Cephalohematoma

GENESIS

Cephalohematoma is a common problem occurring in about 2.5% of newborns. It is a subperiosteal extracranial hemorrhage that may enlarge after delivery, sometimes taking weeks to resolve. This condition contrasts with the scalp edema of caput succedaneum, which reaches its maximal size at birth and usually resolves within a few days. Both lesions are believed to result from an injury to the cranial periosteum during labor or during a traumatic delivery, but they have also been detected as echogenic bulges on the cranium during prenatal ultrasound evaluations, which suggests that they can also arise in utero. Among 16,292 fetuses undergoing comprehensive ultrasound examinations between 1993 and 1996, seven cephalohematomas were detected on exams performed between 23 and 38 weeks of gestation (five occipital and two temporal). A diagnosis of cephalohematoma was confirmed by the neonatologist in two cases, and caput succedaneum was diagnosed in the remaining five cases. It was not possible to distinguish between cephalohematoma and caput succedaneum prenatally. None of these affected neonates were delivered by vacuum extraction or forceps, or had any signs of intracranial hemorrhage or skull fracture by ultrasound, and none required any treatment. Five of these seven cases had associated premature rupture of membranes, with oligohydramnios noted in four cases, suggesting oligohydramnios might have played a role. In 2014, Kim et al. reported that 25 out of 46 of their patients with cephalohematomas had some amount of intracranial hemorrhage on neuroimaging with no significant difference in the clinical manifestations between those with and those without intracranial hemorrhage. In 10 cases of cephalohematomas with a lineal skull facture, 9 had intracranial hemorrhage. In 2021, Ulma et al. reported on their 25-year experience and described their treatment and outcomes of 72 infants diagnosed with cephalohematomas. Thirty required surgery with a mean age at the time of surgery of 8.6 months. Twenty-one surgical patients (70%) required inlay bone grafting. All surgery patients had improvement in calvarial shape, with eight having enough blood loss to require a transfusion.

Cephalohematoma (adjusted odds ratio [aOR], 5.5; P <.001), subdural hematoma (aOR, 2.4; P <.001), and caput succedaneum (aOR 1.13; P =0.006) have all been found more frequently in infants delivered by vacuum extraction than in infants delivered without intervention “spontaneously.” Cephalohematoma occurs in 1–2% of spontaneous deliveries compared with 4% of vacuum or forceps deliveries. In a prospective randomized trial of 322 cases involving continuous versus intermittent vacuum extractions, cephalohematomas were associated with the station of the presenting part, asynclitism, and increasing application-to-delivery time. None of the infants with cephalohematomas experienced any long-term complications or needed blood transfusions, but fetal death and stillbirth have been reported after prenatal diagnosis of a fetal subdural hematoma following suspected or confirmed trauma. Thus cephalohematomas can occur prior to the onset of labor, especially with premature rupture of membranes and prolonged oligohydramnios. Maternal abdominal trauma can result in more serious subdural hematomas that can be seen by prenatal ultrasound, and this type of intracranial hemorrhage may threaten fetal survival.

Because vacuum extraction has been associated with cephalohematomas, there are concerns about whether this mode of delivery may result in more serious intracranial vascular injuries (subdural, cerebral, intraventricular, or subarachnoid hemorrhages). Among 583,340 live-born singleton infants weighing 2500–4000 g who were born to nulliparous women between 1992 and 1994 in California, the rate of intracranial hemorrhage was significantly higher among infants delivered by vacuum extraction, forceps, or cesarean section during labor than among infants delivered spontaneously. Assisted vaginal delivery, which was reported to increase the rate of cephalohematoma up to 10.8%. There was an incremental increase in the rate of hemorrhage if more than one method of delivery was used. Because the rate of hemorrhage was not significantly higher among infants delivered by cesarean section before labor, much of the morbidity associated with operative vaginal delivery is thought to be due to an underlying abnormality of labor rather than the specific operative procedure. The rate of intracranial hemorrhage has decreased threefold (to less than 1%) following the substitution of plastic cups for metal cups in vacuum extractors during the 1980s.

Most cephalohematomas are caused by birth trauma, and documented risk factors include fetal scalp monitors, instrumentation, and increased birth weight. The mechanism of injury is related to forces that lift the scalp and pericranium off the underlying bone, thus shearing vessels and causing blood to collect in this potential space. Most cephalohematomas resolve spontaneously during the first few weeks after birth, depending on their size. Complications can include an underlying skull fracture, anemia, hyperbilirubinemia, calcification/ossification, or (rarely) infection of the hematoma. Infants and toddlers that present to medical care with a cephalohematoma can be because of an accidental impact event or fall, but contact extra-axial hemorrhages with subdural hemorrhages are often considered indicative of abuse or major trauma.