768 - Development of a Prenatal-Perinatal Bundle for the Prevention of Severe IVH in Extremely Premature Infants

Publication Number: 768.4202

Sanket D. Shah, University of Florida College of Medicine, Jackonsville, FL, United States; P Sireesha. Nandula, University of Florida College of Medicine, Jacksonville, FL, United States; Shiva Gautam, University of Florida College of Medicine, Jacksonville, FL, United States; Vasantha HS. Kumar, University of Florida College of Medicine, Jacksonville, Jacksonville, FL, United States

Background: Intraventricular hemorrhage (IVH) is a serious complication of prematurity, especially in extremely premature infants (EPI, < 28 weeks gestational age). In a recent meta-analysis, 34.3% of infants born at < 28 weeks of gestational age (GA) developed IVH, with 15.0% having severe IVH. Both mild (Grade I-II) and severe IVH (Grade III-IV) are associated with adverse neurodevelopmental outcomes in these infants. While several postnatal risk factors are associated with increased IVH risk, prenatal-perinatal care can play a critical role in IVH prevention. Factors such as tocolytic therapy, antenatal steroid (ANS), delayed cord clamping (DCC), and preeclampsia have demonstrated a protective role in reducing IVH incidence. However, the combined impact of perinatal management strategies in the prevention of IVH has not been extensively studied.

Objective: To analyze the impact of prenatal and immediate perinatal factors associated with IVH development in extremely premature infants

Design/Methods: A retrospective cohort study was conducted in infants < 28 weeks GA and admitted to the tertiary NICU at the University of Florida Health from 1/1/2017 to 4/30/2024. Infants with significant congenital/chromosomal anomalies, or those who died before the first head ultrasound were excluded. Perinatal characteristics relevant to IVH were studied by grouping infants into three groups: No IVH, mild IVH (Grade I-II), and severe IVH (Grade III-IV) (Figure 1). Parametric and non-parametric tests were used as appropriate for data analysis.

Results: Of 450 infants, 397 met study criteria (Figure F1). 48.3% (192/397) of these infants had no IVH, while 51.7% (205/397) of infants developed IVH (Grade I-IV); 19.6% of infants (78/397) developed severe IVH. Complete antenatal steroids, preeclampsia, and not being intubated at birth had protective effects, while chorioamnionitis, lower 5-minute Apgar score, and being out born were associated with severe IVH (Table 1). Infants exposed to all the three perinatal management strategies had significantly lower rates of severe IVH (11.5% vs. 42.3%, p = 0.00001) and any IVH (16% vs. 30.7%, p = 0.0005). In contrast, infants not exposed to any of the three strategies had a significantly higher incidence of severe IVH (Table 2).

Conclusion(s): The prenatal-perinatal bundle of complete ANS, magnesium sulfate for neuroprotection, and DCC at birth appears to be highly effective in preventing IVH in EPI. Rigorous implementation of strategies that prevent IVH will not only reduce severe IVH but also prevent other adverse clinical outcomes associated with severe IVH in extremely premature infants.

Table 1 – Prenatal and perinatal factors for severe IVH, mild IVH and no IVH
Data expressed as counts (percentages) in all rows except Gestational Age, Birth weight and 5-min apgar*; median (quartile range)
IVH; intraventricular hemorrhage
Statistically significant P value < 0.05

Table 2: Perinatal factors combination for severe IVH, mild IVH and no IVH
Data expressed as counts (percentages) in all rows
ANS; antenatal steroid, DCC; delayed cord clamping, IVH; intraventricular hemorrhage, MgSo4; magnesium sulfate
Statistically significant P value < 0.05

Figure 1: Flow Diagram
IVH; intraventricular hemorrhage