Fetal Intracranial Hemorrhage (IVH Grading)

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Hemorrhage site/grade (Papile) + cause
   Hemorrhage site/grade (IVH Papile) + cause? (Fetal intracranial hemorrhage. MRI: SWI/T2*-GRE most sensitive for blood, T1-high/T2-low blood breakdown products. IVH grading (as in preterm Papile): I germinal matrix, II IVH without ventricular dilation, III IVH + ventricular dilation, IV periventricular hemorrhagic infarction (PVHI). Causes to check: fetomaternal alloimmune thrombocytopenia (FNAIT), maternal ITP, coagulation/thrombophilia, trauma, TTTS, CMV, COL4A1.)
   • Grade I–II (germinal matrix / IVH without ventricular dilation) → Grade I–II · monitor + check cause
   • Grade III–IV (IVH + ventricular dilation / periventricular hemorrhagic infarction PVHI) → Grade III–IV · poor prognosis
   • Parenchymal/posterior fossa hemorrhage or established porencephaly/post-hemorrhagic hydrocephalus → Parenchymal hemorrhage/porencephaly/post-hemorrhagic hydrocephalus
2. [End] Grade I–II · monitor + check cause
   Grade I–II (germinal matrix/IVH without ventricular dilation): relatively better prognosis; serial fetal MRI/ultrasound monitoring for progression (can worsen) + check cause (platelet antigen typing/HPA antibodies, coagulation, infection); FNAIT has high recurrence → maternal IVIG ± steroids (this and future pregnancies).
3. [End] Grade III–IV · poor prognosis
   Grade III–IV (IVH + ventricular dilation or PVHI): poor prognosis (~51% loss within a month, only ~52% of survivors normal at 12 months); MRI to assess parenchymal injury extent + check FNAIT/coagulation/infection; monitor post-hemorrhagic hydrocephalus; FNAIT → maternal IVIG ± steroids ± fetal platelet transfusion; multidisciplinary counselling.
4. [End] Parenchymal hemorrhage/porencephaly/post-hemorrhagic hydrocephalus
   Parenchymal/posterior fossa hemorrhage, porencephaly or post-hemorrhagic hydrocephalus: MRI to assess injury extent and ventricular dilation; check COL4A1 (familial porencephaly), coagulation, FNAIT; individualized counselling and postnatal management (shunt) by degree of hydrocephalus/injury.

Source guidelines & references

• Fetal intracranial hemorrhage MRI and grading (Papile I–IV; FNAIT; UOG 2024)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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