Subgaleal Haemorrhage (SGH)

Last updated 03.11.12

 

Index

 

Definition

-  Bleeding into space between epicranial aponeurosis & periosteum caused by rupture of emissary veins

 

 

Features

-  Large potential space & therefore potential for large volume haemorrhage (250ml+/-)

-  May loose up to 50-75% of blood volume

-  Neonates requiring ICU mortality rate 12-25%

-  0.6/1000 of all births

-  4.6/1000 of vacuum deliveries

 

Causes

-  Rupture of emissary veins & bleeding into potential space between periosteum & epicranial aponeurosis

-  NVB, LUSCS, Instrumental delivery

-  Vacuum delivery most commonly ass w

 

Risk Factors

-  Forceps delivery

-  Vacuum delivery

-  Primiparous

-  5 min APGAR <7

-  Paramedian cup application

-  Failed vacuum extraction

-  Difficult vacuum extraction

-   Excessive traction, number of pulls or multiple cup detachments

 

DDx

-  Caput seccedaneum

-  Serosanguinous extra-aponeurotic collection

-  May extend across midline & over suture lines

-  Ass w Vacuum extraction

-  Not ass w neonatal haemorrhage

-  Cephalohaematoma

-  Bleeding between periosteum & underlying skull

-  Ass w NVB & instrumental delivery

-  Swelling does not cross suture lines

-  Soft fluctuant localised swelling w well defined outline

 

Associated S/S

-  Insidious onset

-  Scalp swelling

-  Generalised, may extend over head & anterior to ears

-  Laxity of scalp at cup application site

-  Pregressively more fluctuant, gravity dependant

-  Crepitus (fluid thrill, flick test)

-  Crossess suture lines

-  Pitting oedema

-  Elvation & displacement of ear lobes, puffiness of eyelids

-  Increased scalp thickness

-  250ml blood potentially only increases thickness by 1cm

-  APGAR <7 at 5 min

-  should consider Dx if no evidence of asphyxia

-  Esp if ass w vacuum delivery

-  Tachyardia

-  Tachypnoea

-  Pallor

-  Hypotension

-  Poor activity

 

Complications

-  Hypovolaemia

-  Shock

-  Anaemia

-  Coagulopathy

 

Ix

-  +/- serial head measurements

-  Vitals

-  If at risk for early detection

-  Ongoing if Dx

-  Tachycardia, tahcypnoea

-  Cord blood

-  pH, lactate: acidosis

-  Haematocrit: anaemia

-  Platelets: thrombocytopaenia

 

Mx

-  Medical emergency

-  Prevention during Vacuum extraction

-  Vacuum extraction contraindications adhered to

-   <36/40

-   Coagulopathies

-  Appropriate cup placement

-  Steady traction w maternal effort

-  Avoid unduly prolonged traction

-  <20min of cup application

-  Vitamin K post delivery

-  Early Detection

-  All babies delivered by instruments baseline obs at 1hr of age

-  Avoid hats & bonnets

-  Observe neonatal behaviour

-  If at risk

-   Cord blood: haematocrit, platelets

-   Cord gas: pH, lactate

-   Obs every 1hr for 2hrs then every 2hrs for 6hrs

-   If suspicion of SGH alert paediatrician

-  Medical Mx

-  D/W Neonatologist

-  Aggressive resuscitation

-   Cannulation

-   IV fluids

-  Correction of coagulopathy & acidosis

-  Neonatal ICU

 

 

 

References

 

RANZCOG College Statement C-Obs 28: Prevention Detection & Management of Subgaleal Haemorrhage in the Newborn, July 2009

Pic: www.aafp.org/afp/2008/1015/p953.html