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Okay. Good morning, everyone. My name is Caroline Delahanty. Um, as I said on Tuesday, I'm definitely starting to recognize the name. So you've all met me before? I wanted to finish off. I can see that Jugs just coming in as well. Hi, I'm Caroline Delahanty. I'm just going to talk again about which prematurity, but in this session very much focused on the brain because, you know, we can get babies to survive. But what we want is for them to survive and to have normal development, normal motor and cognition skills, and to have a really good quality of life. So it's survival with quality is what the aim of the neonatal world and the pediatric world is. So I'm going to talk to you about the challenges. Premature brain. Let's going back over. You remember, just to highlight, you've seen this slide before. The pregnancy is measured from the first day of the mothers last menstrual period and confirmed on ultrasound at 12 weeks. And in the UK, we take the ultrasound dating as more accurate. Full term is 40 weeks, but there's a range from 37 to 42 preterm is less than 37 weeks. Actually, really. Challengers are the babies of less than 31 weeks and certainly the extreme preterm of 22 to 27 weeks. And I'm going to show you some images. Brain okay. The most important thing is obviously to deal with causes prematurity and stop preterm delivery. So an active smoking cessation program in maternal obstetric health is very important. Good maternal nutrition but avoiding obesity as well. Um, make sure that if they have insulin, the mom has insulin dependent diabetes or developed diabetes that she actually has good control to prevent premature delivery and to prevent large for gestational age babies. So you know anything else that we can find out about for central function treating maternal high BP? So that's her preeclampsia does not progress. An early detection of preeclampsia preeclampsia. So maternal health is really important challenge we have. And this equally applies to the brain that although it's present, that although organs are present early on in the first time in sister, they're underdeveloped and development continues with gestational age. So if you come out early, you come out with an underdeveloped brain. Okay, so we're going to talk now about the brain. So we have immature development, and that's probably one of our biggest challenges. Everyone thinks about intraventricular hemorrhage, and if we can prevent that periventricular leukomalacia, which is white matter injury. Um, if we can prevent that, these things are obviously all helpful, but we're still left with an immature developed brain. So this picture shows you the difference in which I'm representing the difference in weight between a 35 week brain and a term brain brain. And we say a 35 week brain is two thirds the size of a term brain, and what you'll see and you'll see in the next slide as well is look at the gyri folding look at the maturation of the the gyri, the folding of the brain so the brain is originally smooth, and then it starts to fold. And it's those folding is that increase the surface area of the brain and increase your cerebral potential. So if you've got lack of folding on a smooth brain, whereas if that was being gentle, distant developmental abnormality, we would call it listen carefully. Wouldn't we Greek for a smooth brain? This is a problem in prematurity as well. Unfortunately, the 25 week of this image is cut off. But what I'm representing here and I'm going to take the purse of right over to the left hand side. As you're looking at it, you're seeing a very smooth brain. So if we were at post mortem, we'd see the the smooth brain with lack of folding, lack of gyri on ultrasound. We see it, we see the lack of differentiation. And what we see is the lack of gray white Matter differentiation. So as you come up the weeks, we have more folding at the top. But we see it on ultrasound as well, and we start to see it doesn't come out very well on the slides. But certainly in the term brain, you can see that the outer age is much darker. We have gray, white diff correnti, ation appearing and much more folding. And we have the ventricles developing normally as well. So there is a maturation that is naturally gestational e linked. So the problem we have is at as adverse outcome. We can have motor disability. Um, remember, you can have cerebral palsy, which means that your motor difficulties do not progress. It's an umbrella term for a non progressive problem with motor difficulties, so it shouldn't get better, but it shouldn't get worse. You may have the natural not getting betters difficult, but those tone abnormalities are still there. I appreciate, just as a child normally developed from a baby to sit into standing, we can get those developments within cerebral palsy, certainly within the Hemi pleasures but within the spastic diplegia. But they're not going to improve once you've got them through developmental stages that, you know they are stuck with their motor problem. So if you have an ambulance child, but that tone abnormality never goes away. When you start to formally look at them, we can have problems with dyspraxia, and we can have problems with coordination. And then they're really problems. Actually, in a premature baby, if you throw a ball at a five year old ex preterm baby, their hand awareness to catch a ball, you need to be able to bring your hands into the midline to catch it. And it's quite a balanced, mature coordination problem. So when you test these Children, sometimes you can see they've got problems in their coordination may not affect their day to day life, but it's there. You can have sensory difficulties. Okay, We can have problems with the child not wanting to suck because they've got such adverse experiences from all the plastic, the endotracheal tubes, the nasogastric tubes. We may have difficulty getting them to suck, but also haven't kept you know what we need to do. Ex utero is keep them in that fetal midline position. One of the reasons that the fetus is very folded and in that fetal flex position in the womb is because that is good for its development. In that flex position in the womb, if your ultrasound and them you sometimes see them bringing their thumb to their mouth. You know, all this is all part of their in utero development, which we need to mimic ex utero. Otherwise, we lose that development. We can have babies, post prematurity with communication problems. And if you start to want to diagnostically label these, you can have autistic spectrum disorder with the sensory and communication difficulty. Or you can have attention deficit hyperactivity disorder where they seem to have the processing of the stimulation, pathways and their intake and their cognitive ability has been affected. Obviously, we can have deafness. We can have visual difficulties if we have a course Full insult in the acceptable area, we will have cerebral post processing of that visual difficulty. They naturally, if you're very extreme less than 31 weeks, you have your eyeball shape predisposes you to have in myopia and shortsightedness. And obviously, if you have retinopathy of prematurity defect, if you've had laser treatment, you may have lost some of your visual fields from the starring or you may if you have a retinal detachment, you've obviously lost that Mukalla and the ability to see we have the problems and these are very difficult to treat of the cognitive and behavioral difficulties. But what we need to remember is more surviving. And because we've got better at survival, really, we need to sort out the developmental issues. So let's talk about it. What can we do? But the first thing is to prevent preterm birth. Okay, so keep that baby in as long as possible, provided your pulse. Centuries work in and you've got good maternal health. But the most important thing here is the mother you don't want to lose. Um um, For the sake of the baby, you always protect the mom optimizing antenatal care with course ago steroids to stimulate lung development. So you have less difficulties with the respiratory system and therefore less difficulties with hypoxia. But I'm going to talk about magnesium sulfate. This is the new name on the block, but by the new name on the block. What I mean is really the evidence base is absolutely been there since 2017. Okay, so we'll come onto it. So we want to avoid hypoxia and profusion injuries. After that, we want to think very much about our environment, our positioning of the baby, for good development, our environment. We don't want to overstimulate them and get their, um, adrenalin or adrenaline sympathetic overdrive pathways setting as normal. We don't want them to be in sympathetic overdrive. Because if you think a child with a d. H. D there in sympathetic overdrive, aren't they? They're hyperactive. We want to keep that sympathetic system calmed in our neonatal environment. Absolutely breast milk. Okay, we know it improves. I Q. Okay. That's been know, probably since the late nineties. Um, there were studies done babies fed on premature high calorie formula versus maternal breast milk, which remember, can be lower calorie. But actually, even when you took out the nutritional growth issues, the breast fed babies had a I Q lift of four points 4 to 10 points. Okay, so breast fed. And even if you use donor breast to take out the environmentals, you can, uh, certainly in the UK You can argue that it's the middle class mothers that breastfeed, so maybe that baby has a better environmental upbringing. But if you even look at babies who receive donor breast milk, they have a better IQ than babies who were put on to preterm cow's milk formula. So it's the very long change fatty acids that we know improved myelin ation. The formula Companies have tried to take this on, and when the patent patent on it run out, they have added it to premature breast breast milk, premature formula milk. Sorry, So now you have cow and gate and Nestle saying they've got very long chain fatty acids added in. But there are things in breast milk we don't understand, and breast milk is still best. Okay, let's talk about antenatal magnesium sulfate. So any baby being delivered less than 30 weeks, we want them to have foetal neuro protection by giving them antenatal, magnesium sulfate. So what? We know if we give this, there is a reduction in cerebral palsy in women who have received this for neuro protection of the fetus compared with placebo. And it's got a risk ratio of naught. 0.68. You only need to treat 33. I think it as you have written foremothers, right? 34 mothers to prevent one child from a cerebral palsy. Okay, the problem is you have to give that magnesium sulfate within 24 hours of delivery. The effect is not there after 24 hours. So it's timing that mum coming in. But what we do know, there are now studies to what happens is you load for 30 minutes with high dose magnesium sulfate. The moms don't like it. It makes them very jittery. It makes them nauseated. It makes them vomited, they flush. They have a vasal dilatation reaction. They don't like it, but we even a loading dose makes a difference what it's doing. Magnesium is binding to the neuronal cell. The glial cells, and it's blocking the calcium influx. So it's displacing calcium on the outside of the cell, stopping calcium going in, stopping up osmosis water, following in after that and then cell death. So it's it's per preventing the natural hypoxia of labor. Okay, labor is a hypoxic environment. The premature baby is less able to cope that. And if we prevent that cell death, we are reducing cerebral palsy. So this is the big intervention. If you can give your mom's antenatal museum sulphate prevent the delivery. Okay, so what can we do once we've got the baby out? I'm moving on to environment, and this is very much sort of what we call neuro developmental care bundles like. That's another phrase I could have put up. But really, what it is is focus on your neonatal unit environment. If you think about even a term baby, if you bang a door on a term baby, they have a startle reflex, don't they? They have a very sensitive, sympathetic system. They will startle. They'll jump. Okay, their arms go out. They go into that. You know more of that flight. We we call the moral reflex when the baby's arms go out. It's almost a flight. Um, fear flight flee reaction that they it's left from primates. So if you think about if you want to believe in environmental um, not environmental sort of Darwin's theory of evolution. Evolutionary theory. These. If a monkey drops off a branch, it puts its arms out and then comes back in to catch the branch to save itself. It high as a natural reflex. Newborn babies still have that primitive reflex. They will go out and come in to save themselves. So they startled. They jump. That's they're sympathetic system again. Coming in. Okay, so you want to stop that? We're trying not to drive any overstimulation of that brain. We're trying to pretend it's in. The womb is bathed in water. It's very calm, so we want to keep the baby calm so low voices reduce your environmental noise. Don't don't stand by an incubator, tapping on it or leaning on it or touching it. Don't slam the incubator doors. Okay, don't slam your bins in the in your environment. Try to be as quiet as possible and keep your voices down. Some units will even have noise meters that start flashing when the noise level goes up. Okay, I think what's really important is positioning that baby back into the fetal position. And what I'm showing in the picture is, uh, there are various devices, but you can do it with blankets and straps or even a towel. Just make a baby nest. Try to bring it back into fetal sleep position flexed without over flexing the airway. Obviously, they have no tone, so you do unfortunately, have to lift the next slightly but bring their arms in, bring their shoulders in because they've got no tones. If you can put a limp rag doll on a flatbed, it just goes out. And then when As they grow, we're expecting them to have really good flexion of the shoulders. Bring it in, you know, and this is all important for sitting for crawling. If you've been used to lying abducted at your shoulders and at your hips, you're not going to develop the same as the tone Baby who? Natural reflexes. Remember, we can even age babies on their posture. A small, very preterm baby does. It shows no flexion ability. They have no tone to bring themselves into that midline flexion. So we need to do that to allow, because that's what has been happening to their brain development. Their brain wants to process flexion once the shoulders in the hips in. So that's how you position them. So you swaddle and flats into the fetal posture, and we also need to think and again it's all about We don't want to give the brain adverse stimulation. Unfortunately, we're doing blood tests aren't We were doing blood. Sugars were hurting the baby. Everything we do, every touch can actually hurt the baby. So if you are doing a blood test, give them a little bit of breast milk on a just into their lips, which, because obviously if they're old enough, you can syringe it. But even in a premature baby, give them mouthcare with breast milk so they get that taste. They get that pleasure of the sweetness and that calms their heart rate, calms their BP. And you can see this on your monitors. So think about your pain management. Okay, I think. Fascinating thing. And this came out of Columbia, I'm gonna say in the seventies, maybe the eighties, but anyway, it came out of Colombia, where they had a high preterm death rate. And when they looked at the babies that died and looked at what was happening to the babies that didn't die, What they showed is babies. That whose moms were with them all the time. Holding them seemed to become less ill and didn't die. So it's just amazing. You can do this anywhere in the world, kangaroo care, right? Which basically, I'm going to show you a picture in the night. Next side. Maybe I've done this. The wrong way around is when the baby lies on the mum in the nude, then wrapped on the outside and is getting feedback from that maternal body just like it did in the room. It's getting the calm in effect of Mom's presence. We don't really understand it, but we do know it stabilizes the baby's heart rate. We know it reduces death. We know it improves the baby's breathing pattern and makes the breathing more regular. Actually, the saturations go up, you can turn the oxygen down. It's in credible. Okay, we know the baby goes to sleep so and babies need sleep. Sleep is restorative, so they gain and sleep time we know they get better weight gain from having more kangaroo care, and we know they prior less. They're less stressed if they're picked up and they feel them, um, they stop crying. You see it in a normal term, baby, a preterm baby is no different. So just because they only way 500 g or 1.5 g and you think they're going to get cold, you have to deal with that outside environment. You know, they they had they will thermo regulate from mom, and you just monitor their temperature if they're out for 20 minutes. And actually they're only 500 g and they are getting cold, you have to then put them back in. You don't let them get cold, but you let them have that time. Um, we we also know that if a mom has lots more kangaroo care, they're going to get lots more breastfeed. They're more likely to be able to breastfeed and take their baby home breast feeding. They have earlier hospital discharge, and it's better for maternal health, maternal bonding and maternal coast natal depression. Okay, so it improves care. That's a very bad victor. I'm now they're saying it's not in focus. Sorry about that. There there is a baby lying on this mom's chest. This mum is lying down. She must have come across. She's probably post section. She's come across on a bed and she is getting kangaroo care with her newborn baby who has been admitted to the neonatal unit. You can see the pumps and the monitors in the background. Sorry about that. Okay, so there are simple things we can actually do, and everyone can do anywhere in the world. Okay. A magnesium is cheap, remember? And so, of course, go steroids. All these things are cheap. Um, but I want to talk about the pathology of intraventricular hemorrhage because this is what we're trying to avoid as well bleeding into the ventricular spaces it tip right. So go back to your embryology in when the brain develops. It is completely solid filled in that first trimester. So your germinal matrix is vascular. Okay? It is a vascular germinal epithelium, which fills the ventricular spaces. Then as the brain matures, the ventricles develop and become fluid cushioning. So that brain starts to think about how am I going to cope with impact. I want flu. I want cushions of fluid in my extradural spaces, but also in my internally in my brain. So what? My brain coats with impact cooks with movement. I want some cushioning, but that isn't there at the beginning, so the ventricular spaces develop. So unfortunately, when you're born prematurely, prematurely, you've still got a lot of vasculature in that ventricular spay. I appreciate you still have it in adulthood. You still have your choroid plexus. But the problem is even more in premature babies. The other problem that babies have is they don't have good cerebral auto regulation. So if our BP goes up okay or goes down, our brain protects our cerebri the blood flow until you get too extreme variations in your BP. You cope with a certain amount of hypertension as an adult. The baby doesn't that, because the premature brain doesn't have mature auto regulation from its autonomic nervous system, because the autonomic nervous system is immature. Okay, so the bleeding not typically initiates in the germinal matrix, which is at the head of the cord eight nucleus. And if it's substantial, we can actually get breakdown and blood leaks into the ventricles, right? The vasculature leaks into the ventricles because they can't cope with stretch. We grade it according to the amount of blood in the ventricle, and we grade it because it's of prognostic implication. And in fact, some people will argue Some you know, to Ologist will argue, actually like to see a little bit of blood in next. It means that it's not been too hypotensive, because if you've had to be a hypertension, you may not bleed unless you get a reactive vasal dilatation. So one of the reasons you bleed after low BP is because the brain then goes wash with blood and reactively vasal dilates. Okay, but what were the ones we're worried about are the grade threes and the grade fours, right? The grade threes. There's quite a lot of blood in that ventricle and that ventricle re absorption system of that blood and that blood breakdown can't cope and it will block, and therefore you get ventricular enlargement of the CSF cavity. The cerebrospinal fluid can't drain. It can't re absorb from the surface and from the actual circulation, because the blood is the blood, the heme deposits are covering the surface, so it's blocking it. And then you get ventricular megaly, which will then cause pressure on your lateral cortical thalamic tracks that are coming down, which will give you spastic dip Lesia because the leg motor tracks are sitting right next to the vegetables. If it's Grade four, there's going to be pictures. Don't worry. There's bleeding in the surrounding brain matter, so you've hit the parenchymatous, so that's likely to break down and cause loss of brain tissue. Okay, let's talk about the risk factors before we go onto pictures. So the big risk factor is prematurity because you've got this fragile germinal matrix vasculature. Disturbances of cerebral blood flow will give you a risk factor and that can be antenatal and perinatal. Remember, if you've got placental insufficiency, the brain may have lack of blood flow, so hemorrhage can occur and does occur. Antenatal e. So we scan. We like to scan within an hour of birth, because basically we're trying to define Is this an obstetric antenatal hemorrhage? Or is this something a marker of our postnatal care? Okay, most hemorrhages occur within the 1st 72 hours of life, and that's because after 72 hours. Cerebral auto regulation seems to mature, and the baby tends to be more stable. So a lot of it is in that initial perinatal stabilisation. Clearly, period. Hypertension, hypertension. So high BP can force an intraventricular hemorrhage. Hypoxia. Carbon dioxide affects your cerebral auto regulation. Remember, low carbon dioxide forces faizo constriction. High carbon dioxide causes Faiza dilatations severe acidosis altered cardiac output effect on BP. Patent doctors are arteriosclerosis. People monitor cerebral blood flow through infrared spectroscopy and they can show that if you've got a significant dart, you have cerebral steel, severe rds from its effect on hypoxia, actually, and sepsis from the cytokine inflammatory math inflammatory set up which damages white matter. And obviously if you've got a platelet or a coagulation problem, or that we don't quite know what levels to treat. But we do get nervous about coagulopathy she's and low platelets. Okay, The interesting thing about it is most intraventricular hemorrhage is erased symptomatic. So if you didn't offer routine ultrasound less than 32 weeks, you're not going to identify them. Okay, you may get but if you see this, you're probably in trouble, and it's a significant hemorrhage or it's going to extend. You may get neurological features such as altered consciousness. That's very difficult in a baby that looks asleep anyway when they're very preterm. But you want to look, has that baby moved? Other nurses seeing little twitches and movement are they see, you know, if they handle the baby, just the baby move. Because babies on handling will normally flex away from you. Extend away from you, grimace their face But you want to look at their tone. You want to look for seizures, But again, they can have simple myoclonic jerks. They are normal, so it can be very difficult things that worry me is if you've got lots of temperature control out with what you expect or if that baby develops a bradycardia or a tacky cardia, I would think Oh, actually, they've got their breeding in their brain. Obviously, if you see seizures or if you get a collapsed due to a large volume loss of, say, baby suddenly becomes anemic or collapses with blood loss, check the brain. Okay, here are pictures. So we like pictures. Okay, this is great. So I'm going to orientate you actually, So imagine you've taken the face off in the top. I've taken the face off and I'm looking through onto my brain. So what I normally would expect to see Oh, hang on, Right. What I normally expect to see is my brain folding. I don't have many folds here. This isn't a very mature brain, and I normally expect to see gray white matter differentiation. So I normally expect to see this looking gray, the edges looking white with mile a nation. Then I come into my ventricles, and I'm I'm actually quite at anterior here, so I'm looking at my lateral ventricles. Keep losing this and I'm looking at the anterior horn. So I'm just looking at the ventricle space. You can see this small, the thin. They're not large. They're not dilated. Okay? And then I look into the blood vessel back the bag of blood vessels, which we call the Choroid plexus and the germinal matrix. And if it looks slightly brighter than what it should, quite often your benchmark is the bone at the edge. Actually, if it looks as white as the the bone at the edge, then there's blood. If it looks a little bit more subtle. This is a bit rounded. We don't expect it to look so circular. We would expect it to look flatter and more in shape with the ventricles, so there's probably a little bit of blood. Some of this is subjective, but it's not subjective. Once you start to move on to Grade two, when there is more blood sitting in and you're starting to see the ventricles looking a little bit bigger, I'm going to have to minimize the chatter. Minute. I'm going to have to minimize this to show you three. Okay, this is a baby that's got a lot of blood sitting in the ventricles. You can see it's looking like a big blood thrombus, isn't it? And it's dilating up the ventricles. My ventricles are looking fatter. They're too big. They shouldn't look like this. And even in this image, I'm seeing the ventricular body coming in and the posterior horn of the ventricle. I'm seeing blood in the ventricle. The reason I've labeled that as a three is because I can't see it crossing out with the ventricle and what we do. We look at it, face through the face, and then we look at it top down in what we call a lateral image. And again, I can't see the blood going into the brain. Okay, so my brother, my blood stays in in the ventricle. It doesn't cross into the brain tissue. The ventricular wall is defining that you can look here and think of where is that crossing? But actually, you'll take lots of images and you will decide if it's in the ventricle and only a three. Or if it's out of the ventricle and a fall, I'm showing you a fall here to emphasis that the hemorrhage, this ragged brightness is out of my ventricular wall. It's broken through the vawl and is affecting my parent climber Now, unfortunately, what I expect to see over time is that breaks down and becomes a cavity and empty cavity with loss of brain tissue. And even if it doesn't break down, it has been there, so there will be parenchymatous damage that, but at the end of the day, you can only go with neurodevelopmental outcome. But certainly if we saw bilateral grade for or if there was multi organ failure, we would offer the parents consideration of withdrawal of care and saying that nature doesn't want this baby to survive. That is in conjunction with parental viewpoints. Okay, Intraventricular hemorrhage. Obviously the important is to monitor it, treat any complications such as posthemorrhagic hydro Careful iss we used to try. There's been studies where they've tried to flush out the clot early on to see if it would allow deep compression of the ventricles. The multi center study had to stop because they didn't show any benefit and they got infection introduced. So the study was terminated in the earlier stages, and they're still trying to move to, you know, looking again at What can we do? So now we just treat with certain neurosurgical input at the point where we have ventricular parrot when we need a shunt, because the ventricular N index is impeding cerebral blood flow when we do Doppler's on the anterior cerebral artery. What you've got to remember is if you've got great trees and force, you've got increased risks of cerebral palsy because of the motor tracks coming down the side of that ventricle. So our lateral Cordova thalamic bundle Portugal thalamic bundle no corticospinal track. Sorry, The lap, the the nerves running from the cortex down the spine to feed the arms and legs run down the side of the the side of those ventricles with the leg nerves being closest. Then the trunk, then the arm, nerves being further away. Sorry, that's very simple, but that's how it works. You will have. You need to say, Although we expect this to be a motor problem, that you can have other developmental difficulties, we can't always say If you've got a pouring file exist, you may also have cognition. It depends how far extends, and it depends where it is. If it goes into the frontal cortex, that's cognitive function. If it goes into the acceptable cortex, that's visual function. And there is an increased mortality, obviously, with Intraventricular hemorrhage, particularly if it's significant, I want to talk briefly at where I am with time about Paraventricular nucleus, Malaysia. What this? This definition is that we've got changes to the white matter surrounding the ventricles, and we've got tissue necrosis. Okay, so it's not just in the cushions. The ventricular cushions of fluid is actually in the brain tissue itself, and it's normally been caused by hypoxia, infection and inflammation. But even being premature you've got chronic lung disease, potentially, that leads to inflammation, so that leads to a cytokine response. But it causes tissue. Damage is blood flow changes, and it often occurs following an intraventricular hemorrhage. But it can occur independently as well. And one of the reasons that we like to do an ultrasound four weeks after birth because hypertension and hypoxia can take four weeks for tissue loss, we won't necessarily see it straight away. I'm showing you an ultrasound picture, and basically, if you remember that nice brain that you saw with just the ventricles and the white matter surrounding was good here. I've got lots of holes, so if I see holes, I've lost tissue and that's paraventricular Luca Malaysia. This looks quite a defined area, so which is positive, But you will want to look where it is and see what effect you think you're going to have again. The risk factors are prematurity, low birth weight, so in utero growth, retardation, Think about congenital infection. Live listed C M V. Because it's treatable. Um, so CMB we would expect to see other signs you'd expect to get a pattern megaly. You'd expect to get maybe low platelets. So a baby born with low platelets who is very small Freij we would actually screen for our in utero toxic infections such as toxoplasmosis, congenital CV rib, ella and herpes. Your torch. But the the thing about C. M. V is it's now treatable. Okay, ganciclovir will treat, and it won't necessarily. What the studies have shown is that it prevents the sensorineural deafness. It stops the child. Becoming death doesn't necessarily prevent any other neurological problems charges going to get. But we stopped deafness. So we treat when you look at your PVL. Ian going to think about your motor disorders against cerebral palsy. Developmental delay. Are they going to have any of the coordination, vision, hearing or seizure disorders that we've talked about? So, you know, that's where we are. Time is 10 to. So I'm going to stop there. Any questions? Uh, regarding the intraventricular hemorrhage, where the point where the surgical intervention has to be done. Uh, the surgeon drains the, uh I think the entire CSF from the ventricle. In that case, I Is that so? Right. I missed the latter bit. Say it again. So the point of intervention with the surgeon Yeah, So basically, they insert a shunt, right? So there's two ways they can do it. Actually, depending on the stability of the baby, if the baby is not stable, they will actually just put a a tap connection of reservoir. Um, I should have put pictures up. Actually, they'll put like a balloon reservoir, which connects to the ventricle, and they will get us doing cereal aseptic taps to decompress the ventricles. But the ideal would be to go straight to a ventriculoperitoneal shunt so they insert a catheter. And obviously it's very complicated into the ventricle, and they then drain that, and in fact, because the size of the baby we don't. In adults, you may go into the heart because that adult isn't going to grow and the catheter become too short. They drain into the peritoneum so that as the child grows, there's lots of peritoneal catheters to stop the the shunt, having to be replaced too often. So, yeah, they put a catheter between the ventricle, draining it into the peritoneal cavity for the fluid to be re absorbed to allow the ventricle to decompress, but not over shrink. They need to get the flow rate on that catheter from the valve they insert to be correct, but they got to think about they don't want too much sediment. So in a way, they actually want the thrombus to naturally be starting to break down. They don't want big blocks block in their catheter, and they're catheter becoming blocked. But, yeah, it's a, uh a. It's a ventriculoperitoneal shunt that is inserted by under a neurosurgical team. So it's not something a neonatologist did. What we did try doing is actually irrigating. So we tapped into the ventricle, which is very easy through the Antony area. Fontanelle. Actually, you can go straight into the ventricular space we tried under study under a randomized controlled trial to flush out the clot. We thought that if we put irrigation fluid in in the first week of life and took away the thrombus, they wouldn't go on to develop posthemorrhagic hydro careful ISS. But unfortunately, those studies were stopped early. Some people will argue on sub analysis. There is a little bit of benefit in that, but the as far as I know the sip, the study isn't actually going on at the moment. I'm not aware it's running. Uh, the thing is, if we even do the shunt and keep draining it think draining the ventricle fluid will be just a short term, uh, short term solution. You have to stop the blood flow. The the blood which is coming into the wind trickle. Okay, so most of the hemorrhage, because the baby develops cerebral auto regulation. And so most of the hemorrhage occurs within the 1st 72 hours of life, so it naturally stops. They developed the ability to regulate the blood brain barrier, so they developed the blood brain barrier. Sorry, I didn't make that clear. Very good question, actually. Very good point to raise. So the hemorrhage doesn't continue. The hemorrhage is often a one off event. What happens is sometimes we don't see the full extent on day one. And it's really the day three scam that gives us the full extent of what has happened after Day three. You shouldn't see new hemorrhage unless your baby has had a hypertensive crisis or a hypertensive crisis. So there's normally been a trigger for Emery any hemorrhaging after 72 arms of age because the cerebral blood auto regulation has naturally improved. I don't know how the baby does lap, but it just does it. Thank you. Very good question. Actually, Um, I have a question. Do we, um, do ventriculoperitoneal actions in all cases of, uh, interventricular hemorrhage? Or only when it's it has resulted to hydrocepha lot. Okay, so it's when you develop hydrocephalus, which is different. So we've got measurement charts. We know what size those ventricles should be linked to the gestational age of the baby. And once they cross the 97th percentile on the ventricle, what we want to know is that ventricle, because remember the baby's brain a skull isn't fused, so the baby's head can actually grow, and it can expand. So what we really want to know is, is is that are those sorry are those ventricles compressing cerebral blood flow? And one of the beauties is the anterior cerebral artery. It comes very close to the the ventricular wall, and we can measure how much what it's resistance index to its flow is how easy is it for the blood to flow through that? Or is that ventricle compressing that artery and compressing blood flow to my brain tissue? So if the baby is expanding its skull. It's skull bones, and there's no compression on blood flow. The new resurgence don't want to go in. It's got much more sophisticated because going in risks introducing infection, introduces, shunt blockage and may not change outcome. So the outcome factor is felt to be linked to cerebral blood flow to the brain. And is it compressing it so we don't go in on everyone, but absolutely, it's the ones that develop hydrocephalus. It's the grade threes that may re absorb. But we always say to the parents, There is a risk that this is going to progress on. We will be monitoring closely, and we may at some point need to think about other therapies. We may not mention surgical treatment, but they normally ask. You normally have to say, Well, we may need to think about Do we need to involve surgeons to help us drain this blood away, and then they always say, We can't you drain it now and we also have to say, Well, actually, we don't do that. And when we've tried to do that, we've shown that we've actually not helped. Yeah, please, on my question about the Periventricular leukomalacia it said. It's, um it's Wedneday's, uh, necrosis of, uh, the white matter surrounding eventually cools. Where about the degree matter. They're like the visual dangler. Do they affected to, like Do Do you see symptoms of those compression those ones doing in baby the, uh so in the gray matters degree matters surrounding events because you did get affected as well, Apart from the white matters, Yeah, so you can get gray matter loss. We tend to say that's pouring Catholic cysts. So it's, you know, you can absolutely get gray matter loss. One of the reasons that we think the white matter is so important is if you, the white matter really is myelinating brain tissue, isn't it? And that's really important because you have rapid nerve conduction. Once you have matured your brain. So periventricular leukomalacia that you're right, that they we define it as PVL. We call it PVL periventricular leukomalacia. But when you go to biopsy, it is the loss of the white matter. There may be other enlarge insists there, which is the gray matter loss, But PVL itself tends to look quite stippled. Um, it looks like you blogged a little paintbrush all over it. When the gray matter goes, it tends to go into a much larger volume loss. But you can absolutely lose volume loss as well. What? That's slide that I showed of the grade four hemorrhage where you then saw the big cyst. That is gray matter loss as well. That is a pouring phallic cyst. So you've got gray and white matter loss there. Periventricular leukomalacia by definition is white matter loss. But obviously, only if you went histology and brain biopsy would you know if you've got gray there as well, And is it more extensive? MRI is very so if we've got periventricular leukomalacia, we would actually move to MRI actually to give us more detail if there is extension into the gray matter or if it's just right matter. But we don't do that until term or post term because, um, the MRI changes they. What they really have data on is measurements at term when myelin ation is mature because otherwise you get these reports to say there's immature myelin ation. They like it to be mature myelin. For them to absolutely define the degree of white matter loss, I'm not sure if I've made that clear. But PVL is white matter loss. But you're absolutely right. How do you know there isn't grey matter loss? But it tends to be bigger. They tend to be bigger holes. That's very subtle, isn't it? But MRI will give you the real detail. Yeah, I get it. Thank you. I'm sorry. I didn't realize I would take so long on the brain. I was going to go on to ice. Well, but never mind. Are you enjoying prematurity, or would you like me to go back to pediatrics next week? Pretty much already. Okay. Yeah. You got You got a thumbs up from another participant as well. Okay, the majority of my job, I just retired, actually, which is why I've got so much time. But the majority of my job was always neonate and Oh, I love it. I did. I did pediatric clinics, and in the earlier part of my career, I did lots of pediatrics, but the main focus of my job was neonatology. I think that's why I've been to That's why I'm talking too much about it when I get going. Okay. I think we'll have to wrap it up but it's it's great to have someone so enthusiastic. Uh, talking. Um, I'm just, uh, posting the certificate in the chat, so it should be there now, Um, and I'll just put in the, uh, the email in case there's a problem with that. Also, further up the chat, you'll see the feedback form. Please. Please, please fill in the feedback form. It's very important for us, uh, to, uh, to get feedback so we can constantly improve. Thank you, Assad. Um and, um, there's also the links to the next two lectures today. And there is also, uh, a link to the WhatsApp Group if you're not already on that, which gives you details of up and coming lectures. So, uh, thank you very much, Doctor Delahunty. And, uh, I'll stop recording now, but i'll, uh, I'll hang on just to give people a chance to