Subgaleal Hemorrhage Regional Neonatal Conference Decision-making for Optimal Care and Outcomes Jotishna Sharma , MD, MEd Division of Neonatology

It’s All About Safety in Medicine … and in Life

Objectives Describe the initial presentation of subgaleal hemorrhage Recognize the patients at risk for subgaleal hemorrhage Discuss the differential diagnosis of extracranial hemorrhage Describe the acute management of subgaleal hemorrhage

Case 37 wk gestation male infant, BW 3.24kg born to 23 year old, G1P1 ROM 13hrs, clear fluid; CS for NRFH tones Attempted vaginal delivery- vacuum attempted x2, arrested descent Cord pH 7.34, BD 4.8 Intubated due to apnea immediately after birth Infant described as initially to be improving after intubation with PPV Apgars 6 & 8 @ 1 & 5mins Brought to nursery quickly decompensated UVC placed given D10 & NS bolus

Case ~1hr of life- HR 180-190s, hypotensive, Hgb 12 Head: boggy swelling & increasing head size PCP gave NS x1 & called CMH Infant with massive subgaleal hemorrhage clinically with anemia, hypotension & worsening acidosis Time of transfer: pH 6.6, BD 28 Given 5X NS bolus due to significant hypotension, Nabicarbonate, O negative uncxm blood Head wrapped with ace bandage prior to transport Noted rapidly increasing HC with ears bulging

Subgaleal Hemorrhage (SGH) A rare but potentially lethal condition The prevalence at birth of moderate-to-severe SGH is ~ 1.5 per 10 000 births Among infant admitted to NICU with SGH mortality ranges from 12%- 25% Caused by rupture of the emissary veins Usually due to traction on scalp during delivery Emissary veins: connections between the dural sinuses & the scalp veins

Anatomy of SGH & potential consequences Blood accumulates between the epicranial aponeurosis of the scalp & the periosteum The epicranial aponeurosis is a sheet of fibrous tissue covering the entire cranial vault Extends from the orbital ridges to the nape of the neck & laterally to the ears Separation of the epicranial aponeurosis from the underlying periosteum creates a compartment

Anatomy of SGH & potential consequences ~250 ml of blood could be accommodated in this space with only 1 cm ↑ in scalp thickness significant blood loss will occur before clinically head swelling is noted Newborn blood volume 75-85ml/Kg 3Kg infant, 80ml/Kg = 240ml Some infants can lose 50-75% of their blood volume into the subaponeurotic space leading to Hypovolaemic shock Anemia Coagulopathy Death

Scalp Anatomy Reid, Subgaleal Hemorrhage, Neonatal Network, 26(4); 2007

Schierholz, E, Walker, SR, Responding to Traumatic Birth Subgaleal Hemorrhage, Assessment, and Management During Transport . Advances in Neonatal Care , 2010, 10, (6)

Schierholz, E, Walker, SR, Responding to Traumatic Birth Subgaleal Hemorrhage, Assessment, and Management During Transport . Advances in Neonatal Care , 2010, 10, (6)

Cranial Hematomas

Reid, Subgaleal Hemorrhage, Neonatal Network, 26(4); 2007

Risk Factors for SGH Instrumental & multiple methods used- risk greatest 10 X ↑ with the use of forceps or vacuum 91% of SGH had instrumental delivery Vacuum extraction- in ~49% of all SGH Incorrect “flexion point” Multiple “pop-offs” (dislodgment of the suction cup) applications > 10 mins increased number of pulls incorrect manipulation of the vacuum-assisted device Incorrect traction-descent of only the scalp & not of the infant’s entire head Can also occur spontaneously- 1: 2500 SVD

Inadequate birth canal adaption Risk Factors for SGH Rigid birth canal Primiparus Pelvic malformations Inadequate birth canal adaption Breech presentation Precipitous delivery Large baby Macrosomia Cephalopelvic disproportion Primiparous- increased resistance of heavy peri- neal muscles stretching the scalp and causing emissary veins to tear

Abnormal presentation Prematurity Maternal exhaustion Risk Factors for SGH Abnormal presentation Face, brow, transverse, etc Prematurity Maternal exhaustion Prolonged 2nd stage of labor (~50% SGH) Post-maturity Neonatal coagulopathy- cause controversial Neonatal coagulopathy may play a significant role in subgaleal hemorrhages, but its association as a cause is con- troversial. Researchers are uncertain as to whether the coag- ulopathy problem exists before the subgaleal hemorrhage or afterward Vitamin k, factor VIII (hemophilia A), and factor IX (hemophilia B) defi ciencies have all been associ- ated with subgaleal hemorrhages. Male infants are also at higher risk than females, possibly because of their increased incidence of bleeding disorders

Reid, Subgaleal Hemorrhage, Neonatal Network, 26(4); 2007

Vacuum Assisted Birth Use of vacuum-assisted birth devices increased 1980 Forceps: 17.7 /100 vaginal births Vacuum extraction: < 1 /100 vaginal births 2000 Forceps: 4/100 vaginal births Vacuum extraction: 8.4/ 100 vaginal births

Vacuum Assisted Birth 1994 to 1998: FDA reports of 12 deaths & 9 serious injuries resulting from vacuum-assisted delivery Concern: 5X increase over preceding 11 years 1998- FDA: issued a health advisory - caution when using vacuum-assisted devices- awareness of the life- threatening complications associated with use Concern: HCP responsible for caring for infants were not being alerted when a vacuum device had been used & therefore did not monitor for signs and symptoms of a SGH 5 Events/year- small

Clinical Features of SGH Instrument indentation or abrasion Caput (± cephalohematoma) Increasing HC : by 1cm with each 40ml blood deposited Hallmark: presence of a fluctuating mass that straddles cranial sutures & fontanels, may shift with movement Swelling most pronounced in occipital & temporal area (displacement of ears) Expansion of the swelling may occur minutes to hours or even days after delivery (30mins to 30hrs) 5 Events/year- small

Clinical Features of SGH Signs of hypovolemia/ anemia: ↑ HR, ↓ BP, Pallor, respiratory distress Signs of neurological impairment: hypotonia, seizures Discoloration & ecchymoses of the scalp, ears & eyes Signs of DIC: petechiae, bleeding from puncture sites 5 Events/year- small

Subgaleal Hemorrhage - Dr Swinton

Subgaleal Hemorrhage Fletcher, p.185

Note the elongated head with massive subgaleal hemorrhage Note the elongated head with massive subgaleal hemorrhage. The blood collection in subgaleal space was gravity dependent. Elevation of the right ear is also noticeable Houchang D. Modanlou, M.D. Division of Neonatology, Department of Pediatrics, University of California https://ispub.com/IJPN/5/2/7678#

DIC in SGH Reid, Subgaleal Hemorrhage, Neonatal Network, 26(4); 2007

Differential Diagnosis of Birth Related Extracranial Hematomss Occur during delivery Result from edema and/or bleeding into various locations within the scalp & skull Three main types Caput succedaneum Cephalohematoma Subgaleal hemorrhage

Differential Diagnosis of Birth Related Extracranial Hematoms Reid, Subgaleal Hemorrhage, Neonatal Network, 26(4); 2007

Caput Succedaneum Edematous swelling of the scalp above the periosteum occasionally hemorrhagic Present at birth Caused by: prolonged engagement of the fetal head in the birth canal vacuum extraction Extends across the suture lines Usually resolves within a few days and requires no treatment

Caput Succedaneum

Caput Succedaneum Pitting edema is a hallmark feature http://newborns.stanford.edu/PhotoGallery/Caput2.html

Cephalohematoma Localized subperiosteal collection of blood 0.2 – 2.5% of live births Incidence much higher in forceps & vacuum deliveries Caused by rupture of blood vessels that traverse from the skull to the periosteum Does NOT cross suture lines in the skull Most commonly unilateral & over the parietal bones

Cephalohematoma

Cephalohematoma http://newborns.stanford.edu/PhotoGallery/Cephalohematoma1.html

Risk Factors for SGH Instrumental & multiple methods used- risk greatest 10 X ↑ with the use of forceps or vacuum 91% of SGH had instrumental delivery Vacuum extraction- in ~49% of all SGH Incorrect “flexion point” Multiple “pop-offs” (dislodgment of the suction cup) applications > 10 mins increased number of pulls incorrect manipulation of the vacuum-assisted device Incorrect traction-descent of only the scalp & not of the infant’s entire head Can also occur spontaneously- 1: 2500 SVD

Inadequate birth canal adaption Risk Factors for SGH Rigid birth canal Primiparus Pelvic malformations Inadequate birth canal adaption Breech presentation Precipitous delivery Large baby Macrosomia Cephalopelvic disproportion Primiparous- increased resistance of heavy peri- neal muscles stretching the scalp and causing emissary veins to tear

Abnormal presentation Prematurity Maternal exhaustion Risk Factors for SGH Abnormal presentation Face, brow, transverse, etc Prematurity Maternal exhaustion Prolonged 2nd stage of labor (~50% SGH) Post-maturity Neonatal coagulopathy- cause controversial Neonatal coagulopathy may play a significant role in subgaleal hemorrhages, but its association as a cause is con- troversial. Researchers are uncertain as to whether the coag- ulopathy problem exists before the subgaleal hemorrhage or afterward Vitamin k, factor VIII (hemophilia A), and factor IX (hemophilia B) defi ciencies have all been associ- ated with subgaleal hemorrhages. Male infants are also at higher risk than females, possibly because of their increased incidence of bleeding disorders

Risk Factors for SGH Reid, Subgaleal Hemorrhage, Neonatal Network, 26(4); 2007

Vacuum Assisted Birth Use of vacuum-assisted birth devices increased 1980 Forceps: 17.7 /100 vaginal births Vacuum extraction: < 1 /100 vaginal births 2000 Forceps: 4/100 vaginal births Vacuum extraction: 8.4/ 100 vaginal births

Vacuum Assisted Birth 1994 to 1998: FDA reports of 12 deaths & 9 serious injuries resulting from vacuum-assisted delivery Concern: 5X increase over preceding 11 years 1998- FDA: issued a health advisory - caution when using vacuum-assisted devices- awareness of the life- threatening complications associated with use Concern: HCP responsible for caring for infants were not being alerted when a vacuum device had been used & therefore did not monitor for signs and symptoms of a SGH 5 Events/year- small

Case Initial Hgb 12 at ~1hr of life,  9.7 at ~2.5hrs of ife Received 30mls/kg of PRBC transfusion Initial Pl 115, decreased to 91K at ~2.5hrs of life During transport infant continued with given full resuscitation requiring chest compressions, epinephrine On admission: HR<60, resuscitation continued, CBG: pH 6.39, BD - 39, oozing from puncture sites 1.5hrs later: once Dad arrived care withdrawn Summary: Term infant with hx of complicated delivery, developed severe subgaleal hge with severe anemia, acidosis, hypotension, clinically DIC & respiratory failure

Management of SGH Anticipation- surveillance mechanism Acute: medical emergency volume replacement Early transfer to Level 4 Investigations: Lab, Imaging Management of Complications: DIC, HIE, Acidosis, Hyperbilirubinemia

Neonatal Surveillance Regimen for Infants born by Vacuum extractions Level 1 Neonatal Surveillance Minimum surveillance regimen for all infants delivered by instrumental delivery Baseline set of post-delivery observations including activity, color, HR, RR at 1 hr of life Hats & bonnets should be avoided Concerns regarding neonatal behavior (poor feeding, poor activity, pallor)institution of ‘Level 2’ surveillance Give Vitamin K

Neonatal Surveillance Regimen for Infants born by Vacuum extractions Level 2 Neonatal Surveillance Indication: ≥ 1 of the following: Total vacuum extraction time > 20 minutes and/or > 3 pulls and/or > 2 cup detachments 5 minute Apgar score < 7 At clinician request (e.g. if the delivery was felt to have been otherwise ‘difficult’ or the cup placement was found to be paramedian or non-flexing) Level 1 neonatal surveillance observations are causing concern (such as diffuse boggy head swelling)

Neonatal Surveillance Regimen for Infants born by Vacuum extractions Level 2 Neonatal Surveillance If level 2 surveillance established at delivery, cord blood should be taken for assessment of: Acid base status (cord pH and/or lactate levels) Do CBC- Hgb & Pl Formal neonatal observations for SGH should continue for at least the first 12 hours of life Monitor vital sign, activity, color, review head size, shape & nature of swelling hourly for the first 2 hours of life, & then 2 hourly for a further 6 hours. (CRM & Pulse oximeter preferred if available)

Neonatal Surveillance Regimen for Infants born by Vacuum extractions Level 3 Neonatal Surveillance Indications Where there is a clinical suspicion of SGH immediately following delivery Where abnormalities are noted on Level 2 surveillance • The infant should be reviewed by a pediatrician -Admit to nursery - Institution of resuscitation (if necessary) & further laboratory assessment including HCT & coagulation profile - Transfer to Level 4 NICU

Management of Subgaleal Hemorrhage Symptomatic SGH is a medical emergency with a high mortality Immediate discussion with neonatal team recommended Timely Dx & appropriate management: essential for improved outcome

Management of Subgaleal Hemorrhage Stabilization not delayed by attempts to confirm the Dx with imaging Aggressive resuscitation – mainstay of management restore circulating blood volume provide circulatory support correct acidosis correct coagulopathy Head wrapping- difficult to perform & not of benefit Frequent re-evaluation of hemodynamic stability & response to blood & blood products is necessary

Severity of SGH Kilani et al

Complications & Mortality Kilani et al

Subgaleal Hemorrhage

Subgaleal Hemorrhage http://www.tmj.ro/article.php?art=8373984753124426

Subgaleal Hemorrhage

Case A Autopsy Extensive subcutaneous and subgaleal hematoma (350 ml), crossing midline and covering the entire cranial vault. Cephalic hematoma - (15 x 12 x 3 cm): 250 cc organized/clotted blood and 100 cc non-clotted blood Confluent petechial hemorrhages on the inner dural surface Brain: consistent with HIE

Summary Symptomatic SGH is a medical emergency with a high mortality Prevention – hospital/OB integrated guidelines for vacuum Patient selection criteria Appropriate technique Early Diagnosis – Anticipate Identification of at-risk patients- instrumentation deliveries Develop a surveillance regimen • Treatment once Dx clinically suspected Prompt evaluation - Resuscitation & supportive treatment Appropriate technique - accurate positioning of the cup, application of traction and recognising when to abandon the procedure in favour of another mode of delivery

References Davis DJ. Neonatal subgaleal hemorrhage: diagnosis and management. CMAJ. 2001 May 15;164(10):1452-3. Gebremariam A. Subgaleal Haemorrhage: risk factors and neurological and developmental outcome in survivors. Ann Trop Paediatr. 1999 Mar; 19(1):45-50 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. McKee-Garrett M. Birth Injuries. UpToDate. Revised June 15, 2009. Rosenberg A. Traumatic Birth Injury. NeoReviews 2003;4;270. http://newborns.stanford.edu/PhotoGallery/ Reid, J. Subgaleal Hemorrhage, Neonatal Network, 2007, 26(4) RANZCOG College Statement: C-Obs 28; Current: July 2012 Schierholz, E, Walker, SR, Responding to Traumatic Birth- Subgaleal Hemorrhage, Assessment, and Management During Transport . Advances in Neonatal Care , 2010, 10, (6)

Acknowledgment Dr Cameron Swinton

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