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Obstetrica şi Ginecologia

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Obstetrica şi Ginecologia

IN MEMORIAM DR. EMIL GHEORGHIŢĂ

Obstetrica şi Ginecologia

Opinii şi recomandări curente pentru utilizarea meşei în chirurgia ginecologică – review al literaturii

Introduction

Scalp, skull or brain birth injuries are a series of rare complications of instrumentally assisted births due to the unevenly distributed mechanical forces, which can cause hemorrhage, edema, or rupture of cephalic structures. The most common complications are simple cephalhematoma, osteomyelitis of the skull from infected cephalhematoma, subgaleal hemorrhage and skull fracture. Intracranial injuries include extradural, subdural and subarachnoid hemorrhage, leptomeningeal cyst and brain infarction⁽¹⁾.

Cephalhematoma – the most common cranial injury in neonates – is a subperiosteal hemorrhagic collection that occurs in newborns, which is caused mainly through trauma at birth, but it may be seen even after a normal delivery⁽²⁾ (Figure 1).
 

It represents a benign condition that develops during delivery, when the child’s head is subjected to excessive pressure, either due to prolonged delivery or due to the use of tools such as forceps or a vacuum extractor, which can break the blood vessels in the subperiosteal area. There are veins in the diploic space that meet between the inner and outer tables of the skull and communicate superficially with the veins of the pericranium and deeply with the meningeal veins. The rupture of the superficial communicating veins gives rise to the cephalhematoma⁽¹⁾. Nonetheless, cephalhematoma is not a common complication of childbirth, and only 0.2-3% of newborns develop this disease^(3-5).

Cephalhematoma is defined as circumscribed, elastic and fluctuating hematoma and does not extend beyond the cranial sutures because diploic veins of each cranial bone are separated in infants⁽¹⁾. It is most commonly found in the parietal area and is rarely present in the occipital area. Often, cephalhematoma resolves naturally in about a month, but in cases where this process does not occur quickly enough, the hematoma calcifies. The calcification takes place concentrically, from outside to inside, which is defined as an ossification process that ultimately deforms the shape of the head.

Etiology

Cephalematoma usually occurs after a prolonged expulsion or instrumentally assisted birth^(6,7).

The higher rate of the natural births in a region and the more frequent use of forceps or vacuum extractors, the higher the incidence of cephalhematoma. For example, in Germany, 6.2% of all deliveries were instrumental-assisted vaginal deliveries, 5.8% vacuum-assisted and 0.4% forceps-assisted deliveries⁽⁸⁾. In contrast, in North America, forceps are more commonly used than video extractors⁽⁹⁾.

This preference of the technique used influences the frequency of neonatal cephalhematoma, because it was proven that vacuum extractors have twice the rate of leading to this type of hematoma than forceps, due to the specific force distribution^(10-12). A randomized controlled trial showed that metal cups are more likely to cause cephalhematoma than silastic cups or the Omnicup⁽¹³⁾. Other more common complications when using a vacuum extractor are subarachnoid hemorrhage and brachial plexus injury^(14,15).

However, some studies show that caesarean births also come with risks for both the mother and the newborn, which do not differ much in incidence and severity from instrumentally assisted births^(16-19).

Calcified cephalhematoma

Calcified cephalhematomas are classified into two types, depending on the relationship between the contour of the inner calvary bone and the surrounding normal cranial vault. Type 1 has a nondepressed inner bone without encroachment into the cranial cavity (Figure 2), while type 2 has a depressed inner bone into the cranial cavity⁽²⁰⁾.
 

The most common complications of cephalhematoma are: hypotension, anemia, exostosis or jaundice. There is also a risk of primary infection through scalp microlesions, or secondary infection through bacteremia⁽²¹⁾. Also, cephalhematoma is a risk factor for the occurrence of birth-related retinal hemorrhages secondary to the rupture of superficial retinal capillaries consecutive to the increased venous pressure⁽²²⁾.

Diagnosis and treatment

The diagnosis of cephalhematoma is established from the first minutes of life, by the neonatological team. To certify the diagnosis, the fetal skull is visualized using computed tomography, which helps detect the depth of the cranial injury. Following this, the diagnosis of simple cefalhematoma or calcified can be made.

In case of simple cephalhematomas, the newborn is stabilized, but no surgery is performed. The noninvasive approach is preferred, without puncture of the hematoma, but under the careful supervision of the vital functions. However, in the case of large cephalematomas, a puncture is recommended under conditions of maximum asepsis^(3,23,24). In these cases, the administration of coagulation factors was also tested, especially factor XIII, with good results and a marked decrease in symptomatology⁽²⁵⁾.

Massive cephalhematomas predispose the newborn to high blood loss and severe anemia. Cases were described in the literature in which the hematocrit was 13-19%; for these newborns, in addition to aspiration of the hematoma, blood transfusions, antibiotics, phototherapy and dexamethasone are recommended⁽²⁶⁾.

Rarely, the cephalhematoma becomes infected, leading to osteomyelitis or meningitis, the diagnosis being made after the puncture⁽²⁷⁾. An infection is considered when there are a secondary enlargement of the hematoma, fluctuation, erythema, skin lesions or signs of systemic infection. In these cases, paraclinical investigations, such as inflammatory markers and imaging, have little diagnostic power. The most common causes of infected cephalhematoma are instrumental-assisted birth and sepsis, the use of scalp electrodes, skin abrasions or prolonged rupture of membranes. In these cases, the aspiration of the infectious hemorrhagic contents becomes mandatory⁽²⁸⁾.

The most common infectious pathogens are: Escherichia coli (by far, the most common pathogen isolated from infected cephalhematoma), Bacillus proteus, Gardnerella vaginalis, Escherichia hermanii, Streptococcus pneumoniae, beta-hemolytic streptococci, Staphylococcus epidermidis, Paracolobactrum coliforme, bacteroides⁽²⁸⁾.

In case of calcified cephalhematomas, the management of the newborn can take two directions: a conservative one, which follows resorption that generally occurs between 3 and 6 months of age, or the surgical excision of the ossification mass. If the second approach is chosen, it is recommended that the intervention take place as early as possible because any delay brings an enlargement of the defect and a more difficult and prolonged intervention, which often fails to return the normal shape of the skull^(29-31).

Many doctors opt from the onset for surgical correction of calcified cephalhematoma for aesthetic reasons, to confirm the diagnosis and, finally, to prevent the restriction of brain growth and correct the possible associated craniosynostosis^(32-34).

In conclusion, the diagnosis of cephalhematoma requires the carefully monitoring of the newborn by parents and a multidisciplinary team.  

Conflict of interests: The authors declare no conflict of interests.