In a newborn with diffuse, fluctuant scalp swelling after vacuum‑assisted delivery, what are the characteristic findings, diagnosis, and acute management of a subgaleal hematoma?

Subgaleal Hematoma in Newborns

Immediate Recognition

A subgaleal hematoma is a life-threatening neonatal emergency characterized by diffuse, fluctuant scalp swelling that crosses suture lines and can lead to hemorrhagic shock and death in 20-60% of cases if not promptly recognized and treated. 1, 2

Characteristic Clinical Findings

The diagnosis is primarily clinical, with the following key features:

• Diffuse, fluctuant scalp swelling that crosses suture lines and extends from the orbital ridges to the nape of the neck, distinguishing it from benign cephalohematoma which is confined by suture lines 1, 3
• Rapid head circumference expansion (can increase 9+ cm within hours, as documented in cases growing from 33 cm to 42 cm) 2
• Progressive pallor, tachycardia, and hypotension indicating hypovolemic shock from massive blood loss into the subgaleal space 1, 3
• Neurological deterioration including lethargy, posturing movements, and decreased level of consciousness 2
• Pitting edema over the scalp and potential extension to the neck and periorbital regions 3

The subgaleal space can accommodate the infant's entire blood volume (80-260 mL), making exsanguination a real and immediate threat 3.

Risk Factors to Identify

Document the following obstetric and neonatal factors:

• Vacuum extraction (most common cause, present in 60 of 123 cases reviewed) or mid-forceps delivery 1
• Failed instrumental delivery attempts (vacuum followed by forceps, then cesarean section) 2
• Intrapartum fetal hypoxia and neonatal coagulopathies 1
• Prematurity, macrosomia, prolonged labor, cephalopelvic disproportion, primiparity, male sex 1
• Early-onset sepsis which can promote bleeding 4

Acute Management Protocol

Immediate Resuscitation (First Priority)

• Establish large-bore IV access immediately and begin aggressive volume resuscitation with crystalloid boluses (10-20 mL/kg) 3
• Transfuse packed red blood cells urgently for hemoglobin <10 g/dL or signs of shock; anticipate need for multiple transfusions 2, 3
• Provide inotropic support (dopamine, epinephrine) if hypotension persists despite volume resuscitation 2, 3
• Intubate and mechanically ventilate if respiratory distress or decreased level of consciousness develops 2

Coagulopathy Correction (Critical Component)

• Administer fresh frozen plasma (10-20 mL/kg) to correct coagulopathy, which is present in most severe cases 1, 3
• Give vitamin K (1 mg IV/IM) immediately, as vitamin K deficiency contributes to ongoing bleeding 3
• Transfuse platelets if thrombocytopenia is present (goal >50,000/mm³) 3
• Monitor coagulation parameters (PT, aPTT, fibrinogen) every 4-6 hours until stable 3

Monitoring Requirements

• Measure head circumference every 1-2 hours initially to track expansion 2, 3
• Perform serial hemoglobin/hematocrit every 2-4 hours until stabilized 3
• Continuous cardiorespiratory monitoring with frequent vital signs 3
• Monitor urine output (goal >1 mL/kg/hr) as indicator of adequate perfusion 3

Imaging Considerations

• CT head without contrast is indicated if neurological deterioration occurs or to assess for intracranial complications (cerebral edema, suture overlapping, elevated intracranial pressure) 2
• Routine imaging is not required for stable patients with typical clinical presentation 3
• CT findings in severe cases include: massive subgaleal fluid collection, overlapping cranial sutures, diffuse cerebral edema, and signs of elevated intracranial pressure 2

Surgical Intervention (Rare)

Surgical evacuation is reserved only for cases with documented extracranial cerebral compression causing elevated intracranial pressure and neurological decompensation despite maximal medical management. 2

Surgical technique when indicated:

• Small scalp incision with evacuation of hematoma (typically 150+ mL initially) 2
• Jackson-Pratt drain placement for continued drainage (may drain additional 200 mL over 2 days) 2
• This is not standard management; most cases resolve with medical management alone 3

Critical Pitfalls to Avoid

• Do not mistake subgaleal hematoma for benign cephalohematoma—the key difference is that subgaleal hematoma crosses suture lines and can cause life-threatening hemorrhage 1, 3
• Do not delay blood product transfusion while waiting for laboratory confirmation; clinical signs of shock warrant immediate transfusion 3
• Do not underestimate blood loss—the subgaleal space can hold the entire neonatal blood volume 3
• Do not overlook coagulopathy correction—this is as important as volume resuscitation and failure to correct coagulopathy leads to continued bleeding 1, 3
• Do not perform routine surgical drainage—this is indicated only in rare cases with documented cerebral compression and elevated ICP 2, 3

Expected Outcomes

With prompt recognition and aggressive management (volume resuscitation, blood transfusion, coagulopathy correction), survival is achievable even in severe cases 2, 3. However, mortality remains 22.8% overall, with higher rates in cases of delayed recognition or inadequate blood replacement 1. Neurological outcomes depend on the severity of associated hypoxic-ischemic injury and the rapidity of intervention 2, 3.