Neonate case history

1. CEPHALOHEMATOMA
Names : Singh Kirti , Faisal Bilal , 84a
Name- Shruti Suman & Abhishek Srinivas, 81A

2. Case History
• Child’s name - Adrian
• Date of birth – 23rd February 2024
• Age – 5 days
• Gender – Male
• Date of Admission – 28th February 2024
• Clinical diagnosis – Cephalohematoma
• Main diagnosis – Cephalohematoma above the right parietal bone
• Complications – None
• Accompanied diagnosis – Birth injury presented with cephalohematoma above the right
parietal bone

3. Personal Data
• Mother’s name – Elena
• Age – 28 years old
• State of health – Good , satisfactory
• Harmful habits – Smoker , smokes 1-2 cigarettes in a day , occasionally
drinks alcohol sometimes .
• Inheritance history – None

4. Obstetrician History
• Number of pregnancies and it’s flow : 1
• Toxicosis , threat of miscarriage, anaemia , infectious diseases during pregnancy , preclamsia , placenta
insufficiency , threat of preterm deliver , other – None
• Number of deliveries - 1
• Gestational age – 41 weeks
• Delivery flow and complication – Complicated delivery due to large head circumference( macrosomia)
and use of forceps for delivery
• Foetus distress (intrauterine/intrapartum hypoxia ) , preterm membrane rupture , long time without amniotic
fluid - None
• Bleeding , placenta separation, abnormal labour , FAD, VAD, abnormal presentation, amniotic fluid ( clear ,
meconium) other – None

5. • Normal physiological delivery , caesarian section- normal , physiological
delivery
• Birth weight – 4300 g
• Length- 35 cm
• Head – 36 cm
• Chest circumference – 38 cm
• Conclusion on the physical development- satisfactory but is more than
normal ( MACROSOMIA )

6. • APGARscore on the 1min – 7
• After 5mins – 8
• Examination according to Downes score – 2
• Resuscitation in the delivery room – No
• Diagnosis in the delivery room – Normal
• Treatment in the delivery room – None

7. • Apgar score on 1 min – 7
• After 5 minutes – 8
• The child is in normal
condition at the child birth .

8. Disease History
• None

9. The state of the present examination
• Date – 28th February 2024
• Child’s age – 5 days
• General condition – moderate
• Central nervous system –
• Response to exam – poor
• Cry – weak
• Posture – flexor
• Muscle tone – hypotonic
• Seiz
ures – absent

10. • Congenital neonatal reflexes – weak
• Dysmorphic features – enlargement of head in the right side , swelling
present
• Sk
in colour – pale
• Cyanosis – absent
• Subcutaneous fat – good amount
• Sk
eleton system , head shape – deformed
• Sk
ull sutures – swelling limited to the sutures .

11. • Swelling limited to the
suture line.
Soft ,
incompressible .

12. • Respiratory system , RR– 50 breaths / min
• Chest form – symmetrical
• Retraction , grunting , nostril flarring , swing symptom – no
• Pathological breathing – dyspnea absent
• Percussion , auscultation – normal

13. • Cardiovascular system , Heart rate – 190 bpm
• Heart area exam , volume of heart tones – normal
• Digestive system , suck
ling reflux – poor
• Type of feeding – breast feeding
• Vomiting – absent
• Mucus of mouth – pink
• Abdominal examination , visual exam – normal size
• Palpation data – soft
• Percussion , auscultation – no gas filled
• Stool , urine – normal in colour and frequency
• Gender features – mature , male

14. Preliminary Diagnosis
• CEPHALOHEMATOMA OF RIGHT PARIETAL LOBE .
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15. Investigation plan
• Physical exam
• CT scan Head , ultrasound
• X ray head
• Cbc
• Neurological Evaluation
• Duk
es test , coagulation time .

16. Investigation result
• Physical exam – pallor of sk
in , reduced activity , visible swelling on the right
side of the head , incompressible on palpation with increased head
circumference .
• Urine analysis – normal urine output .
• Normal duk
es test , coagulation time.
• Blood Analysis: Decrease in RBc and Hemoglobin indicate blood loss : Mild
Anemia

18. Ct scan of head
• Shows accumulated blood
between right parietal
bone and the periosteum ,
suggestive of
cephalohematoma .
• No sk
ull fractures are seen
• X ray and ultrasound :-
• Decreased echogenicity .
Swelling limited to the
suture lines .
• No fracture .

19. Differential Diagnosis
• Extra cranial inj
uries :
• 1
.
Caput succedaneum
• 2
.
Subgaleal hemorrhage
• 3
.
Chignon

21. Final clinical diagnosis
• Main diagnosis – Extracranial birth injury Cephalohematoma above
right parietal bone , acute phase , mild severity due to birth trauma .
• Complications :- Absent

22. Treatment
• Most extracranial haemorrhages resolve without any intervention .
Only with
observation .
• Observation and monitoring – close observation for signs of resolution and
detect any complications .
• Positioning – k
eep the child head elevated can help reduce swelling and minimise
the riskof complications .
• Pain management – to reduce the discomfort and irritability .
• Prevention of infection – k
eeping the area clean and dry .
• Management of anemia .

23. • Fluid and nutritional management .
• Breast milk/ milkformula .
Total daily fluid 1
2
0– 1
6
0ml/k
g ;
energy 1
1
0-
1
40k
cal/k
g .
• Restore blood volume in the baby through blood and plasma transfusion in
newborn intensive care unit .
• Oxygen therapy if needed .
• Intramuscular vit.
kif needed.
• Normal saline 1
0– 2
0ml/k
g IV during 3
0min
• Phototherapy if needed .
• Compression and bandaging : Gentle pressure or compression using bandage
applied to reduce the siz
e of cephalohematoma and promote healing.

24. Follow up
• After the baby received the treatment , we must checkfor the condition ,
symptoms .
We will need follow up evaluations during their first year of life
to verify that treatment was successful and no symptoms are affecting their
normal lifestyle .
• Visit your doctor if the swelling of the head is not decreasing with time and
treatment .
Or if the child does not show signs of development in first year
of life .

25. Long term complications
• Neonatal encephalopathy
• Seiz
ures
• Brain damage
• Hypoxic – ischemic encephalopathy
• Anemia
• J
aundice

26. Prognosis
• The prognosis of cephalohematoma is generally favourable with most cases
resolving without any long term complications .
However close monitoring
and appropriate medical management are essential to ensure the best possible
outcome for the patient .

27. Bibliography
• https://pediatricmalpracticeguide.
com/caput-succedaneum-and-
cephalohematoma/
• https://www.
ncbi.
nlm.
nih.
gov/book
s/NBK47
0
1
9
2
/
• Gomella neonatology by tricia lacy gomella .