Subgaleal Haemorrhage

Subgaleal haemorrhage is bleeding into the potential space between the epicranial aponeurosis (galea) and the periosteum of the skull. The space is large, extends from the orbital ridges to the nape of the neck and crosses suture lines, so a large volume of blood can accumulate.

It occurs in about 1.5 to 4 in 10 000 live births overall and in about 26 to 45 in 10 000 vacuum assisted births. Mortality is about 12 to 14% in recognised cases, mostly from haemorrhagic shock and coagulopathy.

Each centimetre increase in head circumference can represent about 40 mL of blood, which is a large proportion of the blood volume of a term newborn (about 80 to 90 mL/kg).

Pathophysiology.

Traction or compression during vacuum or forceps delivery ruptures emissary veins that cross the subgaleal space. Bleeding is not limited by sutures, so it spreads across the whole scalp.

Blood loss causes hypovolaemic shock, anaemia, metabolic acidosis and consumption coagulopathy. Later breakdown of the blood causes severe hyperbilirubinaemia.

• Boggy, fluctuant scalp swelling that crosses suture lines, shifts with head position and may pit on pressure. It often becomes obvious several hours after birth.
• Ears displaced forward and outward, periorbital swelling, forehead and neck oedema and increasing head circumference.
• Tachycardia, pallor, hypotension, poor perfusion, lethargy and falling haemoglobin.

Red flags.

• Swelling that spreads after vacuum delivery, with pallor or tachycardia.
• Shock with coagulopathy and falling haemoglobin.
• Family history of a bleeding disorder or no vitamin K given.

• Clinical diagnosis. Measure and record occipitofrontal circumference at the time of diagnosis and every 1 to 2 hours in the first 24 hours.
• Haemoglobin, haematocrit, platelets, prothrombin time, activated partial thromboplastin time and fibrinogen, group and cross-match, blood gas and lactate.
• Cranial ultrasound or CT if neurological signs are present, to exclude intracranial haemorrhage or skull fracture.

Differential diagnosis. Caput succedaneum (superficial to the periosteum, crosses sutures, resolves in 48 hours), cephalohaematoma (does not cross sutures), intracranial haemorrhage and encephalocele.

Resuscitation.

• Establish IV access, preferably two lines. Give 0.9% sodium chloride 10 mL/kg IV while blood is prepared.
• Transfuse group O RhD-negative or cross-matched red cells 10 to 20 mL/kg for shock or haemoglobin loss.
• Correct coagulopathy with fresh frozen plasma 10 to 15 mL/kg, cryoprecipitate 5 to 10 mL/kg when fibrinogen is under 1.0 g/L, and platelets 10 to 15 mL/kg when under 50 x 10^9/L. Give vitamin K 1 mg IM or IV if not already given.
• Use inotropes for persistent hypotension (dopamine 5 to 10 micrograms/kg/min).
• Do not incise or aspirate the swelling because of the risk of infection and further bleeding.

Ongoing care.

• Monitor heart rate, blood pressure, haemoglobin every 4 to 6 hours initially, glucose, calcium (which falls with transfusion) and bilirubin.
• Phototherapy by the gestation specific and age specific chart. Hyperbilirubinaemia can be severe and delayed to days 3 to 5.

Monitoring. Observe for at least 72 hours in a neonatal unit, and longer if still evolving.

Referral and escalation. Early neonatal intensive care referral for any suspected subgaleal haemorrhage after instrumental delivery. Review bleeding disorders if coagulopathy persists.

Special groups. Infants of mothers on anticoagulants or with a family history of haemophilia or platelet disorders need coagulation testing and caution with instrumental delivery.