Neonatal Subgaleal Hematoma: Presentation and Outcome-Radiological Findings and Factors Associated with Mortality

ABSTRACT

To describe the presentation and outcome of infants who develop subgaleal hematoma (SGH), we compared perinatal factors, clinical and head imaging findings, and outcome in a cohort (N = 34) of all infants admitted to Saint Louis Children's Hospital neonatal intensive care unit with SGH from January 1991 to June 2003. All except three of the infants admitted with SGH had instrumental deliveries (31 of 34; 91.2%): 21 vacuum, eight vacuum followed by forceps, two forceps). There was also a high frequency of occurrence of associated intracranial hemorrhage (17 of 34; 50%: subarachnoid hemorrhage, n = 4; intraventricular hemorrhage, n = 4; intraparenchymal hemorrhage, n = 4; subdural hemorrhage, n = 11), and skull fracture (six of 34; 19.4%; three of six [50%] of them depressed fractures). There was mortality associated with SGH (four of 34, 11.8%); those who died had significant volume loss with anemia, coagulopathy, and shock requiring large volumes of blood and blood products transfusions. The presence of ICH did not correlate with the severity of SGH or mortality, but the severity of SGH correlates with mortality. Minor neurological abnormalities were noted in only four infants at discharge. In conclusion, SGH is an uncommon type of birth trauma, and is associated with delivery or attempted delivery by instrumentation (vacuum and/or forceps). Severe hypovolemia and coagulopathy, but not intracranial hemorrhage, were the most commonly associated clinical problems with mortality. ICH does not correlate with severity of SGH. A brain computed tomography or magnetic resonance imaging should be considered in evaluating a clinically symptomatic SGH. There is associated mortality in severe cases but short-term outcome in survivors is good.

KEYWORDS

Subgaleal - hematoma - vacuum

REFERENCES

• 1 Plauche W C. Subgaleal haematoma: a complication of instrumental delivery.  JAMA. 1980;  244 1597-1598
• 2 Boo N. Subaponeurotic haemorrhage in Malaysian neonates.  Singapore Med J. 1990;  31 207-210
• 3 Govaert P, Vanhaesebrouck P, De Praeter C et al.. Vacuum extraction, bone injury and neonatal subgaleal bleeding.  Eur J Pediatr. 1992;  151 532-535
• 4 Ng P C, Siu Y K, Lewindon P J. Subaponeurotic haemorrhage in the 1990s: a 3-year surveillance.  Acta Paediatr. 1995;  84 1065-1069
• 5 Chadwick L M, Pemberton P J, Kurinczuk J J. Neonatal subgaleal haematoma: associated risk factors, complications and outcome.  J Paediatr Child Health. 1996;  32 228-232
• 6 Florentino-Pineda I, Ezhuthachan S G, Sineni L G et al.. Subgaleal hemorrhage in the newborn infant associated with silicone elastomer vacuum extractor.  J Perinatol. 1994;  14 95-100
• 7 Smith S A, Jett P L, Jacobson S L et al.. Subgaleal hematoma: the need for increased awareness of risk.  J Fam Pract. 1995;  41 569-574
• 8 Fortune P, Thomas R M. Subaponeurotic haemorrhage: a rare but life-threatening neonatal complication associated with ventouse delivery.  Br J Obstet Gynaecol. 1999;  106 868-870
• 9 Uchil D, Arulkumaran S. Neonatal subgaleal hemorrhage and its relationship to delivery by vacuum extraction.  Obstet Gynecol Surv. 2003;  58 687-693
• 10 Benjamin B, Khan M R. Pattern of external birth trauma in southwestern Saudi Arabia.  J Trauma. 1993;  35 737-741
• 11 Plauche W C. Fetal cranial injuries related to delivery with the Malmström vacuum extractor: review.  Obstet Gynecol. 1979;  53 750-757
• 12 Eliachar E, Bret A J, Bardriaux M et al.. Hematome soucutane cranieu du nouveaux-ne.  Arch Fr Pediatr. 1963;  20 1105-1111
• 13 Gardella C, Taylor M, Benedetti T, Hitti J, Critchlow C. The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes.  Am J Obstet Gynecol. 2001;  185 896-902
• 14 Hall S L. Simultaneous occurrence of intracranial and subgaleal hemorrhages complicating vacuum extraction delivery.  J Perinatol. 1992;  12 185-187
• 15 Vachharajani A, Mathur A. Ultrasound-guided needle aspiration of cranial epidural hematoma in a neonate: treating a rare complication of vacuum extraction.  Am J Perinatol. 2002;  19 401-404
• 16 Sarnat H B, Sarnat M S. Neonatal encephalopathy following fetal distress: a clinical and electroencephalographic study.  Arch Neurol. 1976;  33 696-705
• 17 Levene M I, Sands C, Grindulis H, Moore J R. Comparison of two methods of predicting outcome in perinatal asphyxia.  Lancet. 1986;  1 67-69
• 18 Ruff R J, Osborn A G, Harnsberger H R, Kubal S W. Extracalvarial soft tissues in cranial computed tomography: normal anatomy and pathology.  Invest Radiol. 1985;  20 374-380
• 19 Hopkins R E, Inward C, Chambers T et al.. Sub-aponeurotic fluid collections in infancy.  Clin Radiol. 2002;  57 114-116
• 20 Wen S W, Liu S, Kramer M S et al.. Comparison of maternal and infant outcomes between vacuum extraction and forceps deliveries.  Am J Epidemiol. 2001;  153 103-107
• 21 Office of Surveillance and Biometrics .FDA public health advisory: need for caution when using vacuum assisted delivery devices. Rockville, MD; U.S. Food and Drug Administration May 21, 1998
• 22 The Use of Vacuum Assisted Delivery Devices and Fetal Subgaleal Haemorrhage .Medical device alert 110. Ottawa, Canada; Health Protection Branch February 23, 1999
• 23 Towner D, Castro M A, Eby-Wilkens E et al.. Effect of mode of delivery in nulliparous women on neonatal intracranial injury.  N Engl J Med. 1999;  341 1709-1714
• 24 Kendall N, Woloshin H. Cephalhematoma associated with fracture of the skull.  J Pediatr. 1952;  41 125-132
• 25 Chessells J M, Wigglesworth J S. Coagulation studies in severe birth asphyxia.  Arch Dis Child. 1971;  46 253-256
• 26 Keimowitz R M, Annis B L. Disseminated intravascular coagulation associated with massive brain injury.  J Neurosurg. 1973;  39 178-180