713 Severe intraventricular haemorrhage (IVH) with or without post-haemorrhagic ventricular dilatation (PHVD) in preterm infants <32 weeks: Practice review and strategy to minimise within network variation

Abstract

<h3></h3> Aims Severe IVH occurs in up to 15% of extremely premature infants with more than half developing PHVD.¹ Affected infants are at significant risk of mortality and adverse neurodevelopmental outcomes. The aetiology is multi-factorial but the use of antenatal steroids, magnesium sulphate, and delivery within a maternity unit with a co-located neonatal intensive care (NICU) can reduce the risk. Monitoring and intervention thresholds for PHVD varies. Some centres react to serial ventricular index (VI) measurements on cranial ultrasound (CrUSS) whilst others assess head circumference or signs of raised intracranial pressure. Management strategies also differ. Temporising measures include lumbar punctures (LP), ventricular taps, insertion of a ventricular reservoir or ventriculosubgaleal shunt prior to the insertion of a definitive ventriculoperitoneal (VP) shunt. The aims were to: • Determine how many infants (&lt;32 weeks) developed severe IVH with or without PHVD across two NICUs in our network • Establish how many didn’t receive antenatal steroids, magnesium sulphate or required postnatal transfer to NICU • Review management strategies between two NICUs and consider ways to minimise variation • Quantify risk of mortality or survival with neurodevelopmental impairment <h3>Methods</h3> Using BadgerNet, infants born &lt;32 weeks, between Jan 2018-Jun 2021, with grade 3 or 4 IVH +/- PHVD or PHVD with any grade IVH, were identified retrospectively. Two NICUs within the same neonatal network were included; Centre 1 had onsite neurosurgery whilst Centre 2 used remote consult prior to transfer for neurosurgical intervention. <h3>Results</h3> Overall, 44 infants were identified, accounting for 6.5% of infants &lt;32 weeks inborn or retrieved following initial stabilisation across both NICUs. Gestational age 23+² –30+⁶ weeks, birth weight 510-1920g. 36% required postnatal transfer to NICU, 29.5% didn’t receive magnesium sulphate and 47.7% received incomplete or no antenatal steroids. 19 (43.2%) infants developed PHVD, 2 had bilateral grade 2 IVH, whilst the remainder had more extensive injury. In both centres, PHVD was monitored using CrUSS with VI and head circumference measurements. In 15.8%, early re-direction towards comfort care was undertaken, whilst 47% were managed conservatively. Variation in temporising strategies was evident between the centres. Centre 2 performed serial LPs (range 2-5 per infant) in 5 infants, 4 of whom subsequently required a subgaleal shunt followed by a VP shunt. In comparison, no Centre 1 infants underwent LP. The primary intervention for 2 infants was a subgaleal shunt, 1 of whom later required a VP shunt. Follow up data was available for 56.8%. Of those, 44% had died and 48% survived with significant neurodevelopmental impairment. <h3>Conclusion</h3> The mortality and morbidity following severe IVH, with or without PHVD, is extremely high. Strategies to minimise this risk are essential. Counselling expectant mothers to identify signs of threatened preterm labour and present early for assessment might further improve receipt of antenatal steroids and magnesium sulphate and facilitate in-utero transfer to a maternity centre with a co-located NICU. The subsequent implementation of a neurosurgical pathway is also hoped to streamline referrals, standardise management strategies and facilitate timely intervention. <h3>Reference</h3> El-Dib M, <i>et al</i>. Management of post-haemorrhagic ventricular dilatation in the preterm infant. <i>J Pediatr</i>. 2020;<b>226</b>:16–27.