Purpose and Goal: CNEP # 2046

  • Describe the characteristics of subgaleal hemorrhage.
  • Identify at least two strategies for the treatment of subgaleal hemorrhage.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for Successful Completion

  • Successfully complete the post-test
  • Complete the evaluation form

Date

  • January 2016 – January 2018

Learning Objectives

  • Describe the pathophysiology of subgaleal hemorrhage.
  • Describe the clinical presentation of subgaleal hemorrhage.
  • Identify at least two strategies for the treatment of subgaleal hemorrhage.

Introduction

  • Subgaleal hemorrhage is a rare complication of birth.
  • It is an infrequent, but potentially fatal, occurrence.
  • It is an accumulation of blood in the subgaleal space.
  • Subgaleal hemorrhage is caused by birth trauma.
  • It may also present in infants with a coagulopathy disorder.
  • Prompt recognition and treatment improves outcomes.

Definition and Incidence

  • Subgaleal hemorrhage is an accumulation of blood in the loose connective tissue of the subgaleal space.
  • The subgaleal space is located between the galea aponeurotica and the periosteum.
  • A subgaleal hemorrhage can be massive and quickly lead to profound hypovolemic shock.
  • The incidence has been estimated as:
    • 4 out of every 10,000 vaginal births
    • 59 out of every 10,000 vacuum assisted births
     
  • The rate of mortality is reported to be between 12–25%.

Anatomy of the Scalp

  • A review of the anatomy of the scalp is helpful in understanding subgaleal hemorrhage.
  • The scalp is made up of 5 layers:
    • Skin
    • Subcutaneous tissue
    • Galea aponeurotica
    • Subgaleal space
    • Periosteum
     
  • The skin contains hair follicles and sweat glands.
    • It contains the epidermis and the dermis.
    • It is tightly bound to deeper tissues.
     
  • The subcutaneous layer is a dense network of connective tissue.
  • The galea aponeurotica is a dense fibrous tissue that covers the entire upper cranium.
  • The subgaleal space is a loose fibrous tissuethat allows the scalp to slide on the periosteum.
    • It contains large valveless veins.
    • The veins connect the deep sinuses with the superficial veins of the scalp.
     
  • The periosteum is the deepest layer of the scalp.
    • It is also known as the pericranium.
    • It is strongly adhered to the cranium.
     

Pathophysiology

  • Subgaleal hemorrhages develop as large collections of blood in the subgaleal space.
  • Shearing forces on the scalp lead to trauma.
    • Subgaleal space veins are torn.
    • The veins rupture and blood accumulates.
     
  • The subgaleal space is a large space.
    • It covers the entire cranial vault:
      • From the eye orbits
      • To the nape of the neck
      • And laterally from ear to ear
       
     
  • The subgaleal area is not limited by sutures.
    • There are no barriers to prevent bleeding.
    • A massive hemorrhage can quickly occur.
     
  • The loose connective tissue can hold up to 260 ml.
  • A newborn’s estimated blood volume is 80 ml/kg.

Vacuum Extraction and Forceps

  • A subgaleal hemorrhage can occur spontaneously.
  • Most are associated with vacuum assisted deliveries.
  • There is also increased risk with use of forceps.
  • The risk is increased with use of vacuum and forceps.
  • Vacuum extraction exerts traction directly on the scalp.
  • An incorrectly positioned vacuum significantly increases risk.
    • Incorrect traction may result in descent of the scalp and not the entire infant head.
    • When the scalp descends without the head, veins are torn and bleeding occurs.
     
  • Several uses of vacuum extraction increase risk:
    • Multiple pop-offs
    • Applications >10 minutes
    • Increased number of pulls
    • Incorrect manipulation of the vacuum
    • Jerking, rocking, or rotational pulls
     
  • Steady smooth pulls that mimic natural labor are recommended.

Other Risk Factors

  • Other risk factors include:
    • Large infants
    • Cephalopelvic disproportion
    • Prolonged second stage
    • Maternal exhaustion
     
  • Prolonged second stage increases friction against the pelvic bone.
    • Friction places the infant at risk.
     
  • Neonatal coagulopathy
    • Vitamin K deficiency
    • Factor VIII deficiency
    • Factor IX deficiency
     
  • Controversy exists about what comes first,the coagulopathy or the subgaleal hemorrhage.

Clinical Features

  • Most subgaleal hemorrhages develop slowly.
    • Over several hours to several days
    • Mean age at onset of symptoms is 9 hours.
     
  • If a hemorrhage is severe, symptoms develop immediately.
  • Symptoms do not present until extensive blood loss has occurred.
  • An increasing head circumference is the first sign to appear.
  • As bleeding fills the subgaleal space, pressure is exerted on the brain.
    • Neurological disturbances may be seen.
    • Seizure activity may be seen
     
  • Hematocrit values decline as bleeding continues.
  • Bruising may appear around the scalp, eyes and ears.
  • Early hyperbilirubinemia is frequently seen.

Clinical Presentation

  • The hallmark sign of a subgaleal hemorrhage is a large, diffuse, fluctuating mass.
    • The mass covers the entire scalp.
    • It crosses suture lines and fontanels.
    • Swelling extends from the bridge of the nose to the base of the neck and from ear to ear.
     
  • Initial appearance can look like a caput.
    • The scalp is boggy or tight.
    • Pitting edema may be present.
    • Swelling may shift with position changes.
     
  • Other early signs include:
    • Pallor
    • Decreased tone
    • Tachycardia
    • Tachypnea
     
  • Later signs include:
    • Discoloration of the scalp and eyelids
    • Bruising that indicates blood deep in the scalp
     

Hypovolemic Shock

  • As blood is lost in the subgaleal space, shock occurs.
  • It has been estimated that for every 1 cm of head circumference growth, 40 ml of blood can be lost to the subgaleal space.
  • A loss of 20–40% of blood volume results in acute shock.
    • In a 3 kg infant, 20–40% is equal to 50-100 ml.
    • The subgaleal space can hold up to 260 ml.
     
  • Profound shock can occur rapidly with blood loss.
  • Initial signs of shock may be nonspecific.
  • Compensatory mechanisms maintain homeostasis.
    • Normal heart rate
    • Normal blood pressure
    • Pallor and skin mottling
    • Increased capillary refill time
    • Hypothermia
    • Lethargy
     
  • As bleeding continues, compensatory mechanisms fail and classic signs of shock become obvious.
    • Tachycardia
    • Tachypnea
    • Hypotension
    • Cyanosis
    • Oliguria
     
  • Metabolic acidosis occurs due to inadequate perfusion.
  • Disseminated coagulopathy can occur.
  • If blood loss continues, uncompensated shock occurs.
    • Hypotension is profound.
    • This stage is irreversible and fatal.
     

Disseminated Intravascular Coagulation

  • Disseminated intravascular coagulation is known as DIC.
  • Hypovolemic shock is a common underlying cause of DIC.
  • DIC is frequently associated with subgaleal hemorrhage.
  • Damage to scalp veins triggers hemostasis.
    • The clotting cascade is initiated to stop bleeding.
     
  • Massive blood loss and hypovolemic shock lead to:
    • Widespread activation of coagulation
    • When normal hemostasis cannot be maintained due to massive hemorrhage, DIC develops.
     
  • DIC is a widespread systemic disorder.
    • Bleeding or oozing occurs at multiple sites:
      • Gastrointestinal
      • Genitourinary
      • Pulmonary
      • Central nervous system
       
     
  • Signs of DIC in infants are unpredictable:
    • Petechiae
    • Bruising
    • Purpura
    • Capillary microclots
      • Discolored fingers
      • Discolored toes
      • Discolored nose
      • Discolored ears
       
    • Systemic microclots
      • Organ dysfunction
       
     

Diagnosis

 

  • The entire clinical presentation must be evaluated.
  • Diagnosis is not based on one single lab value.
    • Most common labs include:
      • Platelet count
      • Prothrombin time
      • Partial thromboplastin time
      • Fibrinogen
       
     
  • Clotting studies are needed to rule out bleeding disorders.
    • Factor VII
    • Factor VIII
    • Factor IX
    • Factor X
     
  • Lab abnormalities indicative of DIC include:
    • Low platelet count
    • Prolonged prothrombin time
    • Prolonged partial thromboplastin time
    • Reduced fibrinogen level
     
  • A CT or MRI scan is needed to evaluate bleeding.
    • Presence of bleeding confirms diagnosis.
     
  • A CUS does not provide adequate views and is not helpful.

 

Differential Diagnosis

 

  • Two other scalp injuries can complicate diagnosis.
  • Caput succedaneum is an edematous collection of fluid.
    • It is a collection of serosanguineous fluid.
    • Located in the subcutaneous layer of the scalp
    • A caput has distinct borders.
      • It does not enlarge and is not fluctuant.
      • It is located where the vacuum was positioned.
      • It is located at the presenting part of the scalp.
       
    • Typically resolves within 12–18 hours
    • No complications beyond a circular area of bruising
     
  • Cephalohematoma is a collection of blood.
    • It is located beneath the periosteum.
    • It does not cross suture lines.
    • It is a self-limiting hemorrhage.
    • It increases in size over 24 hours.
    • It is usually unilateral and firm.
     
  • Caput succedaneum and/or cephalohematoma may be present in addition to subgaleal hemorrhage.
  • Diagnostic and lab tests help identify subgaleal hemorrhage.

 

Treatment and Medical Management

 

  • Subgaleal hemorrhages are difficult to treat.
  • Recognition of risk factors and early signs is critical.
  • Close monitoring for the first 48 hours is important.
    • Frequent head circumference measurements
    • Frequent assessment of vital signs
    • Frequent assessment for signs of shock
     
  • Treatment of a subgaleal hemorrhage includes:
    • Replacing blood volume
    • Treating shock to maintain perfusion
    • Treating neurological disturbances
    • Managing coagulopathy to stop bleeding
     
  • Replacing blood volume
    • Restoring circulating blood volume is critical.
    • Blood products should be administered quickly.
    • Transfusion volume should be estimated by replacing 40 ml for each 1 cm of increased head circumference.
     
  • Treating shock to maintain perfusion
    • Fluid replacement to correct metabolic acidosis
    • Sodium bicarbonate may be needed to correct acidosis.
    • Inotropic support to restore blood circulation
     
  • Treating neurological disturbances
    • Phenobarbital to treat seizure activity
    • CT scan to evaluate severity of bleeding
    • Neurosurgical consultation may be helpful
    • Mild hyperventilation may help control cerebral edema.
    • Pressure bandages to control edema are not recommended.
     
  • Managing coagulopathy to stop bleeding
    • The goal is to correct the underlying cause.
    • Transfusion of blood products
      • Packed red blood cells to correct anemia
      • Fresh frozen plasma to replace clotting factors
      • Cryoprecipitate to provide clotting factors
      • Platelet transfusion to correct ongoing bleeding
       
    • Platelet counts should be maintained at 20–50,000.
    • An exchange transfusion may prevent volume overload.
    • Heparin therapy to prevent microclot formation is controversial.
     

 

Summary

 

  • Neonatal subgaleal hemorrhage is a rare occurrence.
  • Most subgaleal hemorrhages are associated with vacuum or vacuum and forceps assisted deliveries.
  • Bleeding into the large subgaleal space can quickly lead to hypovolemic shock and DIC.
  • Infants should be monitored following a vaccum assisted delivery.
  • Early recognition and treatment is critical for optimal outcomes.

 

References

 

  1. Reid, J. 2007. Neoantal Subgaleal Hemorrhage. Neonatal Network, 26 (4), p. 219-227.
  2. McKee-Garrett, T.M. 2013. Neonatal Birth Injuries. Up-To-Date.
  3. Schierholz, E. & Walker, S. R. Responding to Traumatic Birth: Subgaleal Hemorrhage, Assessment, and Management during Transport. Advances in Neonatal Care, 10 (6), p. 311-315.

 

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