Subgaleal hemorrhage (SGH) is a rare but potentially fatal condition in newborns; however, few studies have reported on this condition. We aimed to identify the clinical characteristics and prognostic factors of SGH.
We retrospectively reviewed the medical records of 20 neonates diagnosed with SGH between January 2000 and June 2017. Enrolled neonates were clinically diagnosed when they had tender fluctuant scalp swelling that crossed the suture lines.
Among 20 neonates with SGH, 12 were boys and 7 were girls; median hospitalization duration was 9.7±6.9 days. Fourteen neonates (70%) were born via vacuum-assisted vaginal delivery, and 4 via vacuum-assisted cesarean section. Of the neonates enrolled, half of them initially showed unstable vital signs, including apnea, desaturation, and cyanosis. Ten neonates had acidosis and 3 had asphyxia (pH<7.0). Intracranial lesions associated with SGH were observed in 15 neonates (75%), including subdural hemorrhage (50%), subarachnoid hemorrhage (15%), intraventricular hemorrhage (5%), cerebral infarct (15%), skull fracture (30%), and cephalohematoma (20%). Twelve neonates (60%) required transfusion, 5 (25%) had seizures, and 3 (15%) died. Eight neonates (40%) had hyperbilirubinemia (mean total bilirubin, 13.1±7.4). The mean follow-up period was 8.4±7.5 months. At follow-up, 10 neonates (58.8%) were healthy with normal development, whereas 7 (41.2%) had neurological deficits.
The morbidity rate was 41.2% due to severe metabolic acidosis. Anemia, hyperbilirubinemia, low Apgar scores, and subdural hemorrhage did not affect the prognosis. The long-term outcomes of neonates with SGH are generally good. Only arterial blood pH was significantly associated with death.
Subgaleal hemorrhage (SGH) is an accumulation of blood in the space between the epicranial aponeurosis and the periosteum, caused by the rupture of the emissary veins [
Meanwhile, cephalhematoma and caput succedaneum can also occur following instrumental delivery. Cephalhematoma is a collection of blood between the skull and its periosteum, and caput succedaneum is an edematous collection of serosanguinous fluid in the subcutaneous layer of the scalp. Cephalhematoma usually involves the parietal or occipital bone, sharply limited by the margins of the bone and does not cross the suture lines [
SGH is a rare and potentially fatal condition in newborns. However, local and international studies on this condition are scarce. Thus, the study aimed to investigate the prognostic factors of SGH by analyzing the clinical characteristics of the disease.
In this single-center retrospective study, we evaluated medical records of 20 neonates with SGH who were admitted to the neonatal intensive care unit of Chonbuk National University Children’s Hospital between January 2000 and June 2017. The medical records were reviewed to obtain the obstetric and neonatal data (i.e., gestational age, birth weight, and mode of delivery, Apgar score, duration of hospitalization, initial impression, and time of diagnosis).
The diagnosis of SGH was made clinically when tender fluctuant scalp swelling that crosses the suture lines exists. The head circumference was measured at the time of hospitalization and then hourly until there was no increase in the neonates’ head circumference. Blood samples were taken from a radial or brachial artery, and capillary blood sampling was performed via heel punctures if arterial blood was difficult to obtain.
Both intracranial and extracranial comorbidities were evaluated using laboratory findings and imaging results during the hospitalization. Hyperbilirubinemia was defined as serum bilirubin level of more than 13 mg/dL. Anemia was defined as serum hemoglobin level<13 g/dL. Metabolic acidosis was defined as serum pH<7.35 and serum bicarbonate (HCO3-)<18 mmol/L. Acute kidney injury was defined as serum creatinine>1.5 mg/dL.
Surviving infants were followed up in the pediatric neurology and neonatal clinics after discharge. The pediatric neurologist completed a neurologic examination of the neonates. Neonates who were suspected to have developmental delay underwent brain magnetic resonance imaging (MRI), electroencephalogram, and language evaluations. The patients were categorized into the following groups according to the results of the examinations: healthy children group included children with normal development and had no diseases, and poor outcome group included children with neurological deficits. The mean follow-up period was 8.4±7.5 months.
Statistical analysis of the results was performed using IBM SPSS Statistics ver. 22.0 (IBM Co., Armonk, NY, USA). All data were expressed as mean±standard deviation. Independent
This study was performed with approval from the Institutional Review Board (IRB) of Chonbuk National University Research Council (CUH 2018-06-027). The requirement for informed consent was exempted by the IRB.
Three patients (15%) died during hospitalization. Fourteen neonates (70%) were delivered via vacuum extraction delivery, 1 (5%) via an emergency cesarean section, 1 (5%) vaginally, and 18 (90%) via vacuum extraction. Vacuum extraction was required during cesarean section in 4 cases (20%). The mean gestational age at birth was 38.9±1.2 weeks. The mean Apgar scores were 6.8±2.4 at 1 minute and 8.3±2.1 at 5 minutes (
Eighteen of the 20 neonates (90%) were transferred from another hospital. The initial presenting symptoms at admission varied, with scalp swelling (20%) being the most common. Half of the patients presented apnea, desaturation, tachypnea, moaning, and cyanosis as the initial symptom (
Comorbid pathology identified by neuroimaging is outlined in
The most common extracranial comorbidities were anemia (60%). Ten neonates (50%) had metabolic acidosis and 3 (15%) had severe asphyxia (pH<7.0). Five neonates (25%) had seizures, 3 (15%) had disseminated intravascular coagulation, 2 (10%) had acute kidney injury, 1 (5%) had brachial plexus injury, and 1 (5%) had hip dislocation (
The mean follow-up period was 8.4±7.5 months. In a clinical follow-up, 2 subgroups were analyzed according to the short-term outcome. Of the 17 neonates who survived, 10 (58.8%) were categorized in the healthy children group, whereas 7 (41.2%) were categorized in the poor outcome group. In the poor outcome group, 1 neonate (5.9%) was diagnosed with spastic cerebral palsy (CP), 2 (11.8%) with spastic CP and epilepsy, 2 (11.8%) with hypotonic CP accompanied by global developmental delay. The patient with brachial plexus injury had an accompanying monoparesis of the left upper limb (
In terms of the time of diagnosis, 10 neonates (58.8%) were diagnosed early at the time of admission, whereas 7 (41.2%) were diagnosed the following day after their admission (
In this retrospective study, we demonstrated that 41.2% of neonates with SGH had comorbidities, including anemia, subdural hematoma, hyperbilirubinemia, and metabolic acidosis. The children who had seizures or disseminated intravascular coagulation showed poor outcomes in the short-term follow-up. The mortality rate was 15%. The mortality cases had the following common characteristics: delivered via vacuum-assisted vaginal delivery and diagnosed with severe SGH. They had severe metabolic acidosis (pH<7.0) in the initial arterial blood gas analysis. All neonates were transferred from other hospitals on the day of birth, with one neonate dying upon arrival and 2 neonates dying within 48 hours after birth.
Swanson et al. [
We also examined the association between the short-term outcomes and the timing of SGH diagnosis. Children who were diagnosed with SGH at the day of admission have shown to have better prognosis than those who were diagnosed the following the day after their admission. In other words, although the symptoms were mild at first, the patients with suspected SGH who underwent repeated examinations and tests early had a good prognosis, whereas those with symptomatic SGH had poor outcomes. The good prognosis is considered to be due to timely and proper treatment following the early diagnosis, which is consistent with the results of other studies [
The factors leading to the poor outcomes of SGH were reported in several studies. Chang et al. [
In this study, half of the cases were accompanied by SDH, but the presence of SDH was not significantly related to the neurologic outcome. Similarly, Kilani and Wetmore [
This study has some limitations. A standardized assessment tool to assess the children’s neurodevelopment status was absent; hence, it is possible that a mere clinical neurological examination is not reliable enough to detect any minor neurologic deficit. The follow-up period varied from each patient and was relatively short duration. It also cannot exclude that the number of patients enrolled in this study is too small to assess the factors affecting the outcome of the SGH. Thus, further studies enrolling larger patient numbers with long-term follow-up is warranted. Moreover, not all neonates underwent the imaging examinations to confirm the diagnosis; only 85% underwent imaging, 35.3% whom only had ultrasonography. Although the imaging study may be helpful in assessing the severity of the disease, it is not necessary for diagnosis. Similar to other studies, the diagnosis was based on clinical features, and ultrasonography or CT was not used to confirm the diagnosis [
In conclusion, SGH initially presents with various symptoms, but if overlooked, it progresses gradually, resulting in serious neurological sequelae or death. Early diagnosis and immediate management are important to improve the outcomes among neonates with SGH. Close monitoring, including hourly recordings of vital signs and head circumference measurements, is required for all infants with unstable vital signs, as well as those who are delivered via vacuum extractions.
No potential conflict of interest relevant to this article was reported.
Initial presenting symptoms in neonates.
Classification of outcomes according to diagnostic timing in the surviving children.
Baseline clinical characteristics of the study population
Variable | Value |
---|---|
Gestational age (wk) | 38.9±1.2 |
Birth weight (kg) | 3.4±0.3 |
Hospital days (day) | 11.4±6.1 |
Apgar score | |
1 Minute | 6.8±2.4 |
5 Minutes | 8.3±2.1 |
Sex, male:female | 12:8 (60:40) |
Transferred from other hospitals | 18 (90) |
Mode of delivery | |
Vaginal delivery | 1 (5) |
Vacuum extractor delivery | 14 (70) |
Emergency cesarean section | 1 (5) |
Vacuum during cesarean section | 4 (20) |
Complete blood count | |
Initial hemoglobin (g/dL) | 13.9±3.8 |
Initial hematocrit (%) | 41.7±11.2 |
Initial platelet count (×103/μL) | 230.7±70.9 |
Arterial blood gas analysis | |
Initial pH | 7.26±0.22 |
Initial HCO3 (mmol/L) | 15.8±4.9 |
Initial pCO2 (mmHg) | 37.8±31.6 |
Initial pO2 (mmHg) | 104.3±74.9 |
Initial lactate (mmol/L) | 8.8±4.9 |
Chemistry | |
Maximum total bilirubin (mg/dL) | 13.1±7.4 |
High sensitive CRP (mg/L) | 1.2±2.0 |
Values are presented as mean±standard deviation or number (%).
CRP, C-reactive protein.
Comorbidities in the neonates
Variable | No. (%) |
---|---|
Imaging modality | |
Brain sonography | 12 (60) |
Brain computed tomography | 5 (25) |
Brain magnetic resonance imaging | 8 (40) |
Intracranial comorbidities | |
Subdural hematoma | 10 (50) |
Intraventricular hemorrhage | 2 (5) |
Cerebral infarction | 3 (15) |
Skull fracture | 5 (25) |
Anemia | 12 (60) |
Hyperbilirubinemia | 8 (40) |
Metabolic acidosis | |
7.25≤pH<7.35 | 4 (20) |
7.10≤pH<7.25 | 2 (10) |
7.0≤pH<7.10 | 1 (5) |
pH<7.0 | 3 (15) |
Seizure | 5 (25) |
Disseminated intravascular coagulation | 3 (15) |
Acute kidney injury | 2 (10) |
Brachial plexus injury | 1 (5) |
Hip dislocation | 1 (5) |
Short-term outcome of surviving children
Variable | Value |
---|---|
Follow-up periods (mo) | 8.4±7.5 |
Healthy with normal development | 10 (58.8) |
Spastic CP | 1 (5.9) |
Spastic CP with epilepsy | 2 (11.8) |
Hypotonic CP with GDD | 2 (11.8) |
Language developmental delay | 1 (5.9) |
Monoparesis | 1 (5.9) |
Values are presented as mean±standard deviation or number (%).
CP, cerebral palsy; GDD, global developmental delay.
Comparisons of clinical factors in 2 subgroups according to short-term outcome
Variable | Healthy children (n=10) | Poor outcome (n=7) | |
---|---|---|---|
Gestational age (wk) | 39.5±0.8 | 38.2±1.4 | 0.035 |
Birth weight (kg) | 3.5±0.3 | 3.2±0.4 | 0.074 |
Hospitalization period (day) | 8.2±2.3 | 15.9±7.1 | 0.029 |
Apgar score | |||
1 Minute | 7.6±2.0 | 6.6±1.9 | 0.298 |
5 Minutes | 9.0±1.4 | 8.3±1.4 | 0.317 |
Hemoglobin (g/dL) | 14.1±4.8 | 13. 7±3.2 | 0.843 |
Platelet (×103/μL) | 242.7±59.9 | 245.1±71.6 | 0.918 |
ABGA pH | 7.37±0.1 | 7.27±0.2 | 0.277 |
Duration of mechanical ventilation use (day) | 0.3±0.9 | 2.9±3.7 | 0.117 |
Presence of SDH | 5 (50.0) | 5 (71.4) | 0.622 |
Diagnosed on admission day | 8 (80.0) | 5 (71.4) | 0.622 |
Values are presented as mean±standard deviation or number (%).
ABGA, arterial blood gas analysis; SDH, subdural hemorrhage.