A 5-day-old girl is brought to the emergency department due to white vaginal discharge with streaks of blood since yesterday. The patient 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 infection early in her pregnancy and subsequently tested negative. The patient was born via forceps-assisted vaginal delivery at 38 weeks gestation. She lives at home with her parents and 9-year-old sister. Temperature is 36.7 C (98 F). On physical examination, a white, mucoid vaginal discharge with streaks of blood is noted. The remainder of the examination is unremarkable. Which of the following is the most likely cause of this patient's vaginal discharge?
Neonatal withdrawal bleeding | |
Physiology |
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Clinical features |
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Diagnosis & management |
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This 5-day-old girl has mucoid vaginal discharge with streaks of blood, the classic findings of neonatal withdrawal bleeding. This benign condition is the most common cause of vaginal bleeding in neonates and is due to withdrawal of maternal hormones.
In utero, maternal estrogen crosses the placenta and stimulates fetal endometrial proliferation. At birth, withdrawal of maternal progesterone and the absence of the trophic effect of maternal estrogen cause endometrial sloughing and light vaginal bleeding, as seen in this patient. Bleeding typically occurs within the first 2 weeks of life and is self-limited (<5 days). Other physiologic effects resulting from exposure to maternal estrogen in utero include leukorrhea (thin, white vaginal discharge), labial swelling, breast hypertrophy, and galactorrhea.
Diagnosis is clinical, and no treatment is required. Management is observation and education and reassurance for parents.
(Choice A) Vaginal candidiasis usually causes a thick, white, adherent discharge. The vaginal mucosa often appears erythematous, and bleeding is not typical. Although candidal diaper rashes are common in young children, vaginal infection in a prepubertal child typically occurs only with recent antibiotic use or immunosuppression.
(Choice B) Vertical transmission of Chlamydia trachomatis typically manifests as conjunctivitis or pneumonia, not vaginal bleeding or discharge.
(Choice C) Group A Streptococcus (S pyogenes) may be transmitted from colonized household contacts (eg, older siblings), but vaginal infection is uncommon and typically presents with mucosal erythema and purulent, not bloody, discharge.
(Choice E) Vaginal foreign bodies can cause vaginal bleeding but typically occur in older children who are at a developmentally appropriate age for toilet training (toilet paper is the most common foreign body) or self-exploration (eg, small toys); foul-smelling discharge and pain are also typical. This diagnosis in a neonate who is otherwise well would be exceedingly unlikely.
Educational objective:
Neonatal vaginal bleeding is usually benign and caused by withdrawal of maternal hormones. Pathophysiology involves fetal endometrial proliferation from maternal estrogen followed by endometrial sloughing after delivery from maternal progesterone withdrawal. Findings include light, self-limited vaginal bleeding.