Neonatal Subgaleal Hemorrhage

We have discussed the notion that pediatric patients are not aliens, but should be regarded as a special population and we must understand what makes them unique. Neonates, on the other hand, are quite odd! (I am only half joking.) This is why there is an entire category of PedEM Morsels addressing neonatal issues. What is challenging with neonates is that the chief complaint may be related to something completely normal, like a Moro Reflex or it may be a subtle neonatal seizure! That umbilical area that looks “funny” – is it a simple granuloma or horrific omphalitis? Clearly, it is important for us to try to discern between these challenging neonatal issues as the management will vary greatly – from giving reassurance to performing an LP! Another parental concern that may be due to either a relatively minor issue or one of critical concern is scalp swelling. Sure we should consider Skull Fractures, but there is another consideration to ponder in the neonate with scalp swelling. Let’s take a minute to review Neonatal Subgaleal Hemorrhage:

Neonatal Subgaleal Hemorrhage: Basics

  • Neonatal Subgaleal Hemorrhage = acclimation of blood and/or fluid in the potential space between the aponeurosis and the periosteum that occurs during the neonatal period, typically during birth. [Christensen, 2022; Levin, 2019; Lee, 2018]
    • Scalp layers include (from superficial to deep): [Vu, 2004]
      • Skin
      • Connective Tissue
      • Galea Aponeurotica
      • Loose Areolar Tissue
      • Periosteum
    • Disruption of these layers can be due to minor or major trauma. [Vu, 2004]
    • Suggested Mechanism for neonatal subgaleal hemorrhage include: [El-Dib, 2019]
      • Suture diastsis
      • Skull fracture
      • Rupture of emissary veins
  • Primary conditions related to neonatal scalp swelling:
    • Caput Succedaneum
      • Fluid collection between Skin and Galea (ie, the subcutaneous tissue).
      • Typically edema or serosanguinous fluid.
      • Can cross suture lines (because it is above the periosteum).
    • Subgaleal Hematoma
      • Fluid collection between Galea and Periosteum
      • Above the periosteum and can cross suture lines.
    • Cephalohematoma
      • Fluid collection between periosteum and skull
      • Restricted to the sub-periosteal space and does NOT cross suture lines.

Neonatal Subgaleal Hemorrhage: Characteristics

  • Anatomy Matters: [Lee, 2018]
    • The sub-aponeurotic space tends to be very vascular with lots of small emissary veins.
    • In neonates, the subgaleal potential space is large!
      • Can accommodate a large volume – can collect as much as 260 mL of blood (that is a lot for a neonate!).
      • May extend anteriorly to the orbits, laterally to the temporal fascia, and posteriorly to the nuchal ridge.
  • Distinctive features of Neonatal Subgaleal Hemorrhage: [El-Dib, 2019; Lee, 2018]
    • Extends WIDELY and does cross suture lines
      • Unlike cephalohematoma, which often has sharp margins and is located in the parietal of occipital areas.
    • Often boggy and PROGRESSIVE
      • Caput succedaneum can feel similarly boggy and also cross suture lines, but it does not continue to grow after the initial trauma (ie, birth).
    • Can develop DEPENDENT EDEMA.
      • Progressive fluid collection can become pitting and can shift with gravity.
      • Can result in displacement of the ear lobe.
      • Can result in eyelid edema.
      • Can result in edema posteriorly to the nuchal ridge.
  • Neonatal Subgaleal Hemorrhage is associated with: [El-Dib, 2019; Lee, 2018]
    • Skull Fracture
    • Subdural hematoma
    • Hypoxic-Ischemic Encephalopathy (HIE)
    • Hyperbilirubinemia
    • Metabolic acidosis
    • Anemia

Neonatal Subgaleal Hemorrhage: Complications

  • Neonatal Subgaleal Hemorrhage can be a minor problem, but the large potential space can also allow significant blood loss.
  • Severe complications due to Neonatal Subgaleal Hemorrhage are rare, but include: [Christensen, 2022; El-Dib, 2019; Lee, 2018]
    • Hypovolemic Shock
    • Acute anemia
    • Coagulopathy and DIC
    • Death
  • While most neonates with subgaleal hemorrhage will have normal development, some will have lasting neurological conditions: [Lee, 2018]
    • Seizure disorders
    • Neurodevelopmental delay
    • Cerebral Palsy

Neonatal Subgaleal Hemorrhage: Management

  • Early identification and monitoring for significant increase in size and evidence of complications.
  • Some suggestions for management of severe neonatal subgaleal hemorrhage include: [Christensen, 2022]
    • Recombinant Activated Factor VII – Facilitate hemostasis
    • Tranexamic Acid (TXA) – Facilitate thrombus stabilization
    • Low-Titer, Cold-Stored, Type O Whole Blood – counteract hypovolemic shock
    • Darbepoetin – stimulate RBC production
    • Treat Disseminated Intravacular Coagulation (DIC) – Whole Blood transfusion or Massive Transfusion Protocols

Moral of the Morsel:

  • Neonates are tricky! While that is true, staying educated and vigilant will help us sort out when we can give good reassurance and guidance and when we need to do labs and get images!
  • Got Bogginess and Crossing sutures? Ok, well now we need to decide if it is a common Caput Succedaneum or a more concerning Subgaleal Hemorrhage.
  • Check those eyelids, ears, and superior neck. Swelling in these areas is much more concerning!
  • Large potential space in a little person can be a Huge Problem! If estimated Blood Volume of a neonate is ~90ml/kg… then a full-term, 8 lb newborn (3.6 kg) can have 324 mL of blood in circulation. Unfortunately, 260 mL (80% of total blood volume) can collect in the subgaleal space!
References:
  • Christensen TR, Bahr TM, Henry E, Ling CY, Hanton TH, Page JM, Ilstrup SJ, Carr NR, Ohls RK, Christensen RD. Neonatal subgaleal hemorrhage: twenty years of trends in incidence, associations, and outcomes. J Perinatol. 2022 Oct 28. doi: 10.1038/s41372-022-01541-z. Epub ahead of print. PMID: 36307481.
  • Esslami GG, Moienafshar A. Neonatal bilateral adrenal hemorrhage and adrenal insufficiency accompanied by Subgaleal hematoma: a case report with brief review of literature. BMC Pediatr. 2022 May 5;22(1):248. doi: 10.1186/s12887-022-03314-1. PMID: 35513814; PMCID: PMC9069721.
  • Levin G, Mankuta D, Eventov-Friedman S, Ezra Y, Elchalal U, Yagel S, Rottenstreich A. Neonatal subgaleal hemorrhage unrelated to assisted vaginal delivery: clinical course and outcomes. Arch Gynecol Obstet. 2020 Jan;301(1):93-99. doi: 10.1007/s00404-019-05392-6. Epub 2019 Nov 25. PMID: 31768745.
  • El-Dib M, Parziale MP, Johnson L, Benson CB, Grant PE, Robinson J, Volpe JJ, Inder T. Encephalopathy in neonates with subgaleal hemorrhage is a key predictor of outcome. Pediatr Res. 2019 Aug;86(2):234-241. doi: 10.1038/s41390-019-0400-1. Epub 2019 Apr 18. PMID: 30999320.
  • Lee SJ, Kim JK, Kim SJ. The clinical characteristics and prognosis of subgaleal hemorrhage in newborn. Korean J Pediatr. 2018 Dec;61(12):387-391. doi: 10.3345/kjp.2018.06800. Epub 2018 Sep 16. PMID: 30304906; PMCID: PMC6313086.
  • Schierholz E, Walker SR. Responding to traumatic birth: subgaleal hemorrhage, assessment, and management during transport. Adv Neonatal Care. 2014 Oct;14 Suppl 5:S11-5. doi: 10.1097/ANC.0b013e3181fe9a49. PMID: 25136749.
  • Vu TT, Guerrera MF, Hamburger EK, Klein BL. Subgaleal hematoma from hair braiding: case report and literature review. Pediatr Emerg Care. 2004 Dec;20(12):821-3. doi: 10.1097/01.pec.0000148031.99339.b7. PMID: 15572970.

Author

Sean M. Fox
Sean M. Fox
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