IVH based on the
cranial ultrasound findings on day 1 of life, which progressed over
the next 3 days. These abnormal sonographic findings completely
resolved by 3 months of age. To the best of our knowledge,
complete resolution of sonographic findings of grade 4 IVH has
never been reported.
As the diagnosis of grade 4 IVH is based upon the increased
echogenicity visible in the head ultrasound images, we
reviewed the differential diagnosis for increased echogenicity
on cranial ultrasound for this infant. Increased echogenicity on
neurosonograms can be seen due to hemorrhage, brain edema,
early leukomalacia due to hypoxia or placental insufficiency
and intracranial tumors like choroid plexus papilloma or
ependymoma [9-11]. Congenital infections (TORCH) usually cause
intracerebral calcifications but rarely cystic encephelomalacia
may be seen . Increased echogenicity due to brain edema is
usually diffuse. Focal ischemic changes due to hypoxia or placental
insufficiency may result in periventricular echogenicity that will
later develop cystic leukomalacia. However, these changes do
not involve large cerebral areas causing subfalcine herniation.
Increased echogenicity secondary to the intracranial tumors is
well circumscribed and does not spontaneously resolve. While
the sonographic abnormality resolved in this infant, both CT
scan and MRI of the brain showed residual effects of previous
Infant was discharged home at 6 months of life with low
flow nasal cannula. At the time of discharge, infant appeared
appropriately responsive and interactive. Neurological
examination was essentially normal. Similar clinical outcomes for
grade 4 IVH were reported by Mahta et al if infants do not develop
post hemorrhagic hydrocephalus .
As the fetal tracheal size is a function of gestational age,
neonatal resuscitation shall not be discouraged for preterm
infants with severe IUGR based on birth weight <400 grams.
Although extremely rare, spontaneous resolution of grade 4 IVH
is possible. For infants with severe IVH, MRI brain should be
performed at term equivalent postmenstrual age especially if the
neurosonograms at 36 weeks post menstrual age shows complete
resolution of IVH.