Arch Dis Child Fetal Neonatal Ed 2000;82:F188-F194 ( May )

Low superior vena cava flow and intraventricular haemorrhage in preterm infants

Martin Kluckow^b, Nick Evans^a

^a Department of Neonatal Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney 2050, Australia, ^b Royal North Shore Hospital and University of Sydney, Sydney, Australia

Correspondence to: Dr Evans email: nevans{at}med.usyd.edu.au

Accepted 23 September 1999

OBJECTIVESTo document the incidence, timing, degree, and associations of systemic hypoperfusion in the preterm infant and to explore the temporal relation between low systemic blood flow and the development of intraventricular haemorrhage (IVH).
STUDY DESIGN126 babies born before 30 weeks' gestation (mean 27 weeks, mean body weight 991 g) were studied with Doppler echocardiography and cerebral ultrasound at 5, 12, 24, and 48 hours of age. Superior vena cava (SVC) flow was assessed by Doppler echocardiography as the primary measure of systemic blood flow returning from the upper body and brain. Other measures included colour Doppler diameters of ductal and atrial shunts, as well as Doppler assessment of shunt direction and velocity, and right and left ventricular outputs. Upper body vascular resistance was calculated from mean blood pressure and SVC flow.
RESULTSSVC flow below the range recorded in well preterm babies was common in the first 24 hours (48 (38%) babies), becoming significantly less common by 48 hours (6 (5%) babies). These low flows were significantly associated with lower gestation, higher upper body vascular resistance, larger diameter ductal shunts, and higher mean airway pressure. Babies whose mothers had received antihypertensives had significantly higher SVC flow during the first 24 hours. Early IVH was already present in 9 babies at 5 hours of age. Normal SVC flows were seen in these babies except in 3 with IVH, which later extended, who all had SVC flow below the normal range at 5 and/or 12 hours. Eight of these 9 babies were delivered vaginally. Late IVH developed in 18 babies. 13 of 14 babies with grade 2 to 4 IVH had SVC flow below the normal range before development of an IVH. Two of 4 babies with grade 1 IVH also had SVC flow below the normal range before developing IVH, and the other 2 had SVC flow in the low normal range. In all, IVH was first seen after the SVC flow had improved, and the grade of IVH related significantly to the severity and duration of low SVC flow. The 9 babies who had SVC flow below the normal range and did not develop IVH or periventricular leucomalacia were considerably more mature (median gestation 28 v 25 weeks).
CONCLUSIONSLow SVC flow may result from an immature myocardium struggling to adapt to increased extrauterine vascular resistances. Critically low flow occurs when this is compounded by high mean airway pressure and large ductal shunts out of the systemic circulation. Late IVH is strongly associated with these low flow states and occurs as perfusion improves.

Key messages Critically low superior vena cava flow occurs in a significant minority of very preterm infants These low flow states are poorly predicted by blood pressure This low flow is commonest in the first 12 to 24 hours, improving spontaneously after this time Late IVH is strongly associated with these low flow states and occurs as perfusion improves

Keywords: very preterm infants; blood flow; cerebral haemorrhage; superior vena cava

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© 2000 by Archives of Disease in Childhood
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