lumps & bumps on the newborn head. when should i worry?

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Lumps & Bumps on the Newborn Head. When should I worry?. Joseph A. Garcia-Prats, M.D. Medical Director, Arnold J. Rudolph NICU Professor, Pediatrics & Ethics Baylor College of Medicine. Objectives. Briefly r eview the process of labor Review anatomy of newborn head - PowerPoint PPT Presentation

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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.

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