©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Regional Neonatal Conference Decision-making for Optimal Care and Outcomes Decision-making

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

Regional Neonatal ConferenceRegional Neonatal Conference Decision-making for Optimal Care and Decision-making for Optimal Care and

OutcomesOutcomes

Jotishna Sharma , MD, MEd Jotishna Sharma , MD, MEd Division of NeonatologyDivision of Neonatology

Subgaleal Hemorrhage Subgaleal Hemorrhage


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

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13

3


ObjectivesObjectives 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


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Case 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


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Case 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


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Subgaleal Hemorrhage (SGH) 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


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Anatomy of SGH & potential consequencesAnatomy 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


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Anatomy of SGH & potential consequencesAnatomy 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 Scalp Anatomy

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


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


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


Cranial Hematomas




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Risk Factors for SGH 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


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Risk Factors for SGH Risk Factors for SGH

Rigid birth canal Primiparus

Pelvic malformations

Inadequate birth canal adaption Breech presentation

Precipitous delivery

Large baby Macrosomia

Cephalopelvic disproportion


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Risk Factors for SGH 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




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Vacuum Assisted BirthVacuum 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


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Vacuum Assisted BirthVacuum 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


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Clinical Features of SGH 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)


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Clinical Features of SGH 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


Subgaleal Hemorrhage

- Dr Swinton


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Subgaleal Hemorrhage Subgaleal Hemorrhage

Fletcher, p.185


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



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Differential Diagnosis of Birth Related Differential Diagnosis of Birth Related Extracranial Hematomss 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 Differential Diagnosis of Birth Related Extracranial Hematoms Extracranial Hematoms



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Caput SuccedaneumCaput 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 SuccedaneumCaput Succedaneum


Caput SuccedaneumCaput Succedaneum

Pitting edema is a hallmark featurehttp://newborns.stanford.edu/PhotoGallery/Caput2.html


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Cephalohematoma 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


Cephalohematoma

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


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Risk Factors for SGH 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


35



Rigid birth canal Primiparus

Pelvic malformations

Inadequate birth canal adaption Breech presentation

Precipitous delivery

Large baby Macrosomia

Cephalopelvic disproportion


36


Risk Factors for SGH 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





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Vacuum Assisted BirthVacuum 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


39


Vacuum Assisted BirthVacuum 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


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CaseCase 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


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Management of SGHManagement 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


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Neonatal Surveillance Regimen for Neonatal Surveillance Regimen for Infants born by Vacuum extractions 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


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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)


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– 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)


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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


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Management of Subgaleal Hemorrhage 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


47


Management of Subgaleal Hemorrhage 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


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Severity of SGHSeverity of SGH

Kilani et al


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Complications & MortalityComplications & Mortality

Kilani et al




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





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Case A 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




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SummarySummary 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


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ReferencesReferences 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)


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Acknowledgment Acknowledgment

Dr Cameron Swinton


THANK YOU

Documents

©2013 Children's Mercy Hospitals and Clinics. All Rights Reserved. 03/13 Regional Neonatal Conference Decision-making for Optimal Care and Outcomes Decision-making