Giant Cephalhematoma of Newborn

Early needle aspiration of large infant cephalohematoma: a safe procedure to avoid esthetic complications

Cephalohematoma is a common pathology in newborns. Observation is the primary treatment for most patients with small uncomplicated cephalohematoma. Conversely, a large cephalohematoma can lead to calcification with unesthetic local deformation or deformational plagiocephaly. The objective of the study was to evaluate the iatrogenic risk associated with early puncture under local anesthesia and oral sucrose. This is a retrospective study of 67 consecutive newborns followed at Montpellier University Hospital, France, between 2010 and 2017. Large cephalohematoma was defined on the basis of the bump projection. Due to the uncertainty of the spontaneous resorption and the risk of calcification after 4 weeks which render the needle aspiration ineffective, puncture was performed between 2 and 4 weeks of life after coagulation evaluation and ultrasound of the skull and scalp. Puncture was performed in 43 boys (64%) and 24 (36%) girls between day 15 and day 30 after birth. The cephalohematoma maximal projection measured by ultrasound ranged from 9 to 13 mm (Q1,Q4) with a median value of 12 mm. No puncture-related complication was recorded during the intervention and at the 1-month follow-up visit.Conclusion: In newborns with large and persistent unesthetic cephalohematoma, puncture under local anesthesia with oral sucrose can be safely proposed between day 15 and day 30 after birth.What is Known:• Infant cephalohematoma is a frequent pathology of newborns, consisting of a traumatic subperiosteal hematoma of the skull. Most cephalohematomas are small and require no treatment because they spontaneously disappear within the first month.• Large and non-resorptive cephalohematomas may have significant esthetic and functional consequences.What is New:• Early puncture under local anesthesia is a safe, effective, and rapid procedure, decreasing the risk of persistent skull deformities.• Puncture can be proposed for newborns with a large (high projection and/or high angle connection) persistent anesthetic cephalohematoma, between day 15 and day 30, before spontaneous calcification.

Birth injury of the cranium and central nervous system

Birth injury of the scalp, skull and central nervous system (CNS) is a well-recognized complication of a difficult delivery. The rate of birth trauma has dropped precipitously and now accounts for less than 2% of neonatal deaths. Despite this dramatic decrease in birth-trauma mortality significant injuries still occur. A variety of risk factors clearly predispose certain infants to birth-related injury. Recent neuroradiology studies indicate that intracranial hemorrhage, even in asymptomatic infants, is not rare. Pathologists' (neuropathologists and forensic pathologists) appreciation of the spectrum of birth injuries and their sequelae is critical in order to be able to distinguish these from inflicted injuries and post-mortem changes.

[Neonatal hemorrhagic syndromes]

PURPOSE

The purpose of our study was to clarify the frequency of these causes.

PATIENTS AND METHODS

Retrospective study using reports of newborns in the neonatal unit in Sousse (Tunisia) from 1991 to 1996, hospitalized for hemorrhagic syndrome defined by bleeding, exteriorized or not, whatever its importance, severity, causes and the associated clinical and biological disorders. Isolated meningeal hemorrhages, limited cutaneo-mucous hemorrhages (conjunctival hemorrhages, bruises), and genital crises of the newborn, were excluded.

RESULTS

One hundred and fifty-five hemorrhagic syndromes were observed from 7,128 newborn infants (2.17% of hospitalization). Sex ratio was 1.42. Prematurity rate was 35.7%. The Apgar score was < 7 at one minute in 40.7% of cases. Disorders associated with hemorrhagic syndromes were observed in 118 newborn infants (76.1%) with a predominance of neonatal infections (35.6%). The etiology of neonatal hemorrhages was specified in 93% of cases: newborn hemorrhagic disease (27.7%), disseminated intravascular coagulation (27.1%), isolated thrombocytopenia (9%), digestive lesions (13.5%), and obstetrical trauma (2.6%).

CONCLUSION

The frequency of the newborns hemorrhagic syndromes underlines the need for its systematic prevention by vitamin K in the antenatal period to the mother and after birth to the newborn.

Purpura in infants and children

Hemorrhage into the skin (purpura) may result from abnormalities in any of the three components of hemostasis: platelets, plasma coagulation factors, and blood vessels. The morphology, size, and distribution of the hemorrhagic lesions are helpful diagnostic features. The main causes of purpura in the newborn and the more common hemorrhagic disorders in children are reviewed.

Haemorrhagic disease of the newborn: a review of 127 cases

A review of 127 infants with haemorrhagic disease of the newborn (HDN) is presented. The case definition of HDN used in the selection of patients was bleeding during the 1st week of life in a newborn with normal platelet count, normal peripheral blood smear and complete clinical response to parenteral vitamin K. Equivocal cases with respect to cause of bleeding were excluded. The eligible cases consisted of 0.9% of all admissions to the unit and the male:female ratio was 1.8:1. Most were from families of low economic status and poor educational background. Omission of vitamin K prophylaxis and exclusive breastfeeding were the commonest antecedents. The mean (SE) gestation and admission weight were 39.3 (0.2) weeks and 2981 (78) g, respectively. One hundred and two (80.3%) had classical HDN with a mean (SE) age at onset of 63 (4.4) hours. Gastro-intestinal bleeding was the commonest observation. Thirty-three infants (26%) died, most of them from exsanguination. There is a need for well designed work to determine the magnitude of the problem, including that of late-onset HDN, the antecedent risk factors, the preferred route for administering prophylactic vitamin K and a clear policy guideline on prevention of the disease.

Vacuum extraction, bone injury and neonatal subgaleal bleeding

In a population of 27 flemish newborns with subgaleal bleeding encountered within a period of 6 years, we studied the obstetrical, clinical and radiological data. In contrast with controversial findings from the available literature, there is little doubt that difficult, often elective vacuum extraction is the main cause of this neonatal emergency. Disturbances in haemostasis, when documented, were attributed to focal intrahaematoma consumption, except for one boy who presented with haemophilia and neonatal subgaleal bleeding. Conventional X-ray examination continues to be of importance for the documentation of suture diastasis, fissures and fractures. CT scan reveals both the amount of extra-osseous bleeding, the degree of bone displacement and injury as well as the type and extent of associated intracranial damage. Subgaleal haemorrhage rarely hides a growing synchrondrosal rupture.

Perinatal coagulopathies complicating fetal blood sampling

In a neonatal postmortem histological study of scalp stabs made with a fetal blood sampling blade the aponeurosis was punctured in up to 38% of cases even when it was more than 2 mm deep. This and other indirect and direct evidence discussed suggest that five of the seven reported cases of major bleeding after fetal blood sampling in labour were due to blood clotting defects and that these should be considered urgently in the management of future cases.

Massive subaponeurotic haemorrhage in infants born by vacuum extraction

Nine out of 232 infants on whom the vacuum extractor was employed developed subaponeurotic haemorrhage and two of these infants died. In a further 78 infants born by vacuum extraction, all of whom received intramuscular vitamin K(1), four sustained subaponeurotic haemorrhage and one died. This type of haemorrhage was not encountered in over 12,000 infants born by other methods. Its relationship to vacuum extraction was found to be significantly more frequent when the thrombotest level was 10% or below of normal adult activity. It is suggested that infants born by vacuum extraction and with a thrombotest level of 10% or below might be protected from subaponeurotic haemorrhage by the transfusion of fresh frozen plasma.

Exsanguinating cephalhaematomata in African newborn infants

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