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,
– Prolonged labor
– Nulliparity

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

6. • Loose 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, pallor,
hypotonia.
• Pitting edema
• Progressive posterior and lateral spread.
• Periorbital swelling
• Ecchymosis
• Hypovolemic shock
• Multiorgan failure,
• Signs of cerebral irritation

8. • Clinical Manifestations:
• Massive lesions  Extracranial cerebral compression 
Rapid 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, Subgaleal 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:
• Examination of scalp and repeat review at 1 and 4
hours
• Prognosis.
• Around 25% mortality
• Long-term prognosis for survivors good