Cephalhaematoma Induced Hyperbilirubinemia – Case Report

Dr Lakshmi Prathyusha Chitturi

Cephalohematoma is a subperiosteal hemorrhage and thus always limited to the surface of one cranial bone. Cephalohematomas occur in 1–2% of live births. No discoloration of the overlying scalp occurs, and swelling is not usually visible for several hours  after  birth  because subperiosteal bleeding is a slow process. The lesion becomes a firm, tense mass with a palpable rim localized over one area of the skull. Most cephalohematomas are resorbed within 2 weeks to  3months, depending on their size. They may begin to calcify by the end of the 2nd wk. A few remain for years as bony protuberances and are detectable on radiographs as widening of the diploic space; cyst like defects may persist for months or years. An underlying skull fracture, usually linear and not depressed, may be associated with 10–25% of cases. A sensation of central depression suggesting but not indicative of an underlying fracture or bony defect is usually encountered on palpation of the organized rim of a cephalohematoma.

Cephalohematomas require no treatment, although phototherapy may be necessary to treat hyperbilirubinemia. Infection of the hematoma is a very rare complication. (1)

 Clinical course: A male neonate aged 11 days presented on  17/12/2019 with symptoms of swelling  on  right  occipital  region  since 6 days which is gradually increasing since then; presented with 6cm×8cm; soft rigid, on palpation no tenderness. Yellowish discoloration of whole body since 2 days.

Delivery history: A normal healthy male baby of weight 3.2 kg born on

7/12/2019 through emergency LSCS due to drop in fetal heart rate and rupture of membranes before 1 week of EDD. Neonate cried immediately after birth; all reflexes are normal; Sucking was good; meconium passed on the same day of birth.  Neonate presented  with arrhythmia after   5 days where ECHO showed Patent foramen ovale with mild PAH with TR. No medication was prescribed. Blood report revealed Hb-18.5 gms%, RBC-5millions/cu mm, PCV-53.7%, MCV-  106 UM, MCH-36.3 pg, MCHC-34.4 gm/dl, Platelet count-1.84lakhs/cumm, total WBC-12,300 cells/cumm, Granuls-47%, Lymphocytes-40%, monocytes-13%, total bilirubin-16.5mg/dl, direct bilirubin-0.4mg/dl. Neonate was admitted for double surface phototherapy on 11/12/2019 for 1 day and discharged next day 12/12/2019 as bilirubin level dropped to11.2mg/dl.

Mother pregnancy history: First delivery was emergency LSCS due to big baby. Present pregnancy is of natural conception. Obese mother had PIH and on antihypertensive one  tablet/day. She didn’t have any other systemic disorders. USG, NT, TIFA scans are  normal  during present pregnancy.

Family history: Consanguineous marriage where mother and father are first degree relatives. Father suffering from bronchial asthma since childhood and is taking allopathic medication. Mother is apparently healthy where PIH subsided after delivery. Brother has recurrent colds {on homeopathic RX}.Paternal grandmother suffering with cardiac complaints. Had a silent MI. surgery was done & grandfather is apparently healthy. Maternal grandparents are healthy.

Personal history:

  • Feeds: Exclusive breast feeding every 3 hours.
  • Urine: 3-4 nappies in day and one in night, yellow in colour.
  • Bowels: 6-7 times/day, semisolid yellow in colour.
  • Perspiration: Not marked.
  • Sleep: 16-18 hrs/day, sound.

Vital signs: Temperature- 98 0F; Pulse- 86 beats/ minute; Heart rate- 120 beats/minute, Respiratory rate- 24 breaths/ minute.

General physical examination:
The child is active & conscious. Yellowish discoloration of whole body {sclera, gums, conjunctiva, nails}. Skin blanched to yellow colour on  pressure on sternum, abdomen,  extremities which  stood for 5-10seconds. Swelling on right occipital region 6cm×8cms & 1.5 cm depth; soft rigid   on palpation. Anterior fontanel open diamond shaped; no dehydration or  bulge;  Posterior  fontanel open, round; Sutures overriding. Sclera and conjunctiva yellow. Gums yellow & tongue white coated. Nose, ears showed no abnormality. Neck has no lymphadenopathy. Nipple sized 0.7cms. Abdomen round; umbilical cord detached. Extremities show no abnormalities.

Weight- 2.9 kg, Head circumference-33 cm, Chest circumference-30cm, Mid arm circumference- 9cm, Height- 49 cm.

SYSTEMIC EXAMINATION:
Respiratory system O/E showed bilateral air entry equal. No added sounds.  Cardiovascular  system showed normal S1 & S2 heart sounds; arrhythmia only while crying. Per abdomen umbilicus centrally placed, non tender, no swellings felt.

Central nervous system: Cry good; bilateral pupillary reflexes normal. Moro’s reflex positive; rooting reflex normal; grasp reflex normal; Sucking reflex is good; active movements of limbs with flexion posture.

Investigations:
Blood report on 18/12/2019 revealed WBC-13,400 cells/cmm, RBC-4.83 millions/cumm, HB- 14.5gm%, PCV-47.2%, MCV-97.7 FL, MCH-33.1 PG, MCHC-33.9G/DL, platelet count-3.15 lakhs/cmm, NEUTROPHILS-46%, EOSINOPHILS-1.9%, LYMPHOCTES-52.1%, SERUM TOTAL BILIRUBIN-15.7%, SERUM DIRECT BILIRUBIN-1.9%. Blood group is O positive.

Prescription : Arnica Montana 30 3pills/ TDS was given for 2 days . (pills to be mixed in mother’s milk).

Follow up: All the 3 days neonate  was  active.  On the 19/12/2019  swelling became softer, less  rigid 5cm×7cm in size. Yellow blanching of skin reduced to 4-5sec. Neonate is active and taking feeds. Stools and urine are dark yellow colour. On 20/12/2020 blanching of skin  to  yellow  colour reduced to 2-3seconds. Swelling became softer, 5cm×5cm in size. Blood report on 20/12/2019 revealed WBC-14,400 cells/cumm, RBC-5.35 milions/cumm, HB-14.5 gms %, PCV-51.1%, MCV-95.5 fl, MCH-31.6 pg, MCHC-33.1g/dl, platelet count-3.28lakhs/cmm, neutrophils-44.5%, eosinophils-5.2%, lymphocytes-50.3%, SERUM TOTAL BIIRUBIN-9.7%, SERUM DIRECT BILIRUBIN-0.9%. Swelling reduced completely after 7 days i.e. 27/12/2019.

Discussion: Neonatal cephalhaematoma is generally a benign condition resolving within a week  to a month. Some calcify at the end of the second week. Occasionally complicated by hyperbilirubinemia, infection, fracture of skull in neglected cases. In above case, prolonged labor of mother caused gradual development of cephalhaematoma which started on 5th day after  delivery noticed prominently on 8th day. Pediatrician suggested wait and watch as it subsides in a week usually. On the contrary neonate started developing hyperbilirubinemia on 10th  day which  is due to increase in bilirubin level caused by accumulation of blood in cephalhaematoma. Phototherapy is a choice of management. On the contrary in Homeopathy we treat the cause to relieve the symptoms. As we know the physiological action of Arnica Montana, stimulates the absorbent power of venous capillaries, clears the extravasation of blood. (2) So Arnica montana    30 was prescribed in frequent repetition as it was an acute condition for 3 days which almost cleared the excess bilirubin levels in the blood. Dark yellow colour of urine and stools indicated the excretion of bilirubin from the body. As we know that cephalhaematoma reduces gradually, medicine was tapered slowly as the jaundice came down. Swelling completely reduced after one week.

NOTE:

  • X- Ray of skull was not done in order to avoid exposure of radiation to the neonate.
  • No proper sun exposure as a matter of winter season.
  • PDA in neonate might be due to the antihypertensive Rx of mother during her pregnancy, condition usually subsides in 3-6 months. No treatment was given.

References:

  1. Kliegmann M.Robert MD-Nelson Textbook of pediatrics, volume-1 first south  Asia  edition,  reprint edition 2016, Reed Elsevier India Pvt.Ltd., New Delhi, India.
  2. Burt.H.WM Physiological Materia Medica, Reprint edition 1994, B.Jain publishers Pvt. Ltd, New Delhi, India.

Dr. Lakshmi Prathyusha Chitturi
Department of Paediatrics PG Part 2
Under the Guidance of Dr Nahida M Mulla. M.D (HOM); MACH
Professor & HOD Paediatrics
A M Shaikh Homoeopathic Medical College, PG Research Centre & Hospital
Nehru Nagar Belagavi – Karnataka

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