Peer Reviewed

Photo Essay

An Atlas of Lumps and Bumps: Part 22

Alexander K.C. Leung, MD1,2—Series Editor • Benjamin Barankin, MD3 • Joseph M. Lam, MD4 • Andrew A.H. Leung, BSc5 • Alex H.C. Wong, MD6

Volume 62 - Issue 11 - November 2022

AFFILIATIONS:
1Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
2Alberta Children’s Hospital, Calgary, Alberta, Canada
3Toronto Dermatology Centre, Toronto, Ontario, Canada
4Department of Pediatrics and Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
5Faculty of Medicine, St. George’s University, Grenada
6Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada

CITATION:
Leung AKC, Barankin B, Lam JM, Leung AAH, Wong AHC. An atlas of lumps and bumps, part 22. Consultant. 2022;62(11):e11. doi:10.25270/con.2022.11.000001.

DISCLOSURES:
Dr Leung is the series editor. He was not involved with the handling of this paper, which was sent out for independent external peer review

CORRESPONDENCE:
Alexander K. C. Leung, MD, #200, 233 16th Ave NW, Calgary, AB T2M 0H5, Canada (aleung@ucalgary.ca)

EDITOR’S NOTE:
This article is part of a series describing and differentiating dermatologic lumps and bumps. To access previously published articles in the series, visit https://www.consultant360.com/resource-center/atlas-lumps-and-bumps.

Caput Succedaneum

A caput succedaneum presents as a diffuse edematous swelling of the soft tissues of the scalp above the periosteum involving the presenting part of the neonate during delivery.1 It is most frequently seen on the vertex and the occipital midline of the head (Figures 1 and 2). The swelling is pitting in nature, not sharply defined, and usually crosses over cranial suture lines.1 Discoloration of the scalp may occur secondary to petechiae and/or ecchymosis.

 


Figure 1. A caput succedaneum presents as a diffuse edematous swelling of the soft tissues of the scalp above the periosteum involving the presenting part of the neonate during delivery.

 


Figure 2. A caput succedaneum is most frequently seen on the vertex and the occipital midline of the head.

Caput succedaneum occurs in approximately 1.8% of deliveries (mainly vaginal).2 It may develop secondary to injury to the presenting portion of the neonate’s head during difficult or prolonged labor or during vacuum extraction or forceps delivery.3 The swelling results from the uterine, cervical, and vaginal pressure on the neonate’s head. This leads to obstruction of the venous return of the scalp with consequent exudation/extravasation of serosanguineous fluid into the subcutaneous tissue above the periosteum.4 The condition is more common in neonates of primiparous mothers.2,5 Other risk factors include maternal obesity, prolonged rupture of membranes (inadequate amniotic fluid to cushion the neonate’s head during labor), and fetal macrosomia.1

Caput succedaneum has been diagnosed in utero in the third trimester by prenatal ultrasonography in those with oligohydramnios.1 The thickness of caput succedaneum is measurable in those cases with a prolonged second stage of labor using transperineal sonography.4 It has been shown that oxygen saturation readings from the caput succedaneum are consistently lower than those in the unaffected areas of the neonate’s scalp.6

The size of caput succedaneum is maximal at birth, and it usually resolves within a few days. Halo scalp ring—an annular nonscarring alopecic ring, presumably resulting from pressure necrosis of the neonatal scalp tissue—is an uncommon complication of caput succedaneum.3,5 Focal neonatal alopecia elsewhere on the scalp as a complication of caput succedaneum has also been reported.3,7 Rarely, septicemia may occur as a complication of an infected caput succedaneum.8 It is unusual for skull fractures and subaponeurotic hemorrhage to be associated with a caput succedaneum.

Cephalohematoma

A cephalohematoma is a subperiosteal collection of blood between the pericranium and the skull.9 The hematoma is almost always limited by the periosteal attachments at the suture lines.9 Therefore, a cephalohematoma is confined to the area on top of one of the cranial bones and does not cross the midline or suture lines (Figure 3).9 As the subperiosteal bleeding is gradual, a cephalohematoma often is not evident at birth, but it usually presents within the first 24 to 72 hours after delivery.1 Typically, a cephalohematoma presents as a localized, soft, and fluctuant swelling that cannot be transilluminated.1 The overlying skin is usually not discolored.9 The site of predilection is the parietal area (Figure 4), possibly because it is the most prominent presenting point.1 Unilateral cephalohematomas are approximately 5 times more common than bilateral cephalohematomas.1


Figure 3. Because the hematoma is almost always limited by the periosteal attachments at the suture lines, cephalohematoma is confined to the area on top of one of the cranial bones and does not cross the midline or suture lines.


Figure 4. The site of predilection is the parietal area.

Cephalohematomas occur in approximately 1% to 2% of spontaneous vaginal deliveries and approximately 4% of vacuum-assisted or forceps deliveries.10 A cephalohematoma may result from rupture of emissary and diploic veins as the neonate’s head is forcefully compressed against the maternal pelvic bones or the vaginal wall when the neonate’s head goes through the birth canal.1 This is especially so if there is an abnormal fetal presentation at the onset of labor or if the labor is difficult or prolonged.1 The condition is more common in large neonates and neonates of primiparous mothers.1,9 For unknown reasons, cephalohematomas occur twice as often in male neonates than in female neonates.9 Neonates may develop a late cephalohematoma following craniofacial surgery.

Most neonatal cephalohematomas are asymptomatic and reabsorb over a course of a few weeks to months without sequelae.11 However, larger cephalohematomas may cause anemia and hyperbilirubinemia.12 Linear skull fractures occur in approximately 5% of unilateral and 18% of bilateral cephalohematomas.1 Cephalohematomas may become infected either hematogenously or, more commonly, by contiguous spread of infection, with Escherichia coli as the most commonly reported causative agent.13,14 An infected cephalohematoma may occasionally lead to abscess formation, cellulitis, and, rarely, meningitis, osteomyelitis, and septicemia.1,10,13,15 Peripheral calcification may develop if the cephalohematoma persists beyond 4 weeks.1,16,17 In a small percentage of cases, it can lead to significant asymmetry and deformity of the skull.16

Subgaleal Hemorrhage

Subgaleal hemorrhage refers to bleeding in the loose areolar tissue in the space between the epicranial aponeurosis and the periosteum of the skull.18 The hemorrhage occurs when the emissary veins between the dural sinuses and the scalp are torn because of traction on the scalp during delivery. The condition occurs in approximately 6 per 10,000 spontaneous vaginal deliveries and 46 per 10,000 deliveries by vacuum extractions.19-21 Subgaleal hemorrhage is most common following vacuum extraction, followed by forceps delivery.18,20,22 Other risk factors include being small for gestational age, prematurity, primiparity, malposition of the fetal head, macrosomia, cephalopelvic disproportion, multiple dislodgments of the suction cup, prolonged second stage of labor, presence of meconium-stained amniotic fluid, fetal distress, presence of caput succedaneum, skull fracture, and bleeding diathesis.18,20,21,23-29

Clinically, subgaleal hemorrhage/hematoma presents as a diffuse, boggy, gravity-dependent, fluctuant mass under the scalp (Figures 5 and 6).19,20,30 Characteristically, subgaleal hemorrhage/hematoma are not restricted by suture lines and may shift with movement.30 An increase in head circumference is common.3 Massive subgaleal hemorrhage/hematoma may extend from the orbital ridges to the nape of the neck, and the ears may be displaced inferiorly.29,20 Bruising and ecchymosis may be seen on the scalp. There may be an associated skull fracture.27


Figure 5. Subgaleal hemorrhage/hematoma presents as a diffuse, boggy, gravity-dependent, fluctuant mass under the scalp.


Figure 6. Subgaleal hemorrhage/hematoma are not restricted by suture lines and may shift with movement.

Subgaleal hemorrhage/hematoma may result in hyperbilirubinemia because of the breakdown of red blood cells.31,32 At times, a subgaleal hematoma may become infected, notably by E. coli.30,33,34

If the hemorrhage is sufficiently massive, anemia and hypovolemic shock may result. This manifests as pallor, reduced spontaneous activity, poor peripheral refill, hypotension, tachycardia, and tachypnea.20 Subgaleal hemorrhage can be life-threatening. If unrecognized and untreated, subgaleal hemorrhage/hematoma of substantial size are associated with a mortality rate of 12% to 25%.19,21,27 On the other hand, if the subgaleal hemorrhage does not impact overall hemodynamics, the prognosis is good as the subgaleal hematoma tends to resolve spontaneously.22,35 Long-term sequelae of severe subgaleal hemorrhage include developmental delay, cerebral palsy, epilepsy, and impaired auditory function.19

References

 

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  2. Ekiz O, Gül U, Mollamahmutoğlu L, Gönül M. Skin findings in newborns and their relationship with maternal factors: observational research. Ann Dermatol. 2013;25(1):1-4. doi:10.5021/ad.2013.25.1.1
  3. Liberati G, Starace M, Patrizi A, Piraccini BM. Neonatal alopecia due to birth trauma: Case report and trichoscopic findings. Pediatr Dermatol. 2016;33(4):e254-e255. doi:10.1111/pde.12882
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  7. Douri TH. Two cases of halo scalp ring. Dermatol Online J. 2016;22(11):13030/qt7rt592tz. doi.10.5070/D32211033165
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  9. Raines DA, Krawiec C, Jain S. Cephalohematoma. In: StatPearls. StatPearls Publishing; April 30, 2022.  https://www.ncbi.nlm.nih.gov/books/NBK470192/
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