A newborn female was born by Cesarean section for failure to descend to a 41.5 week, gravida 2, para 2, 24-year-old female who had gestational onset diabetes mellitus.
Her mother was in labor for 36 hours and had rupture of membranes for 26 hours. The fluid was meconium stained.
At delivery, she was intubated and there was no meconium below the cords. Her Apgar scores were 4 and 8 at one and five minutes respectively.
The family history was negative for bleeding disorders.
The pertinent physical exam showed poor initial respiratory effort, duskiness, and poor tone that later improved. Her birthweight was 4540 grams (>97%), head circumference was 37 cm (75%), length was 56 cm (90%).
Her vital signs were stable and her physical examination was normal except for severe molding of the posterior occiput. She had bruising and swelling of the lower left parietal area and anterior occipital areas.
The diagnosis of large for gestation (LGA) infant, with a complicated intrapartum course and possible subgaleal hematoma was made.
The work-up for possible hypoglycemia, sepsis, and bleeding diatheses was begun.
The laboratory evaluation showed a complete blood count, erythrocyte sedimentation rate, C-reactive protein, and a bleeding panel testing as all normal.
The radiologic evaluation of a head skull plain film was consistent with a left frontoparietal subgaleal hematoma.
The patient’s clinical course over her admission found her to have stable glucose levels when monitored on an LGA glucose protocol.
She also had hyperbilirubinemia that was within the expected amount for her gestational age.
She was discharged on day of 4 as she seemed more tired during day 1 and 2 of life and was observed. At 2 weeks of age her head showed mild swelling in the left parietal area that resolved by one month of age.
Figure 69 – AP and lateral radiographs of the skull
demonstrate diffuse soft tissue swelling of the scalp that crosses
sutures and that is especially prominent over the left fronto-
parietal region. The findings were felt to be most compatible with a
Bleeding into the soft tissues of the head is a common problem associated with birth and usually does not require intervention. These include:
- A caput succedaneum is localized serosanguineous edema of the scalp that occurs between the skin and aponeurosis of the scalp. These swellings can cross suture lines and are usually due to pressure from the pelvis, uterus or vagina.
- A subgaleal or aponeuneuroic hematoma occurs between the aponeurosis of the scalp and the periosteum of the bone. The galea aponeurotica occurs from the occiput to the eyebrows and laterally to the temporalis fascia. It therefore can cross suture lines and is a large potential space where hemorrhage can occur.
Subgaleal hematomas usually occur due to shearing of emissary veins between the intracranial venous sinus and the scalp.
- A cephalohematoma is due to bleeding beneath the periosteum of the bone, i.e. between the periosteum and cortical bone. Therefore these swellings occur only over bone and do not cross suture lines. They occur in 2.5% of births.
Subgaleal hematomas are the least common and can occur along with caputs and cephalohematomas and therefore it is important to be aware of this diagnosis.
Caputs have localized skin edema. Subgaleal hematomas may be ballotable and have a fluid wave. As noted previously, a cephalohematoma does not cross suture lines, whereas the other two may.
Subgaleal hematomas are more common after assisted deliveries such as forceps and vacuum.
Moderate to severe subgaleal hematomas occur in 30/10,000 live births.
Of those cases, progressive anemia leading to hypovolemic shock and death occurs in 12-25% of cases.
Blood loss can be life threatening and even modest bleeding can cause exaggerated hyperbilirubinemia necessitating phototherapy and even exchange transfusion.
It is estimated that ~260 ml of blood increases the head circumference by 1 cm.
Intracranial hemorrhages are also more frequently associated with subgaleal hematomas (~50% in one study) and therefore seizures are also a possible complication.
Secondary infection of the hematoma is also an very uncommon complication.
Treatment includes treating the underlying hemorrhage with blood volume replacement, and treatment of congenital or acquired coagulopathies if present. Careful monitoring of the clinical condition and vital signs is necessary. Physical compression of the head may be helpful.
Questions for Further Discussion
1. Name the potential spaces where intraxial central nervous system hemorrhaging may occur?
2. List some of the potential complications of infants of diabetic mothers?
- Subgaleal (Aponeurotic) Hematoma
Head and Brain Injuries
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Cranial trauma following birth in term infants.
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Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:186-187.
Kilani RA, Wetmore J.
Neonatal subgaleal hematoma: presentation and outcome–radiological findings and factors associated with mortality.
Am J Perinatol. 2006 Jan;23(1):41-8.
Pollack S, Kassis I, Soudack M, Sprecher H, Sujov P, Guilburd JN, Makhoul IR.
Infected subgaleal hematoma in a neonate.
Pediatr Infect Dis J. 2007 Aug;26(8):757-9.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
December 1, 2008