What is the management of subgaleal neonatal hemorrhage?

Management of Subgaleal Neonatal Hemorrhage

Subgaleal neonatal hemorrhage requires immediate recognition and aggressive management with volume resuscitation, blood product replacement, and correction of coagulopathy to prevent mortality and reduce morbidity.

Clinical Presentation and Recognition

• Fluctuant swelling of the scalp that crosses suture lines and may extend toward the neck
• Progressive head enlargement
• Pallor, lethargy, and signs of hypovolemic shock (tachycardia, hypotension)
• Often associated with vacuum-assisted delivery (incidence 4.6/1000 vacuum deliveries) 1
• Can occur spontaneously, particularly in neonates with bleeding disorders 2

Initial Assessment and Management

Immediate Actions

1. Recognize the emergency - Subgaleal hemorrhage can lead to significant blood loss (up to 260 mL, which may represent >40% of a neonate's blood volume)
2. Establish vascular access - Secure at least two IV lines
3. Laboratory assessment:
   • Complete blood count (CBC)
   • Prothrombin time (PT)
   • Activated partial thromboplastin time (aPTT)
   • Fibrinogen level (Clauss method)
   • Blood type and cross-match 3

Volume Resuscitation

1. Blood transfusion - Early transfusion of packed red blood cells (40 mL/kg) is critical for neonates with significant blood loss 4
2. Maintain hemodynamic stability - Use warmed blood products and fluids 3

Management of Coagulopathy

Disseminated intravascular coagulation (DIC) is a common complication of massive subgaleal hemorrhage that requires aggressive management:

1. Fresh frozen plasma (FFP) - Administer 15 mL/kg to correct coagulopathy 5
2. Platelet transfusion - Target platelet count >75 × 10^9/L during active bleeding 5
3. Cryoprecipitate - Indicated for hypofibrinogenemia with target fibrinogen level >1.5 g/L 5
4. Consider tranexamic acid - May be beneficial in cases with hyperfibrinolysis 3

Monitoring and Supportive Care

1. Frequent vital sign assessment - Every 15-30 minutes during acute phase
2. Serial head circumference measurements - To track progression of hemorrhage
3. Repeat laboratory tests - Every 30-60 minutes during active bleeding 5
4. Active warming - Prevent hypothermia which can worsen coagulopathy 3
5. Correct acidosis - Maintain adequate tissue perfusion 3

Predictors of Poor Prognosis

The following factors are associated with poor outcomes and require more aggressive management 1:

• Hypotension requiring vasopressors
• Seizures
• Severe anemia requiring blood transfusion
• Coagulopathy
• Metabolic acidosis
• Renal impairment
• Skull fractures

Additional Considerations

1. Evaluate for underlying bleeding disorders - Especially in cases without obvious risk factors (e.g., vacuum extraction) 2
2. Neuroimaging - Consider brain imaging to evaluate for associated intracranial hemorrhage
3. Intensive care admission - Required for close monitoring and management of complications

Long-term Follow-up

Neonates who survive subgaleal hemorrhage should be monitored for potential long-term complications:

• Neurodevelopmental outcomes
• Hearing assessment
• Seizure monitoring

Prevention

• Careful use of vacuum extraction during delivery
• Awareness of risk factors (primiparity, prolonged labor, macrosomia)
• Close observation of all neonates delivered by instrumental methods for the first 24-48 hours of life

Subgaleal hemorrhage represents a true neonatal emergency with high morbidity and mortality if not recognized and treated promptly. The key to successful management is early recognition, aggressive volume resuscitation with blood products, and correction of coagulopathy.