PC2169: Full-thickness Scalp Necrosis Following a Complex Perinatal Course

Introduction: Birth trauma occurs in 3.1% of neonates in the U.S., and 80% of those injuries involve the scalp. Risk factors for birth trauma include macrosomia and operative delivery. Forceps delivery carries risk for head injuries such as lacerations and multiple types of hemorrhage. Literature suggests that neonatal scalp necrosis is usually caused by local infection, external pressure, or infusion extravasation. We discuss a neonate who developed extensive scalp necrosis following several perinatal complications.

Case Description: We describe a newborn male born large for gestational age at 37+1 weeks in a large military hospital to a primiparous mother with type 1 diabetes mellitus. Induction was planned for gestational hypertension. Delivery required forceps assistance and was complicated by shoulder dystocia. Baby was admitted to the NICU for respiratory distress requiring CPAP. Initial exams were notable for significant bruising and abrasions of the face and scalp, caput succedaneum, and right cephalohematoma. Despite low risk for early-onset sepsis and initial resolution of respiratory distress, he progressed to E. coli sepsis with shock and disseminated intravascular coagulation (DIC) day-of-life (DOL) 1. Resuscitation produced remarkable generalized edema. His skin wounds were managed conservatively with a multidisciplinary approach given clinical instability (see images for progression of wounds). Multiple modalities of head imaging were obtained as permitted by his critical status. Despite uninterrupted parenteral antibiotics from DOL 1, MRI showed a large subgaleal fluid collection with features suggesting secondary wound infection. Wound cultures demonstrated polymicrobial growth. Upon improvements of his hemodynamics and respiratory status, he was taken for multiple surgical debridements. Operative findings included full-thickness soft tissue necrosis of the bilateral posterior jawlines, bilateral postauricular regions, left occiput, and right parietal area. A majority of his jawline wounds were able to be closed primarily after infection resolved. Integra® neodermis was applied to remaining wounds with wound vacuum assistance. Ultimately, he was transferred to a pediatric burn center for split-thickness skin grafting.

Discussion: Given the distribution, the inciting insult for our patient’s full-thickness skin necrosis was likely a forceps injury to the manipulated tissues and left occipital artery. The extent of his necrosis was exacerbated by sepsis, DIC, anasarca, and pressure from extracranial hemorrhages. Wound care was difficult due to his age, wound location, critical status, and need for position changes even with simple dressing changes. Due to wound location, he will eventually require staged reconstruction with tissue expanders to achieve hair restoration.

Conclusion: Full-thickness scalp necrosis in critically ill neonates is rarely reported in the literature. Complicated scalp injuries should be managed by a multidisciplinary team with early debridement of necrotic lesions as permitted by clinical status. Our case also demonstrates the need for military treatment facilities to maintain strong civilian partnerships to provide ongoing and specialized care for complex patients.