A 10-minute-old boy is being evaluated in the delivery room. The patient was born at term to a 30-year-old primigravida woman. Pregnancy was unremarkable, but labor was complicated by recurrent late decelerations necessitating vacuum assistance for vaginal delivery. Apgar scores were 6 and 8 at 1 and 5 minutes, respectively. Temperature is 37 C (98.6 F), pulse is 170/min, and respirations are 40/min. Scalp examination shows large, fluctuant swelling at the occiput that extends bilaterally to the ears, superiorly toward the crown, and inferiorly into the nape of the neck. This patient's hemorrhage is most likely located between which of the following structures?

Question

A 10-minute-old boy is being evaluated in the delivery room.  The patient was born at term to a 30-year-old primigravida woman.  Pregnancy was unremarkable, but labor was complicated by recurrent late decelerations necessitating vacuum assistance for vaginal delivery.  Apgar scores were 6 and 8 at 1 and 5 minutes, respectively.  Temperature is 37 C (98.6 F), pulse is 170/min, and respirations are 40/min.  Scalp examination shows large, fluctuant swelling at the occiput that extends bilaterally to the ears, superiorly toward the crown, and inferiorly into the nape of the neck.  This patient's hemorrhage is most likely located between which of the following structures?

Quizplus · Accepted Answer

11ec160b_35d7_d09c_9249_f9fe74b51f4c_MD0001_00 This newborn has diffuse, fluctuant swelling across the scalp and into the neck, findings concerning for a subgaleal hemorrhage. Subgaleal hemorrhage is a rare, neonatal extracranial head injury caused by damage to the emissary veins, typically from traction on the scalp during vacuum-assisted delivery. Shearing of these veins, which connect veins of the scalp to the meningeal veins and dural sinuses, leads to hemorrhage in the potential space between the periosteum and galea aponeurosis (subgaleal space). This potential space extends over the whole calvaria and into the neck. Therefore, massive blood accumulation (eg, 20%-40% of neonatal blood volume) can occur. Physical examination typically shows diffuse, fluctuant scalp swelling that extends beyond suture lines and potentially into the neck. The swelling may shift with movement and can continue to expand over 2-3 days. Progressive bleeding can lead to hypovolemia, shock, and death, making prompt recognition critical. (Choices A, B, and C) Neonatal intracranial bleeds are also associated with assisted deliveries. Subarachnoid hemorrhage develops between the brain and arachnoid mater; subdural hematoma occurs between the arachnoid mater and dura mater; and epidural hematoma occurs between the dura mater and periosteum. Symptomatic intracranial bleeds typically present with seizures or hemodynamic instability, not diffuse scalp fluctuance. (Choice E) Bleeding between the skull and periosteum results in a cephalohematoma, which usually presents as a small area of swelling over the parietal or occipital bone. Because the periosteum is fixed at suture lines (eg, sagittal, coronal), the firm, nonfluctuant swelling of a cephalohematoma does not cross suture lines and spread over the calvaria. Educational objective: Subgaleal hemorrhage is a potentially fatal neonatal bleed that occurs during delivery when emissary veins between the dural sinuses and scalp are sheared. The accumulation of blood between the periosteum and galea aponeurosis presents with a diffuse, progressive, fluctuant scalp and neck swelling; massive blood loss can lead to shock and death if not promptly recognized. __________ References: Neurological neonatal birth injuries: a literature review. (http://www.ncbi.nlm.nih.gov/pubmed/29464145)

A 10-Minute-Old Boy Is Being Evaluated in the Delivery Room