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

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

3. 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

4. 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

5. 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

6. Subgaleal Hemorrhage (SGH)
A rare but potentially lethal condition
The prevalence at birth of moderate-to-severe SGH is ~ 1.5 per 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

7. 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

8. 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

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

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

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

12. Cranial Hematomas

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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. Subgaleal Hemorrhage
- Dr Swinton

23. Subgaleal Hemorrhage
Fletcher, p.185

24. 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

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

26. 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

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

28. 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

29. Caput Succedaneum

30. Caput Succedaneum
Pitting edema is a hallmark feature

31. 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

32. Cephalohematoma

33. Cephalohematoma

34. 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. 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

36. 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

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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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)

44. 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)

45. 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

46. 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
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

48. Severity of SGH
Kilani et al

49. Complications & Mortality
Kilani et al

50. Subgaleal Hemorrhage

51. Subgaleal Hemorrhage

52. Subgaleal Hemorrhage

53. 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

56. 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

57. References
Davis DJ. Neonatal subgaleal hemorrhage: diagnosis and management. CMAJ May 15;164(10):
Gebremariam A. Subgaleal Haemorrhage: risk factors and neurological and developmental outcome in survivors. Ann Trop Paediatr 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 Jan;23(1):41-8.
McKee-Garrett M. Birth Injuries. UpToDate. Revised June 15, 2009.
Rosenberg A. Traumatic Birth Injury. NeoReviews 2003;4;270.
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)

58. Acknowledgment
Dr Cameron Swinton

59. THANK YOU