Monday, October 16, 2017

Swelling over newborn's scalp: What can it be?


The swelling over the scalp in newborn can be of benign significant to rapidly fatal and emergency condition. Before learning about the differential diagnosis of scalp swelling after birth, we must understand the anatomy of Scalp.
Here we will not discuss congenital lesions like Dermoid cyst, Encephaloceles and Hemangiomas as such.


Scalp Anatomy:

The layers of scalp include- Skin, Connective tissue, Aponeurotic layer ( Galea aponeurotica), Loose connective tissue ( Subgaleal ) and Periosteum . ( SCALP )


Mainly 3 swellings are important in newborn period

1. Caput succedaneum: Most commonly encountered in newborn period.  It occurs as a result of accumulation of serosangineous fluid in subcutaneous tissue layer, located over the presenting part of fetus during delivery.  The swelling is fluctuant , boggy and crosses suture lines. There is minimal blood loss and usually swelling resolved by 72 hours without residual effects. Complications are less likely.

2.Cephalhematoma : There is accumulation of blood between periosteum and skull ( subperiosteal bleed). The swelling usually is limited by suture lines and are seen over parietal and occipital bones. The swelling is initially firm and becomes fluctuant after 48 hours. Blood loss is rarely severe but severe cases have been documented. It can be present bilaterally. Underlying skull fracture might be palpable. Xray can demonstrate it if fracture is suspected. The swelling takes 2 weeks to 3 months to resolve.
Complications can be Hyperbilirubinemia and Infection.
Avoid massaging or aspiration with needle.



3. Subgaleal bleed: The most dreaded diagnosis.
 The subgaleal space can accomodate entire volume of blood of a neonate, so bleeding to exsanguiation is a possibility. Rupture of an emissary vein may result in subtle to massive hemorrhage into the subgaleal space. 
Crosses suture lines and may entend to nape of neck and eyes. Ecchymosis around the eyes can be seen. Swelling is boggy ( firm to fluctuant ) and dependent. Usually resolves in 2-3 weeks. 
Subgaleal bleed has high morbidity and mortality.
Blood loss may lead to severe anemia, hypovolemic shock and death.


Risk factors are:
Assisted deliveries ( Vacuum, forceps ), Difficult deliveries, Congenital coagulation disorders.

Guidelines for monitoring:
All difficult or assisted deliveries need to be notified to Pediatrician, in responsibility of Obstetrician.
Observe babies for atleast 8 hours even when APGAR is normal.
Assess vital signs hourly, scalp examination, head circumference and swelling.
Assess neurological status, change in consiousness.
Baseline Hb, PCV and platelet may be needed, if SG bleed is suspected, repeat every 4 to 8 hours.

If Subgaleal bleed is seen,
Send PT, aPTT and fibrinogen.
Skull Xray to rule out fractures.
Imaging may be needed- CT, MRI

Management:
Blood transfusion
Blood products
Inotropes.

Suggested reading : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC81073/

Therefore, subgaleal bleed being fatal should always be kept in mind, while assessing swelling in newborn born via assisted or difficult deliveries.

Resource:
STABLE course





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