Cerebral hemorrhage in the neonate is mostly a consequence of the prematurity itself. Additional factors, such as sepsis, asphyxia, or postnatal transport, increase the risk of bleeding, but in the absence of extreme prematurity they rarely lead to hemorrhage. In contrast to cerebral hemorrhage in mature neonates, however, primarily hemostaseological causes play a negligible part.
Professor Kiesewetter appropriately explains the pathogenetic sequence from parenchymal hemorrhage as a result of germinal matrix hemorrhage and other factors (venous infarction if the flow from venous vessels is obstructed). This obstruction in the thin-walled, large-lumen venous collection vessels is presumably due to the vascular anatomy, the raised intrathoracic pressure, and partly to iatrogenic pressure variations, but typically not to venous thrombosis. Because of this, and bearing in mind the prohemorrhagic side effects of heparin, we would, on the basis of the current evidence, strongly advise against heparin treatment (1).
An individual clotting status, for which 1.6 mL citrate blood is required, extracts about 4% of the total blood volume from a premature neonate weighing 500 g. In view of the uncertain age-specific reference range and uncertain intervention thresholds, this intervention should be based on careful weighing up of the benefits and harms. Intervention thresholds in thrombocytopenia are not evidence based, either (2).
The administration of magnesium was the subject of controversial discussion in our working group. In order to utilize the neuroprotective effects of magnesium, a high serum concentration is required; the therapeutic range is narrow. The side effects of muscular hypotension and apnea counteract the attempt to avoid intubation and respiration. Data from the German Neonatal Network have shown an increased rate of intracranial hemorrhage in the combination with fenoterol. Medications with a more beneficial risk profile are available for the purposes of tocolysis (3).
Dr. med. Manuel B. Schmid
Sektion Neonatologie und Pädiatrische Intensivmedizin
Conflict of interest statement
The authors of both contributions declare that no conflict of interest exists.
|1.||Lesko SM, Mitchell AA, Epstein MF, Louik C, Giacoia GP, Shapiro S: Heparin use as a risk factor for intraventricular hemorrhage in low-birth-weight infants. N Engl J Med 1986; 314: 1156–60 CrossRef MEDLINE|
|2.||Muthukumar P, Venkatesh V, Curley A, et al.: Severe thrombocytopenia and patterns of bleeding in neonates: results from a prospective observational study and implications for use of platelet transfusions. Transfusion Med 2012; 22: 338–43 CrossRef MEDLINE|
|3.||Schleußner E: The prevention, diagnosis and treatment of premature labor. Dtsch Arztebl Int 2013; 110(13): 227–36 VOLLTEXT|
|4.||Schmid MB, Reister F, Mayer B, Hopfner RJ, Fuchs H, Hummler HD: Prospective risk factor monitoring reduces intracranial hemorrhage rates in preterm infants. Dtsch Arztebl Int 2013; 110(29–30): 489–96. VOLLTEXT|