EDU-QUICK

Subgaleal Hemorrhage

Updated October 2014 OVERVIEW

•Review the definition of

•Review the risk factors for developing subgaleal hemorrhage

•Review the differences between subgaleal hemorrhage, and caput

•Describe the revised monitoring parameters for BCW new policy

Definition of Subgaleal Hemorrhage  A collection of blood in the soft tissue space between the galea aponeurotica and the periosteum of skull.  Caused by rupture between the dural sinuses and the scalp veins. This space extends forward to the eyes, backward to the nuchal ridge and across to the temporal fascia  May hold as much as 260 ml of blood (which is almost equivalent to the baby’s blood volume).

Picture for Definition

Subgaleal hemorrhages are characterized by a collection of fluid that fluctuates when palpated and may shift with repositioning of the head. Incidence  Rare  Potentially lethal condition  More prevalent following a difficult vacuum or forceps-assisted birth.  The prevalence of moderate-to-severe SGH is reported as 1.5 per 10,000 births.  Up to 25% of babies who require neonatal intensive care for this condition can die.

RISK FACTORS FOR SGH Risk Factors

At Risk Newborns:

 Any vacuum delivery, (in particular with more than 3 pulls or pop-offs)  Any delivery where a has been attempted  Eg: includes failed vacuum delivery that results in c- section delivery  Delivery where vacuum delivery has been attempted and another instrument, such as forceps, has been used as the final method of delivery  Any rotational forceps delivery

Signs and symptoms of SGH

May notice immediately or over the next several hours following delivery.

1. Diffuse fluctuating swelling of the head that crosses suture lines, shifts dependently when the 's head is repositioned and indents easily on palpation.

2. Increasing Head Circumference

3. Evidence of (lethargy, pallor, poor perfusion, tachycardia, increased respiratory rate, decreased urinary output, )

4. Prolonged (late sign)

5. Seizures (not usually until advanced hemorrhage) DIFFERENCES BETWEEN SGH, CAPUT AND CEPHALOHEMATOMA Diagnosis

 Diagnosis of SGH is clinical. The scalp is boggy (feels like a water balloon, fluid is firm to fluctuant with ill defined borders, may have crepitus or waves and shifts dependently when the infant’s head is repositioned). SGH may be misdiagnosed as cephalohematomas or .

Cephalhematoma vs Caput . Cephalhematoma is the collection of blood under the periosteum and does not cross the suture lines. Cephalhematomas are firm masses that will resolve in 2 weeks to 6 months. . Caput is localized scalp that is the result of venous congestion from the pressure of the head applied to the dilating cervix. The edema can cross the suture lines. Caput does not increase in size over time and resolves several days after birth.

MONITORING PARAMETERS FOR SGH Newborns at risk for SGH

 Can remain with their mother as long as their vital signs are normal and the infant is not demonstrating any signs of distress.  Those should be observed for symptoms for 24 hours before discharge.

Post-delivery assessment monitoring

 Immediately after birth

 Every hour after birth X 3, then at 6 hours

 If stable, then every 4 hours until 24 hours after birth

 If newborn is unstable, call the primary care provider to arrange transfer to the Intermediate Nursery

 Assess more frequently if there is a change in newborn status

 Call the most responsible care provider for immediate assessment if SGH is suspected

Assessments to include close observation and documentation of the following:  Vital Signs (Heart Rate, Respirations, Temperature)

 Colour, perfusion and appearance of the scalp (DO NOT use hats/bonnets)

 Assess for bogginess of the head

 Visual inspection and manual palpation of the head including the scalp

 Behavioural State

 Tone

No measurement of head circumference required by RN MANAGEMENT OF SGH Early Identification

 Identification  Investigations:

 Screen and monitor all at-  CBC, hematocrit, risk newborns as hemoglobin should be recognition and supportive performed as soon as care can improve survival possible and should be and outcome monitored every 4–8 hours.  Coagulation screen (INR,  No hats or bonnets PTT, PTT, fibrinogen, d- dimers) every 4-8 hours.  CT scan or MRI of the head. MRI scan is the preferred method of imaging  Radiographs of the skull can also be useful to identify underlying fractures Inspection Manual Palpation Newborns with SGH

 Assess colour,  Early recognition and perfusion, pain and the institution of appearance of scalp supportive care such as blood transfusion, volume support, and Admit to IN/NICU  coagulation factors in the presence of DIC.

 Treat /hypovolemic shock with blood volume replacement.

Decrease  Interventions to minimize blood loss: i. Avoid IM injections when possible. ii. Avoid percutaneous arterial punctures if possible. iii. Provide prolonged pressure after venipuncture, heel-stick, or arterial stick. iv. Minimize invasive procedures as much as possible v. Gentle suction only when needed.

PROGNOSIS Prognosis depends on the severity of the hemorrhage;  with early recognition and aggressive volume resuscitation, full recovery is possible and long-term outlook for survivors is good.

 Severe hypovolemia and shock is the most common cause death in 20% to 60% of patients.

Risk Factors for Death

. Decrease in hematocrit >25% of the baseline value at birth requiring urgent blood transfusion in the first 12 hours. . Hypovolemic shock . DIC . Association with significant birth asphyxia . Intracranial hemorrhages are also more frequently associated with SGH (~50% in one study).

Summary  Subgaleal hemorrhage is a rare but potentially lethal condition that impacts newborns in their first hours of life.  It is important for perinatal care providers to have knowledge of this condition and be able to recognize it early  Clear appropriate criteria helps to identify which babies are at risk so that we monitor the right group  Vacuum deliveries and rotational forceps deliveries put babies at increased risk