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Pediatric Dermatology Vol. 34 No. 1 e40–e41, 2017 Initial physical examination revealed four 0.

7- to
1.4-cm red-orange, firm papulonodules arranged
linearly, each with a central collarette of scale, no
evidence of follicular loss, and no hair collar sign
Neonatal Subgaleal Hematoma from Trauma (Fig. 1). Two lesions were on the right posterior
During Vaginal Delivery without Instrument scalp, one on the left occipital region, and one over
Use the left parietal scalp. There was no purulence,
discharge, or pulsations. The two lesions on the
posterior scalp were fluctuant centrally. Initial
differential diagnosis included subcutaneous fat
Abstract: Neonatal subgaleal hematomas (SGHs)
are rare but potentially life-threatening complications of necrosis, dermoid cysts, abscesses, and cephaloceles.
vacuum extraction deliveries. We report a rare case of Head ultrasound revealed four areas of anechoic
four enlarging SGHs in an 11-day-old boy born without fluid accumulation along the scalp, each measuring
use of instruments during delivery. It is likely that 1.5 cm. Two crossed sutures, consistent with a
trauma from the provider’s fingers caused these SGHs diagnosis of SGH (Fig. 2). A family member
during a normal vaginal delivery. Ultrasound findings present in the delivery room witnessed the obstetri-
confirmed the diagnosis of SGH, distinct from other cian use a hand to press the infant’s head down
birth trauma such as cephalohematoma or caput suc- firmly to assist in delivery of the shoulders. Given
cedaneum. the lack of a toxic appearance and the self-resolving
nature of SGHs, he was discharged with close
outpatient follow-up. The lesions fully resolved by 8
weeks of age.
Subgaleal hematoma or hemorrhage (SGH) in a
newborn is a potentially fatal accumulation of blood
between the galea aponeurotica and skull periosteum. DISCUSSION
Almost all SGHs are associated with instrument- It can be difficult to differentiate SGH clinically from
assisted deliveries, especially vacuum extraction (1). other newborn traumatic head injuries such as
The incidence of SGH is approximately 0.5 per 1,000 cephalohematomas and caput succedaneums.
live births, with risk factors including vacuum extrac- Cephalohematomas are collections of blood under
tion delivery, male sex, and primiparity (2). We report the periosteum. Unlike SGHs, cephalohematomas are
a case of four SGHs in a newborn, presumably caused confined by periosteal attachments and cannot cross
by trauma from fingers pressing the head down during suture lines. Complications of cephalohematomas are
normal vaginal delivery. To our knowledge, this is the rare but potentially fatal (3). Caput succedaneums are
first reported case of neonatal SGHs from such minor benign collections of fluid between the scalp and
trauma. subcutaneous tissue above the periosteum; these
present maximally at birth and resolve within days.
CASE REPORT In contrast, SGH occurs between the aponeurosis and
periosteum and often progresses in severity after
An African American boy born at 37 weeks gesta- birth.
tional age and 2,600 g presented at 11 days old with SGH, unconstrained by periosteum, can become
four discrete scalp nodules that had been growing in extensive, with a mortality rate greater than 20% (4).
size since birth. His birth history included maternal Therefore, close monitoring in the first 48 hours of
smoking during pregnancy, polyhydramnios, and diagnosis is essential. SGH can be associated with
scalp electrode placement for late fetal decelerations. coagulopathy, anemia, hypovolemic shock, and brain
He was born via spontaneous vaginal delivery with compression (1,2,4). Blood transfusions or activated
vertex presentation. He was admitted to our hospital factor VII can prevent deterioration (2,5). Long-term
for suspicion of bacterial infection and sepsis evalu- outcomes of SGH survivors are typically good.
ation. Localized SGH from minor trauma should be
included in the differential diagnosis of neonatal scalp
nodules. Ultrasonography can assist in arriving at a
timely diagnosis and avoiding unnecessary invasive
tests or procedures. Close follow-up is warranted until
DOI: 10.1111/pde.13037 lesions resolve.

e40 © 2016 Wiley Periodicals, Inc.


Brief Report e41

A B C

Figure 1. Presentation of subgaleal hemorrhages on the (A) left occipital, (B) left parietal, and (C) right posterior scalp.

A B

Figure 2. Ultrasound of head and neck soft tissues. (A) Right-sided lesion, corresponding to the lesion depicted in Fig. 1C.
(B) Left-sided lesion, corresponding to the lesion depicted in Fig. 1A. Anechoic fluid accumulations are identified along the
scalp, adjacent to the lambdoid suture bilaterally and left parietal (not shown) and midline occipital (not shown) regions.
They are not accompanied by hyperemia on color Doppler (not shown) and they cross over sutures, probably representing
subgaleal hemorrhages. Arrows point to the lambdoid suture. The visualized underlying calvarium appears normal.

ACKNOWLEDGMENT 4. Amar AP, Aryan HE, Meltzer HS et al. Neonatal


subgaleal hematoma causing brain compression: report
We would like to thank Cicero Silva, M.D., for his of two cases and review of the literature. Neurosurgery
description, analysis of imaging, and review of the 2003;52:1470–1474; discussion 1474.
article. 5. Strauss T, Kenet G, Schushan-Eisen I et al. Rescue
recombinant activated factor VII for neonatal subgaleal
hemorrhage. Isr Med Assoc J 2009;11:639–640.

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