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Early Recognition, Management and Outcome of a Large Subgaleal Hemorrhage in a Neonate at Birth

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Early Recognition, Management and Outcome of a Large Subgaleal Hemorrhage in a Neonate at Birth Clinical AND Health Affairs Early recognition, management and outcome of a large subgaleal hemorrhage in a neonate at birth BY VINAYAK NADAR, MD, AND ASHAJYOTHI M SIDDAPPA, MD 30-year-old mother was admitted in brain revealed a right frontal bone frac- active labor at 37 weeks of gestation. ture, large amounts of blood in subgaleal Neonatal AHer pregnancy was uncomplicated; space with relatively small subarachnoid complications she had her first prenatal visit at six weeks and subdural hemorrhages. On the second associated with gestation and her lab work was within nor- day of life, the infant had seizure activity vacuum-extraction mal limits. Her labor was prolonged and that was treated with levetiracetam (Kep- deliveries there was fetal bradycardia, but the family pra). By the third day of life, the infant Scalp Injuries, bruising, hematoma was undecided about C-section, so vac- remained hemodynamically stable with Large caput succedaneum uum instrumentation was attempted. The reduced swelling and edema around the Subgaleal hemorrhage fetal heart rate decelerations continued, occiput and neck. An MRI of the brain Cephalhematoma with a failed vacuum attempt and con- showed intraparenchymal, subarachnoid cern for shoulder dystocia, so a decision hemorrhage involving the right cortex and Intracranial hemorrhage ( subdural, subarchanoid, intraventricular and was made to deliver by STAT C-section. concern for acute infarctions involving cerebral) The newborn intensive care unit (NICU) similar distribution in right parietal/tem- Skull fracture team was notified and present at time of poral/frontal regions and corpus callosum, Seizures delivery. The infant was resuscitated with SGH. The patient continued to improve Anemia intubation in the delivery room and trans- without seizure activity, with progressive ferred to NICU for further management. resolution of neck edema/swelling. The Severe/persistent metabolic acidosis At admission, the infant’s hemoglobin parents were updated on the guarded Shock was 13.4 gm/dL, but dropped to 6 gm/ prognosis and the high risk for long-term DIC dL within a few hours; severe subgaleal neuro-developmental problems. Hyperbilirubinemia bleeding was noted on exam. The infant Bilirubin peaked at 7.1/0.8, then Shoulder dystocia was resuscitated aggressively with multiple trended down thereafter. An EEG was Clavicle fracture boluses of fresh frozen plasma, cryopre- mildly abnormal with excessive sharp Brachial plexus Injury cipitate, and packed red cell transfusions activity, which was nonspecific for sei- Retinal hemorrhage to correct coagulopathy and hypotension. zures and indicated mild diffuse cerebral Subconjunctival hemorrhage Skull X-ray and cranial ultrasound find- dysfunction. The infant was discharged 13 Fetal/Neonatal death ings were consistent with a very large sub- days after birth in a stable condition. The galeal hemorrhage (SGH). CT scan of the discharge physical exam was notable for 40 | MINNESOTA MEDICINE | MAY/JUNE 2018 Clinical AND Health Affairs showing a resolving subgaleal hematoma FIGURE 1 with minimal bruising over the eyelids and occiput, and grossly normal neu- Schematic representation of the five anatomic layers of the scalp and their relationship to various hemorrhages that may rological examination. The infant went develop within this layers.3 home breastfeeding successfully and was discharged on Keppra for seizure prophy- laxis, with a plan for repeat EEG and MRI brain and close follow-up with a pediatric neurologist, NICU follow-up clinic, and occupational and physiotherapist and pediatric hematology. At 24 months old, she continues to do well; her growth and development are good and she shows no significant neurological deficits. SGH occurring during the neonatal period is a rare complication, but it is im- portant for all medical staff working with fectively, or when there is non-reassuring Incidence is 0.1-0.6/1000 of all deliver- neonates to remember that even though fetal heart rate so that shortening the sec- ies and is 3-7.6/1000 following vacuum- it is rare, it is associated with significant ond stage of labor is necessary. Vacuum assisted births.9, 10 Vacuum use is reported mortality, 12-25%, when not recognized. It extraction is used successfully most of the in 49% of all instances of subgaleal hemor- was first reported by Naegele in 1819 and time, but difficult vacuum extractions are rhage. Bleeding is gradual and may not be later was cited by Virchow in 1863.1 It was associated with neonatal complications. apparent right away after delivery; bleed- initially named “false cephalohematoma,” Difficult vacuum extractions could in- ing may occur over several hours. A large then was renamed by Malmstrom in 1957 clude cup dislodgements, more than three SGH could be confused with large caput as “subgaleal hemorrhage,” when he first extractions, or a total duration exceeding or cephalhematoma (Fig.1). SGH usually introduced the vacuum extractor.2 15-20 minutes.5, 6 Nulliparity, fetal malposi- presents as a boggy, fluctuant swelling. Anatomically, the scalp has five layers. tion, and mid-pelvic fetal station are some Mainly accumulating in dependent areas, From top to bottom, the layers are skin, of the common risk factors associated with in severe cases it can cause elevation and dense connective tissue, galea aponeuro- failed vacuum extractions.7, 8 displacement of ear lobes and puffiness tica, loose connective tissue, and perios- Subgaleal hemorrhage is a rare com- of the eyes. When not recognized in time, teum. SGH occurs in the loose connective plication following vacuum-extraction massive subgaleal hemorrhage can lead to tissue underneath the galea aponeurotica. delivery, but there are case reports of SGH hypovolemic shock, DIC, persistent meta- This area has many emissary veins which occurring following caesarian section and bolic acidosis, and death, despite volume connect the intradural venous system with even with spontaneous vaginal delivery. resuscitation. superficial scalp veins.3 These veins are Management of SGH includes a prompt torn when shear tractional force is applied FIGURE 2 initial assessment by an experienced to the skin over the scalp. Bleeding occurs X-ray showing extensive soft staff, pediatrician, or neonatologist, with in the potential space between the galea tissue swelling along the careful examination of scalp in an infant aponeurotica and the periosteum of the vertex of the skull consistent born after a vacuum delivery or if the skull. Subgaleal space extends from the or- with a large subgaleal delivery has been difficult. Monitoring hemorrhage bital ridge to the nape of the neck, and can hemoglobin/hematocrit and measuring accommodate a large amount of blood— head circumference around the clock up to several hundred milliliters in a neo- during initial period is critical. Diagnosis nate (50-80% of the blood volume).4 can be confirmed by MRI/CT scan/head Over the past three decades, however, ultrasound once infant is medically stable there has been a drastic decrease in instru- (Fig.2). If SGH is seen following a non- ment deliveries in conjunction with an in- traumatic delivery, a coagulation screen crease in C-sections for difficult deliveries. should be considered to rule out bleeding Instrument-assisted deliveries are associ- disorders.11 Treatment per se is related to ated with an increased risk of birth trauma blood loss: aggressive fluid boluses/blood (Table 1). Vacuum extraction is used when transfusion to treat hypotension, coagu- the second stage of labor is prolonged, lopathy with fresh frozen plasma. Recom- when the mother is unable to push ef- binant activated factor VII has been used MAY/JUNE 2018 | MINNESOTA MEDICINE | 41 Clinical AND Health Affairs Neurosurgery 2003; 52: 1470–4, discussion1474 in some cases to stop hemorrhage in in- newborn infants regarding complications 4 McQuivey RW. Vacuum assisted delivery: a review. J fants where hemorrhage is not controlled following instrumental delivery. Given the Maternal Fetal Neonatal Med 2004; 16:171-180 with FFP and platelet transfusion. More insidious nature of bleeding from such 5 Murphy DJ, Liebling RE, Patel R. Cohort study of operative delivery in the second stage of labour and severe cases may include cerebral involve- deliveries, increased awareness on iden- standard of obstetric care.BJOG 2003; 110:610–15 ment with seizures that require treatment tifying SGH is important. Though SGH 6 Teng FY, Sayre JW. Vacuum extraction: does dura- tion predict scalp injury? Obstet Gynecol 1997; and neurology involvement, or intracra- is a rare complication, early recognition, 89:281–5. nial extension that requires neurosurgery careful monitoring, and prompt treatment 7 Al-Kadri H, Sabr Y, Al-Saif S, et al. Failed individual evaluation. Monitoring for hyperbilirubi- is critical for improving survival and out- and sequential instrumental vaginal delivery: contrib- uting risk factors and maternal-neonatal complica- nemia is important during resolution of a comes. MM tions. Acta Obstet Gynecol Scand 2003; 82: 642–8. large subgaleal bleed, as some infants will 8 Ben-Haroush A, Melamed N, Kaplan B, Yogev Vinayak Nadar, MD, is a a resident in the Y. Predictors of failed operative vaginal delivery: a require phototherapy. Once bleeding is Department of Anesthesia at the University of single-center experience. Am J Obstet Gynecol 2007; controlled, the swelling generally resolves Minnesota. Ashajyothi M. Siddappa, MD, is a 197:308e1–5. neonatologist in the Department of Pediatrics over weeks and there is a good prognosis, 9 Chang HY, Peng, CC, Kao HA, Hsu CH, Hung at Hennepin County Medical Center. HY & Chang JH. Neonatal subgaleal hemorrhage: but it is prudent to have close neurology clinical; presentation, treatment and predictors of follow-up to identify and evaluate for any poor prognosis. Pediatrics International, 2007: 49; REFERENCES 903-907. residual neurological deficits during the 10 Chadwick LM, Pemberton PJ, Kurinczuk JJ. first year of life. Poor neurodevelopmental 1 Virchow R. Die Krankhaften Geschwülste. Berlin: A. Neonatal subgaleal hematoma: associated risk factors, 9 Hirschwald, 1865. complications and outcome. J. Pediatric. Child Health outcomes are seen with severe SGH.
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