Subgaleal Hemorrhage in Newborns: The Dangerous bleed you can’t miss!!

During our careers we are definitely going to see a few babies with a sub-galenal hemorrhage and it's going to be super important that we recognize this type of head bleed and realize that it's not a catheter or a cephalohematoma so that we can make an early diagnosis and treat aggressively which really may end up being life-saving. I'm Dr. Tala a board-certified neonatologist and I'm wearing red so if you get nothing else out of this you'll remember This topic was requested by our members so please consider joining us if you want that sort of power. So today we are going to cover 1. What a sub-galenal hemorrhage is 2. The risk factors 3. How do we diagnose a sub-galenal hemorrhage 4. The management and 5. The prognosis Let's start with 1. What is a sub-galenal hemorrhage? Well it is a type of extracranial bleed so outside the skull that can occur in neonate often as a result of instrumentation at the time of delivery so forceps or a vacuum. The incidence of sub-galenal hemorrhages is estimated to be between 1.5 and 70 per 10,000 live births which obviously is a huge spectrum and this variation is thought to be because some of the milder cases of the sub-galenal bleeds are not necessarily reported. It is more common in males and this isn't just because males are generally a little bit bigger. For some reason males have an increased predisposition to get a sub-galenal bleed. What differs sub-galenal hemorrhages from CAPIT or cephalohematomas is the space where the fluid or in this case the blood is accumulated. Here the blood builds up in the connective tissue space between the periosteum of the skull and the galea aponeurotica. Words that I've really never said out loud. What you really have to know about this space is that it's absolutely massive and it's got no boundaries. It's not like a cephalohematoma which is always compartmentalized onto like a skull plate. So remember cephalohematomas don't cross suture lines whereas a sub-galenal bleed has no boundaries to it. So the space is absolutely enormous where the blood can accumulate. So a baby could lose massive amounts of blood into this space. In fact it's been estimated that it can fill up to 300 milliliters of blood. A baby can lose about 80 percent of its blood volume within three hours of birth. So obviously go into shock and it can be life-threatening immediately. Now we've talked about why they're absolutely terrifying let's talk about two the risk factors for a sub-galenal bleed. Two, as we've already discussed and as you would expect having any instrumentation at the time of birth is going to increase the risk of a sub-galenal bleed. It also increases the risk of a cephalohematoma as well as a catheter. So when we say instrumentation we mean either forceps delivery or a vacuum delivery. And this could be during a vaginal delivery or vacuums are sometimes used during C-sections as well. For a vacuum delivery the risk goes up even more if the cup was detached at least once. And then logically if you're trying forceps after a failed vacuum attempt then obviously the risk goes up a lot. A longer second stage of labor has also been associated with sub-galenal bleeds. So actually some researchers have suggested that maybe not actually the instrumentation where that's increasing the risk of the baby getting the sub-galenal bleed but rather the long second stage of labor that's kind of forcing people to actually do the instrumentation. If a baby does have a sub-galenal bleed and you look back and it was a very run-of-the-mill delivery then it is possible that the baby has an underlying coagulation defect. For example baby could have hemophilia or some sort of bad platelet dysfunction or thrombocytopenia. So logically anything that worsens the baby's ability to clot blood so sepsis or just HIE then also these babies are going to be at increased risk of getting a sub-galenal hemorrhage. Having said that all babies have an immature clotting system. They all have vitamin K deficiency which is why it's so important that we give vitamin K a topic for another day. So it could just be this underlying slight coagulation issues with a very mild birth trauma that could trigger a sub-galenal bleed. The trauma will cause tearing or injury to the fragile veins in the scalp. So the combination of the tearing of those fragile veins bleeding into a space that literally has no boundaries is going to end up with this massive amount of blood loss. Three, diagnosis. Basically this diagnosis is made clinically which means that you actually have to examine the baby serially and again if you're not thinking about this diagnosis you will miss it. So again I'm going to emphasize the importance of always thinking about this whenever you see any sort of swelling in the baby's scalp shortly after birth. Any baby that's considered high risk so maybe the mother had a prolonged second stage of labor and then a vacuum was used and there were a couple of pop-ups then that baby should be monitored carefully after delivery and then quite intermittently for the first few hours after birth. If there is any concern that this baby may have a sub-galenal hemorrhage then the baby should probably be moved to an intensive care unit or at least to a unit where they can be monitored very closely. On exam you are going to feel a soft fluctuant mass that crosses suture lines. So at the beginning it may feel just like a caput. If it crosses suture lines then it's not a cephalohematoma. Remember cephalohematomas do not cross suture lines but right after birth it's difficult to tell if it's a caput or if it is a sub-galenal bleed. A caput is at its largest immediately after birth and then it kind of gets smaller within a few hours whereas like we said a sub-galenal hemorrhage is just going to carry on bleeding and bleeding into that space. So you can end up with that mass just spreading all over the scalp and then down the neck to the point that the ears start getting pushed forward. It can go down into the eyelids as well. So you just get this swelling absolutely everywhere. Obviously very different from a caput. Just as an aside this normally happens within a few hours after birth. If you're noticing a sub-galenal hemorrhage like a few days after birth then this is a lot more likely to be associated with a coagulation defect. Most of the time the diagnosis is made clinically but sometimes we also want imaging to see if there's any other issues associated with a sub-galenal hemorrhage. So for example we'd want to see if there's been a skull fracture or an intracranial bleed or some cerebral edema. A head ultrasound is the imaging of choice. It's quick, it's at bedside, you don't have to move the baby anywhere and you'll be able to see if there are any obvious other issues going on. The argument is always made that a CT scan is much better to see if there is any other bleed that a neurosurgeon needs to do something about. But then you can make the argument that if the bleed is bad enough that the neurosurgeon is going to do something about it you're going to pick it up on a cranial ultrasound. Some institutions will just do serial cranial ultrasounds. Also remember that if you are writing for it remember to ask specifically that you also do want the soft tissue views so they get as good a look as possible at the kind of extracranial area as well. Obviously the most sensitive and specific brain imaging is an MRI and that's going to give you a lot of detail about what else may be going in the brain. Maybe you've got white matter injury. But MRIs can take a pretty long time and so if anybody feels that extra imaging is needed often these babies will get a CT scan which is very good at delineating the bleed. Unfortunately it is associated with radiation but the babies can get in and out of there very quickly which is critical when you're worried about the stability of the baby. Generally if neurosurgery is involved for other associated bleeds not for a subgala hemorrhage then they will want a CT scan. But in a nutshell the diagnosis of the subgala hemorrhage is made clinically. You may want to get imaging start with an ultrasound and then if you're worried about anything else going on that might be associated with a subgala bleed then you can get a CT scan or an MRI. Four, management. Like we said a big part of taking care of babies with a subgala bleed is recognizing which babies are at high risk of getting a subgala hemorrhage and acting immediately and observing these babies closely. There have been suggestions in literature on how to prognosticate infants with a subgala hemorrhage. So for example how fast is the head circumference or the OFC is increasing? Or how much blood products has the baby needed? Or is there end organ damage from how much blood loss the baby has? Obviously the faster the head circumference is growing the more blood the baby needs the more end organ damage there is the higher the stage and the worse the subgala hemorrhage is. We don't really use these clinically like I don't find out this is a stage two subgala hemorrhage but also realize that some are a lot worse than others. What do you do if you suspect a baby has a subgala bleed? Well like I keep saying the most important thing is actually serially examining the baby looking at the baby's head looking to see where that swelling is going and then we also routinely measure the head circumference as well and so in the first few hours of life we should be getting the OFC or the head circumference about every two hours. Obviously if the baby's head circumference is increasing by one two or even three centimeters then this is significant of increased swelling and more blood loss into that space. Initial lab investigations should include a CBC, check that baseline hematocrit, check to see what the platelets are. Do we actually have to give platelets? If we have an active bleed you're going to have a pretty low threshold to actually give platelets. Also it's recommended that you get a set of lights including LFTs, see just the baseline or whether we've already got end organ damage to the liver as well as check the creatinine, make sure that there is enough perfusion to the kidneys. Obviously if we're worried about the baby bleeding out then we're worried about hyperperfusion and hypertension so we want a good way of being able to measure the baby's blood pressure so think about central axis putting in a UAC so that we know exactly what's going on with the blood pressure. Also if we are going to have to give blood products then make sure that we have good access for that like at least a nice big IV sometimes we even put blood products through the central catheters so just be very aware that these babies really do need good access just so that we can constantly check their levels as well as we can give them blood if needed. A big part of management is just watching for anemia and hypovolemia and just staying on top of it so like I said constantly checking the lab and giving the blood products that's needed. If the baby is becoming hypertensive then get an ultrasound of the heart or an echo and see how much blood there is actually filling the ventricles. If there is kind of okay blood and the baby is hypertensive then maybe the baby would benefit from giving a vasopressor to actually kind of squeeze the blood vessels to increase that blood pressure. Let's talk more about the blood products. Obviously it's whole blood that's oozing into that connective tissue space it's not just the packed red blood cells. It's been estimated that for every one centimeter increase in the OFC or one centimeter larger head circumference a baby has lost approximately 40 mls of blood. I mean crazy. Obviously if you're giving any blood then you should also be checking the platelets the PT, PTT and fibrinogen to see if you do need to give platelets or cryo or FFP and obviously because the baby by definition is bleeding you're going to have a very low threshold to give all of these if any of them are slightly out of whack and a reminder if this baby had a really smooth delivery but looks like it's got a subgala hemorrhage then you should definitely be checking all these lab values really early and if you can't remember when you give FFP or cryo then go back and watch one of our previous videos on coagulation defects. I shouldn't have to say this but I will if you suspect that a baby has any bleed and they didn't receive vitamin K then make sure that you give that baby vitamin K and another thing that you could use is recombinant factor 7. At some point it was suggested that putting compressive bandages around babies with subgala hemorrhages may try to kind of stop some of the bleeding with a kind of tamponade effect but if anything this may make it worse because it kind of prevents venous drainage back into the baby so we do not use compressive bandages on babies really you're just trying to support the baby from a volume status. Remember that because the baby may lose a lot of blood they may be at risk for other issues for example because of cerebral hyperperfusion babies may be increased risk for having a seizure so you may have to put an EEG on these babies just to make sure that they are getting enough blood to their brain and they're not having seizures. There is no neurosurgical option for getting rid of this blood so neurosurgery can't do an intervention and like drain this blood from that space in fact it might even make it worse because it will encourage more blood to go in however when there is an associated bleed somewhere else there may be something that neurosurgery has to do whether it's a subdural or an epidural bleed again you would probably see this bleed on an ultrasound if it's big enough for a neurosurgeon to want to do something about it going back to the fact that normally a cranial ultrasound is enough for a baby that has a subgaleal hematoma so again you are supporting the baby constantly monitoring the baby checking the blood pressure checking labs and replacing with blood products as needed hoping that eventually this bleeding will stop and five the prognosis generally the outcomes for babies that had subgaleal hematomas that ended up surviving are very good however it does put them at increased risk for morbidities and obviously just having a subgaleal hemorrhage greatly increases the risk of mortality like we keep saying major complications of subgaleal hemorrhages are hypovolemia profound anemia going into DIC renal failure hepatic failure hyperperfusion especially cerebral hyperperfusion ending up with seizures subgaleal hemorrhages have been associated with seizures intracranial bleeds as well as hypoxic ischemic encephalopathy realize these could be all secondary to a severe subgaleal hemorrhage or whatever caused the increased risk for the sh in the first place also ended up resulting in hie or the intracranial some of these babies may have such bad hie that they do qualify for cooling or hypothermic therapy obviously there's the concern that by just cooling babies it makes their coagulation even worse however it is generally considered that even if a baby does have an sh that is not a good enough reason to not call the baby for their neurological status it is possible to get a secondary infection of that bleed especially if there's like an open scalp wound so from the forceps or whatever else so if there's any concern that there could be infection obviously these babies should be started on broad spectrum antibiotics obviously mortality can be a complication of a subgaleal hemorrhage and older studies quote a mortality rate of about 20 percent more recent studies have lower mortality rates between 2.8 to 14 percent and the reason that this mortality rate seems to be going down is probably because they're diagnosed earlier and people are treating more aggressively unfortunately though in cases of severe subgaleal hemorrhages the mortality rate as well as the neurodevelopmental impairment in survivors is still very high in fact studies have suggested that survivors of severe subgaleal hemorrhages have an increased risk of neurodevelopmental impairment at two years in fact about a third of them can have either cerebral palsy deafness or a seizure disorder at two years of life in a nutshell be aware of this diagnosis and follow these babies carefully if you feel like that swelling is increasing especially if the ears kind of start poking out you can't see my ears if they start poking out take this very seriously start getting the labs make sure that you're following the blood pressure start checking the ofcs routinely and then aggressively resuscitate these babies it can be life-saving okay i hope that you learned something if you got this far then please like this video and if you're at all interested in neonatal education then please subscribe to our thank you so much for being here