Dear Colleagues, I would be grateful of any existing protocols or clinical guidelines on the Protocol for the management and early identification of subgaleal haemorrhage following instrumental (vacuum) assisted birth.

Hi! This thread may get some input regarding management of subgaleal hematoma.

http://www.99nicu.org/forum/showthread.php?15779-Septicemia-Subgaleal-Hemorrhage-and-complications

I have unfortunately not come across any protocol or guidelines for management or early identification.

But, we have great respect for suspected subgaleal hematomas and admission for surveillance of clinical status and blood counts are common, when the diagnosis is suspected.

Treatment - if there is any indication of active bleeding, I advocate liberal use of blood products (plasma and erytrocytes, sometimes trombocytes), while waiting for the bleeding to stop.

NICU Guidelines --- Women’s Hospital -HAMAD MEDICAL CORPORATION-DOHA-QATAR

Effective Date; March 1, 2010 Revision Date; March 1, 2012

Subgaleal Hemorrhage Guidelines

Introduction

Subgaleal hemorrhage (SGH) is a collection of blood in the soft tissue space between the galea aponeurotica and the periosteum of skull. This hemorrhage is caused by rupture of the emissary veins, which are connections between the dural sinuses and the scalp veins. This potential space extends forward to the orbital margins, backward to the nuchal ridge and laterally to the temporal fascia, and, in term infants, may hold as much as 260 ml of blood (which is almost equivalent to the baby’s blood volume).

SGH is a rare, potentially lethal condition. It most commonly occurs following a difficult vacuum or forceps-assisted birth. The prevalence of moderate-to-severe SGH is reported as 1.5 per 10,000 births. Once bleeding into this space starts, it can be difficult to control because of subsequent blood loss and a resulting coagulopathy. SGH, therefore, can lead to severe hypovolemia, and up to 25% of babies who require neonatal intensive care for this condition can die.

At Risk Newborns:

1. Forceps and vacuum delivery

2. Vacuum extraction with more than 3 pulls or pop-offs of a vacuum extractor

3. Any failed instrumental delivery

Signs and symptoms of SGH:

The signs may be present at birth or may not become clinically apparent until several hours or up to a few days following delivery.

1. SGH usually presents with nonspecific symptoms such as pallor, grunting (as a result of metabolic acidosis), tachypnea, or hypotonia.

2. Diffuse fluctuating swelling of the head; the swelling is usually diffuse, crosses suture lines, shifts dependently when the infant's head is repositioned and indents easily on palpation. The ears are pushed forward when there is a large amount of fluid present. In some cases the swelling is difficult to distinguish from the edema of the scalp.

3. Increasing HC

4. Evidence of hypovolemic shock (lethargy, pallor, poor perfusion, hypotension, tachycardia, increased respiratory rate, metabolic acidosis, decreased urinary output)

5. Prolonged bleeding

6. Seizures

Diagnosis

Diagnosis of SGH is clinical. The scalp is boggy (feels like a water balloon, fluid is firm to fluctuant with ill defined borders, may have crepitus or waves and shifts dependently when the infant’s head is repositioned). SGH may be misdiagnosed as cephalohematomas or caput succedaneum.

 Cephalhematoma is the collection of blood under the periosteum and does not cross the suture lines. Cephalhematomas are firm masses that will resolve in 2 weeks to 6 months.

 Caput succedaneum is localized scalp edema that is the result of venous congestion from the pressure of the head applied to the dilating cervix. The edema can cross the suture lines. Caput does not increase in size over time and resolves several days after birth.

Feature Caput succedaneum Cephalhematoma Subgaleal hemorrhage

Location At point of contact; can extend across sutures Usually over parietal bones; does not cross sutures Beneath epicranial aponeurosis; may extend to orbits, nape of neck

Characteristic findings Vaguely demarcated; pitting edema that shifts with gravity Distinct margins; initially firm, more fluctuant after

48 h Firm to fluctuant; ill-defined borders; may have crepitus or fluid waves

Timing Maximal size and firmness at birth; resolves in 48-72 h Increases after birth for 12-24 h; resolution over

2-weeks to 6 months Progressive after birth; resolution over 2-3 weeks

Volume of blood Minimal / No bleeding Rarely severe May be massive, especially if there is an associated coagulopathy

Investigations:

1. CBC, hematocrit, when SGH is suspected, hemoglobin measurement should be performed as soon as possible and should be monitored every 4–8 hours.

2. Coagulation screen (INR, PTT, PTT, fibrinogen, d-dimers) every 4-8 hours.

3. CT scan or MRI of the head. MRI scan is the preferred method of imaging

4. Radiographs of the skull can also be useful to identify underlying fractures

Management of SGH

1. The first step in the management of SGH is to screen all at-risk newborns as recognition and supportive care can improve survival and outcome

2. Newborns at risk for SGH:

a. Can remain with their mother as long as their vital signs are normal and the infant is not demonstrating any signs of distress. Those infants should be observed for symptoms for 24-48 hours before discharge.

b. Monitor vital signs at birth, 2, 4 and 6 hours of life, then every 4 hours for all babies after difficult vacuum extractions.

c. Measure HC immediately after birth and then every 4 hours.

3. Newborns with SGH; early recognition of SGH and the institution of supportive care such as blood transfusion, volume support, and coagulation factors in the presence of DIC, may be useful.

a. Admit to IC/NICU

b. Monitor vital signs hourly for the first 4 hours then 2-4 hours depending on the severity of the case.

c. Assess, color, perfusion, pain and appearance of scalp with vital signs

d. Measure HC immediately after birth and then every 4 hours. If an increase in the HC is noted, then measure HC every 2 hours. The HC increase about 1 cm with each 40 ml of blood deposited in the subaponeurotic space.

e. Treat anemia/hypovolemic shock with blood volume replacement.

f. Treat congenital or acquired coagulation problem

g. Interventions to minimize blood loss:

i. Avoid IM injections when possible.

ii. Avoid percutaneous arterial punctures if possible.

iii. Provide prolonged pressure after venipuncture, heel-stick, or arterial stick.

iv. Minimize invasive procedures as much as possible

v. Gentle suction only when needed.

vi. If intubated, do not deep suction.

h. Ensure the availability of 1 unit of cross matched packed RBCs in the blood bank in case transfusion is needed.

i. Pressure wrapping of the head has been advocated by some, but the large subaponeurotic space is difficult to wrap; wrapping might be disadvantageous if cerebral edema is present.

Prognosis:

Prognosis depends on the severity of the hemorrhage; with early recognition and aggressive volume resuscitation full recovery is possible and long-term outlook for survivors is good. The subaponeurotic space may hold as much as 260 ml of blood, therefore can lead to severe hypovolemia and cause death in 20% to 60% of patients. The most important risk factors for death in babies with SGH are:

 Decrease in hematocrit >25% of the baseline value at birth requiring urgent blood transfusion in the first 12 hours.

 Hhypovolemic shock

 DIC

 Association with significant birth asphyxia

 Intracranial hemorrhages are also more frequently associated with SGH (~50% in one study).

References

3. Chadwick LM, Pemberton PJ, Kurinczuk JJ. Neonatal subgaleal hematoma: associated risk factors, Zcomplications and outcome. J Paediatr Child Health. 1996; 32(3):228-32.

4. Kilani RA, Wetmore J. Neonatal subgaleal hematoma: presentation and outcome-- radiological findings and factors associated with mortality. Am J Prinatol. 2006;23(6): 41-8.

5. Hall SL. Simultaneous occurrence of intracranial and subgaleal hemorrhages complicating vacuum extraction delivery. J Perinatol. 1992;12(2):185-7.

6. Davis DJ. Neonatal subgaleal hemorrhage: diagnosis and management. CMAJ. 001; 164(10):1452-3.

7. Ng PC, Siu YK, Lewindon PJ. Subaponeurotic hemorrhage in the 1990s; a 3-year surveillance. Acta Paediatr. 1995; 84(9):1065-9.

There has been report of use of Factor 7 in treating difficult subgaleal hemorrhage

http://www.ima.org.il/imaj/dynamic/web/ArtFromPubmed.asp?year=2009&month=10&page=639

NICU Guidelines --- Women’s Hospital -HAMAD MEDICAL CORPORATION-DOHA-QATAR

Effective Date; March 1, 2010 Revision Date; March 1, 2012

Subgaleal Hemorrhage Guidelines

Thanks for sharing your protocol!

Hi dr Salamah

Thanks a lot for this awesome work ! I think that subgaleal hemorrhage incidence is higher than 1.5 per 10,000 but actually not reported or recognized.. I've seen few of them in the last 2-3 years. Most of those SGH were already "healed" when I was consulted, coz it was already late !! Usually 8-12 hrs after delivery..

Anyway, I have 2 questions reg. Your protocol:

1- what about vitamin K IM injection or po?

2- I didn't see pain management there, I think it's quite painful to have SGH, any comments?

Sincerely yours

Feras Alkhudari

Thanks for your comment;

1-Coagulation screen (INR, PTT, PTT, fibrinogen, d-dimers) every 4-8 hours (2) DIAGNOSIS.

if abnormal vitamin k or FFP will be given. (Treat congenital or acquired coagulation problem)( F MANAGAMENT)

For pain management we have protocol for pain assessment and management for all babies in NICU.

Actually, I was commenting that you mention to avoid IM injections, but what do you do with administering regular prophylactic IM vitamin K?

Regular prophylactic IM vitamin K usualy given in LR shortly after delivery ,subgaleal hrg may diagnosed later,but in acase that you diagnsed subgaleal hrg befor regular V K,should be given IV

there was a nice breif article about that recently

http://www.neonatologytoday.net/newsletters/nt-oct10.pdf

there was a nice breif article about that recently

http://www.neonatologytoday.net/newsletters/nt-oct10.pdf

Thanks for sharing this link!