Lumps & BumpsLumps & Bumps on the Newborn Head. on the Newborn Head.
When should I worry?When should I worry?
Joseph A. Garcia-Prats, M.D.Medical Director,
Arnold J. Rudolph NICUProfessor, Pediatrics & Ethics
Baylor College of Medicine
ObjectivesObjectives Briefly rBriefly review the process of laboreview the process of labor Review anatomy of newborn headReview anatomy of newborn head Identify abnormal extra cranial Identify abnormal extra cranial
findingsfindings Discuss the most common extra Discuss the most common extra
cranial lumps and bumps: Caput cranial lumps and bumps: Caput succedaneum, cephalohematoma, succedaneum, cephalohematoma, subgaleal hemorrhage subgaleal hemorrhage
Process of LaborProcess of Labor Goal of labor is to prepare the Goal of labor is to prepare the
cervix and pelvic bones to expel cervix and pelvic bones to expel the uterine contentsthe uterine contents
Describe three phases: latent, Describe three phases: latent, active, descentactive, descent
Approximately 9%- 30% of Approximately 9%- 30% of women have non-vaginal deliveries women have non-vaginal deliveries in the U.S.in the U.S.
Female PelvisFemale Pelvis
Female PelvisFemale Pelvis
Anatomy of the ScalpAnatomy of the Scalp
Skull boneSkull bone
PeriosteumPeriosteum Galea aponeurotica
Scalp
BrainBrain
Dura/pia/arachnoidDura/pia/arachnoid
Caput SuccedaneumCaput SuccedaneumDefinitionDefinition: a lesion characterized by a : a lesion characterized by a
vaguely demarcated area of edema over vaguely demarcated area of edema over that portion of the scalp that was the that portion of the scalp that was the presenting part during a vertex deliverypresenting part during a vertex delivery
EtiologyEtiology: extravasation of serum and/or : extravasation of serum and/or blood from the higher pressures of the blood from the higher pressures of the uterus and vaginal wall on those areas uterus and vaginal wall on those areas of the fetal head that border the caput of the fetal head that border the caput that accumulates over the periosteum that accumulates over the periosteum
Anatomy of the ScalpAnatomy of the Scalp
Caput Caput succedaneumsuccedaneum
Skull boneSkull bone
PeriosteumPeriosteum Galea aponeuroticaGalea aponeurotica
Scalp
BrainBrainDura/pia/arachoidDura/pia/arachoid
EdemaEdema
EdemaEdemaEdemaEdema
EdemaEdema BloodBlood
BloodBlood
Caput SuccedaneumCaput SuccedaneumOccurrence rate: Occurrence rate: very commonvery commonClinical manifestationClinical manifestation: soft swelling : soft swelling
usually a few millimeters thick (although usually a few millimeters thick (although it may be much thicker) and may be it may be much thicker) and may be associated with overlying petechiae, associated with overlying petechiae, purpura or ecchymosis. purpura or ecchymosis. Extends Extends beyond suture lines.beyond suture lines.
Caput SuccedaneumCaput SuccedaneumTreatmentTreatment: none: noneResolutionResolution: hours to 1-2 days: hours to 1-2 daysComplicationsComplications: none: none
CephalohematomaCephalohematomaDefinition: bleeding below the
periosteum of the skullEtiology: mechanism of of the
bleeding is not exactly known (may occur in uncomplicated vaginal deliveries or in newborns delivered by caesarian section)
Anatomy of the ScalpAnatomy of the Scalp
Cephalo-Cephalo-hematomahematoma
Skull boneSkull bone
PeriosteumPeriosteum Galea aponeurotica
Scalp
BrainBrainDura/pia/arachnoidDura/pia/arachnoid
cephalohematoma SutureSuture
CephalohematomaCephalohematomaOccurrence: 0.41% - 2.5% of deliveries
Noted more often in: (1) males, (2) on right side, (3) newborns delivered vaginally. Bilateral involvement: 15%
Diagnosis: “fluid like accumulation” best appreciated at 6-24 hours after delivery; does not transilluminate; boundaries are the suture lines.
BackBack
FrontFront
CephalohematomaCephalohematomaResolutionResolution: 2-8 weeks with a “crater : 2-8 weeks with a “crater
like ridge” noted as it resolveslike ridge” noted as it resolvesComplicationsComplications: Hyperbilirubinemia: Hyperbilirubinemia, ,
anemia, infection, calcification, anemia, infection, calcification, osteomyelitis, skull fracture (5 % osteomyelitis, skull fracture (5 % occurrence with unilateral and 18% occurrence with unilateral and 18% with bilateral cephalohematoma – with bilateral cephalohematoma – rarely associated morbidity)rarely associated morbidity)
TreatmentTreatment: “Expectant”: “Expectant”
Subgaleal HemorrhageSubgaleal HemorrhageDefinitionDefinition: extracranial bleeding from : extracranial bleeding from
under the scalp which may become under the scalp which may become massive and life threateningmassive and life threatening
EtiologyEtiology: rupture of emissary veins : rupture of emissary veins with blood accumulating between with blood accumulating between the epicranial aponeurosis of the the epicranial aponeurosis of the scalp and the periosteum.scalp and the periosteum.
Anatomy of the ScalpAnatomy of the ScalpSubgaleal Subgaleal hemorrhagehemorrhage
Skull boneSkull bone
PeriosteumPeriosteum
Galea aponeuroticaGalea aponeurotica
Scalp
BrainBrainDura materDura mater
Subgaleal hemorrhage Muscle attach
Muscle attach
Subgaleal HemorrhageSubgaleal HemorrhageOccurrenceOccurrence: : RARERARE -- 1.5 per 10,000 -- 1.5 per 10,000
births to 1 per 30,000 births. births to 1 per 30,000 births. Appears to be an increased occurrence Appears to be an increased occurrence
with vacuum extraction, forceps with vacuum extraction, forceps delivery, but may also be seen in delivery, but may also be seen in spontaneous deliveries. spontaneous deliveries.
Contributing factors may be Contributing factors may be inappropriate placement and/or failed inappropriate placement and/or failed vacuum extractionvacuum extraction
Subgaleal HemorrhageSubgaleal Hemorrhage
Clinical manifestationsClinical manifestations: Ill-defined : Ill-defined borders,firm to fluctuant, may have borders,firm to fluctuant, may have fluid wavesfluid waves
Potential space includes the limits of: Potential space includes the limits of: orbital margins back to the nuchal orbital margins back to the nuchal ridge, laterally temporal facia. ridge, laterally temporal facia. “Football helmet” like location“Football helmet” like location
Anterior Anterior borderborder
Posterior Posterior borderborder
Lateral Lateral borderborder
Posterior Posterior borderborder
Lateral Lateral borderborder
Anterior Anterior borderborder
Subgaleal HemorrhageSubgaleal HemorrhageTreatmentTreatment: Close monitoring of vital signs : Close monitoring of vital signs
looking for increasing FOC and signs of looking for increasing FOC and signs of hypovolemia. Supportive care very hypovolemia. Supportive care very important which includes: volume important which includes: volume replacement, monitoring for DIC, factor replacement, monitoring for DIC, factor replacementreplacement
ResolutionResolution: 2-3 weeks: 2-3 weeksComplicationsComplications: Encephalopathy, intracranial : Encephalopathy, intracranial
pathology(ICH, edema, skull fracture), DIC, pathology(ICH, edema, skull fracture), DIC, jaundicejaundice
Anatomy of the ScalpAnatomy of the ScalpCaput succedaneum
Subgaleal hemorrhage
Cephalo-hematoma
Skull boneSkull bone
PeriosteumPeriosteum
Galea aponeuroticaGalea aponeurotica
Scalp
BrainBrainDura materDura mater
Subgaleal hemorrhage
Cephalohematoma
EdemaEdemaEdemaEdema
EdemaEdema EdemaEdema BloodBloodBloodBlood
Muscle attach
Muscle attach
SutureSuture
FeatureFeature CaputCaput Cepahlo-Cepahlo-hematomahematoma
Subgaleal hemorrhage
LocationLocation Crosses Crosses suturessutures
Distinct Distinct margins;margins;sutures are sutures are limitslimits
Crosses Crosses sutures; sutures; “football “football helmet-like”helmet-like”
FindingsFindings Firm edema-Firm edema-vaguely vaguely demarcateddemarcated
Initially firm; Initially firm; distinct distinct margins; margins; fluctuant > 48 fluctuant > 48
Diffuse, Diffuse, shifts shifts depedently, depedently, fluid likefluid like
TimingTiming Noted at Noted at birthbirth
hours -- days hours -- days after birthafter birth
At birth or At birth or hours laterhours later
Volume Volume of bloodof blood
None to very None to very littlelittle
10 – 40 ml10 – 40 ml 50-100 ml or 50-100 ml or moremore
In ConclusionIn ConclusionUnderstanding the anatomy of
the tissues surrounding the skull makes it easier to distinguishing the different “lumps and bumps”.
Armed with this knowledge the perinatal health care provider is in a better position to identify patients at risk for complications associated with these lesions.
