Approach to the Problem
Most newborn scalp swellings are related to the forces exerted on the head by the birth canal or assistive equipment during delivery. These problems are usually self-limited, and they resolve within a couple of days to weeks, although some may require close monitoring. Swelling may occur despite skilled obstetric and neonatal care. Cesarean deliveries are associated less frequently with swelling. Fixed abnormalities in the skull shape and skin lesions of the head are described in chapters 3 and 4.
Key Points in the History
• Molding and caput succedaneum are usually evident right after birth, but a cephalohematoma or subgaleal hemorrhage may take hours to form or become evident.
• Obesity, diabetes, and short stature are maternal risk factors for molding, caput, cephalohematoma, or subgaleal hemorrhage.
• Macrosomia, cephalopelvic disproportion, and instrumented vaginal deliveries are newborn risk factors for molding, caput, cephalohematoma, or subgaleal hemorrhage.
• Caput succedaneum results from local subcutaneous edema and fluid collection, most commonly in the parieto-occipital region following a vaginal birth.
• Caput succedaneum and molding usually resolve in the first few days of life.
• Cephalohematoma, a hemorrhage that occurs between the periosteum and the skull bone, occurs in 1%–2% of all deliveries, and may take weeks to resolve.
• Five percent to twenty-five percent of patients with cephalohematomas may have an accompanying skull fracture.
• Subgaleal hemorrhage is a worrisome type of bleeding caused by trauma to the diploic veins under the galea aponeurotica that may occur with particularly traumatic deliveries. There is an increased incidence of subgaleal hemorrhage with vacuum extraction.
Key Points in the Physical Examination
• The swelling in caput succedaneum crosses suture lines because it is above the cranium in the subcutaneous tissue.
• The scalp with a caput succedaneum, unlike with a cephalohematoma, tends to have pitting edema.
• A caput succedaneum may be associated with a “halo scalp ring” of alopecia as a result of prolonged pressure of the scalp against the cervical os.
• Cephalohematomas are tense and do not extend across suture lines because they are limited by the boundaries of the periosteum.
• Skull fractures may underlie a cephalohematoma, but can be difficult to detect on physical examination.
• A cephalohematoma may leave a palpable calcification upon the skull as it resolves, which is typically small and nontender.
• There is no discoloration of the scalp with a cephalohematoma unless there is an overlying caput or bruising in the subcutaneous tissue.
• Subgaleal hematomas are fluctuant masses that cross suture lines, may be associated with a fluid wave or ecchymoses behind the ear, and may extend to other areas of the scalp.
• The ecchymoses associated with caput succedaneum and the bleeding seen with cephalohematomas and subgaleal hematomas can contribute to neonatal jaundice.
• Cranial meningoceles and encephaloceles are pulsatile midline masses that may present as cyst-like structures or a small sac with a pedunculated stalk. They will both transilluminate with a light, and neural tissue may be seen with an encephalocele.
PHOTOGRAPHS OF SELECTED DIAGNOSES
Figure 2-1 Molding. Note the superior and posterior displacement of the skull bones. (Courtesy of Joseph Piatt, MD.)
Figure 2-2 Caput succedaneum. Caput succedaneum shows pitting on pressure. (Used with permission from O’Doherty N. Atlas of the Newborn. Philadelphia, PA: JB Lippincott Co.; 1979:136.)
Figure 2-3 Caput succedaneum. Large soft swelling over the vertex, not confined to suture lines. (Courtesy of the late Peter Sol, MD.)
Figure 2-4 Cephalohematoma. Note the swelling over the right parietal area. (Used with permission from Fletcher MA. Physical Diagnosis in Neonatology. Philadelphia, PA: Lippincott–Raven Publishers; 1998:185.)
Figure 2-5 Cephalohematoma. Well-demarcated swelling over the left parietal bone. (Courtesy of the late Peter Sol, MD.)
Figure 2-6 Cephalohematoma. Note the prominence of the left parieto-occipital area in this newborn with a cephalohematoma. (Courtesy of Esther K. Chung, MD, MPH.)
Figure 2-7 Subgaleal hematoma. Discoloration and swelling extends across suture lines onto the neck, even onto the ear, causing protuberance of the pinna. (Used with permission from Fletcher MA. Physical Diagnosis in Neonatology. Philadelphia, PA: Lippincott–Raven Publishers; 1998:185.)
Figure 2-8 Ecchymosis after subgaleal hemorrhage. The bilateral location of this blood collection away from the site of forceps application suggests a wide area of involvement typical of a moderately large subgaleal hematoma. (Used with permission from Fletcher MA. Physical Diagnosis in Neonatology. Philadelphia, PA: Lippincott–Raven Publishers; 1998:128.)
Other Diagnoses to Consider
• Skull fractures
• Porencephalic or leptomeningeal cyst
When to Consider Further Evaluation or Treatment
• A cephalohematoma with an accompanying skull fracture should be referred to neurosurgery, and neuroimaging should be considered, particularly if the fracture is depressed.
• Cephalohematomas, subgaleal hematomas, and caput succedanea may be complicated by anemia or jaundice severe enough to require phototherapy or blood transfusions.
• Subgaleal hematomas require observation in a neonatal ICU for progressive enlargement and associated anemia, hypovolemia, shock, or jaundice.
• If a cranial meningocele is a consideration, an x-ray must be done to confirm if there is a skull defect, and additional neuroimaging should be pursued to evaluate for associated complications.
• If a cranial encephalocele is a consideration, prompt neurosurgical consultation should be arranged for possible decompression.
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