A 5-day-old girl is brought to the emergency department for evaluation of vaginal discharge. Her mother has noticed white vaginal discharge mixed with a small amount of blood since yesterday. The girl does not appear to be in pain and has been voiding and stooling adequately. She is exclusively breastfed every 2-3 hours. The mother mentions that she was treated "with a shot and a pill" for a sexually transmitted disease early in her pregnancy and subsequently tested negative. The girl was born via forceps-assisted vaginal delivery due to protracted labor at 38 weeks gestation. Temperature is 36.7 C (98 F). Physical examination reveals a thin, white, odorless vaginal discharge with blood streaking. The external genitalia are otherwise unremarkable, and the abdomen is soft and nontender without palpable masses. What is the most likely cause of this patient's vaginal discharge?

Question

A 5-day-old girl is brought to the emergency department for evaluation of vaginal discharge.  Her mother has noticed white vaginal discharge mixed with a small amount of blood since yesterday.  The girl does not appear to be in pain and has been voiding and stooling adequately.  She is exclusively breastfed every 2-3 hours.  The mother mentions that she was treated "with a shot and a pill" for a sexually transmitted disease early in her pregnancy and subsequently tested negative.  The girl was born via forceps-assisted vaginal delivery due to protracted labor at 38 weeks gestation.  Temperature is 36.7 C (98 F).  Physical examination reveals a thin, white, odorless vaginal discharge with blood streaking.  The external genitalia are otherwise unremarkable, and the abdomen is soft and nontender without palpable masses.  What is the most likely cause of this patient's vaginal discharge?

Quizplus · Accepted Answer

11ec25c8_d668_ebfb_bc81_496c99461a27_MD0003_00 The most common cause of vaginal bleeding and discharge in the neonatal period is maternal withdrawal of estrogen. Similar to the follicular phase of menstruation, maternal estrogen crosses the placenta during pregnancy and causes growth of the fetal endometrial lining. Following delivery, the neonatal endometrium may slough off, causing self-limited, mucoid, vaginal bleeding. This bleeding typically occurs within the first 2 weeks of life and may last for several days. The effect of maternal hormones may also lead to temporary breast bud and external genitalia engorgement during the first month of life. There is no required treatment, and parents should be reassured that this brief bleeding is physiologic and normal. (Choice A) Candidal vaginitis causes a thick, white vaginal discharge and vaginal pruritus. It is uncommon in a prepubertal child unless there is a history of recent antibiotics or immunosuppression. The vulva and vagina may appear erythematous, but bleeding is not typical. (Choice B) Neonatal chlamydia infection can cause acute conjunctivitis or pneumonia. Most cases are transmitted during delivery while in contact with the mother's genital flora. It does not present with vaginal bleeding or discharge. (Choice D) Pediatric genital tract malignancies (eg, rhabdomyosarcoma) are very rare but may present with vaginal bleeding. Physical examination may show nodules resembling grapes protruding from the vagina. In an otherwise healthy neonate, maternal withdrawal of hormones is a far more common cause. (Choices E and F) Vaginal bleeding can result from lacerations to the external genitalia or vagina but typically occurs in older children with a history of blunt or penetrating trauma. Vaginal foreign bodies (eg, toilet paper) can also present with bleeding but are usually accompanied by foul-smelling discharge. This neonate does not appear to be in pain and has a normal physical examination. Educational objective: The most common cause of vaginal bleeding in the neonatal period is maternal withdrawal of estrogen. The bleeding is self-limited, and no treatment is required. References: Prepubertal vaginal bleeding: etiology, diagnostic approach, and management. (http://www.ncbi.nlm.nih.gov/pubmed/27065069) Vaginal bleeding in prepubertal girls: etiology and clinical management. (http://www.ncbi.nlm.nih.gov/pubmed/26506030)

A 5-Day-Old Girl Is Brought to the Emergency Department for Evaluation