Subgaleal Hemorrhage - Dr Padmesh - Neonatology

Subgaleal hemorrhage in neonates

1. Subgaleal Hemorrhage Dr Padmesh V

2. Collection of blood in space between galea aponeurotica and periosteum .

3. Incidence: 4 per 10,000 in non-instrumented deliveries Up to 64 per 10,000 in vacuum extraction. Etiology : Most common cause: Difficult instrumental vaginal delivery, especially mid-forceps delivery and vacuum extraction .

4. Risk factors: Coagulopathies , Prematurity , Macrosomia , Fetal dystocia, Precipitous labor , Intrapartum hypoxia, Male sex, Cephalopelvic disproportion, P rolonged labor N ulliparity

5. Mechanism of Injury : Vacuum traction P ulls scalp away from stationary bony calvarium Avulses open the subgaleal space Bridging vessels are torn Bleed into subgaleal space .

6. L oose connective tissue of subgaleal space is very expansive extends over entire area of scalp . This space can accommodate the entire neonatal blood volume (>=250 mL in term baby) hypovolemic shock, disseminated intravascular coagulation , multiorgan failure death (25% cases)

7. Clinical Manifestations: Mean time to diagnosis is 1-6 h after birth. Early manifestations: Diffuse swelling of scalp, p allor , hypotonia . Pitting edema Progressive posterior and lateral spread. Periorbital swelling E cchymosis Hypovolemic shock Multiorgan failure, Signs of cerebral irritation

8. Clinical Manifestations: Massive lesions  E xtracranial cerebral compression  Ra pid neurologic decompensation . “Silent presentation”, in which fluctuant mass is not apparent initially. Subgaleal hemorrhage should be considered in a neonate born through vacuum delivery, with shock & falling hematocrit even in the absence of a detectable fluctuant mass . Close monitoring even in infants who are considered stable.

9. Radiographic Manifestations. Xray Skull: To look for fractures CT Scan Differential Diagnosis: Unlike Cephalhematoma , S ubgaleal hemorrhage is more diffusely distributed, has more rapid course, significant anemia , signs of CNS trauma ( hypotonia , lethargy, seizures), frequent lethal outcome.

10. Treatment: Prompt restoration of blood volume with FFP or blood. Recombinant activated factor VII . Use of tranexamic acid reported. Note: Bandaging may increase SGH mass effect and elevate ICP and is not recommended.

11. Treatment: If continued deterioration  neurosurgery as last resort. Bicoronal incision Exposure of subgaleal space . Cauterization of any bleeding points Drain left in the subgaleal space.

12. Screening after vacuum delivery: E xamination of scalp and repeat review at 1 and 4 hours Prognosis . Around 25% mortality Long-term prognosis for survivors good

13. Thank you!