A female infant was born at 41 weeks' gestation to a 28-year-old primiparous woman after an uneventful pregnancy. The baby was delivered vaginally without instrumentation in a breech presentation 14 hours after spontaneous rupture of the membranes. She weighed 3360 g, was 49.5 cm long and had a head circumference of 36 cm. The only abnormalities on physical examination were diffuse hematomas of the labia majora and an edematous tag originating from the posterior part of the hymeneal ring that had a bluish discoloration (Fig. 1A). Figs. 1B and 1C show the lesions at day 2 and at 1 week. The baby was also seen at 3 months (not shown) and at 1 year (Fig. 1D) without any sequelae related to the birth trauma. A congenital midline fusion of the anogenital area, unrelated to the birth trauma, was also observed (arrows in Figs. 1B, 1C and 1D).
Figure 1. Photo: Courtesy: Dr. Ana Carceller
In a similar case a female infant was born at 38 weeks' gestation to a 37-year-old primiparous woman after an uneventful pregnancy. The baby was in breech presentation and was delivered by cesarean section after a 12-hour trial of labour. She weighed 3190 g, was 46 cm long and had a head circumference of 36 cm. The findings at physical examination were unremarkable except for a bilateral hip dislocation and a diffuse hematoma of the labia majora (Fig. 2A). Fig. 2B (day 2) and Fig. 2C (1 week) demonstrate the rapid resolution of these lesions. The baby had orthopedic and physiotherapy follow-up but no further gynecologic sequelae.
Figure 2. Photo: Courtesy: Dr. Ana Carceller
Neonatal genital trauma is a recognized but relatively uncommon complication of breech presentations.1,2,3 It is more common in babies of primiparous women than in those of multiparous women and can theoretically be prevented by cesarean section without a trial of labour. Diffuse ecchymoses secondary to leakage from capillaries or venules may appear during labour and result in swollen and tender masses with port wine discoloration of the labia majora and labia minora in girls; in boys it results in diffuse hematoma of the scrotum, which has to be differentiated from neonatal testicular torsion. Injury to the abdominal viscera, especially the liver, the spleen or the adrenals, may also occur during a difficult breech presentation and extraction. Hemoperitoneum may also cause a scrotal hematoma in the presence of a patent processus vaginalis.4
Infants with neonatal genital trauma may experience mild perineal discomfort and pain on voiding but are otherwise asymptomatic. Jaundice sometimes results from the breakdown and resorption of large hematomas. The appearance of new bruises or petechiae after the delivery may indicate a bleeding disorder.
A congenital midline fusion anomaly of the genital area is sometimes noted during routine physical examination of young girls. Documentation of such congenital abnormalities in the patient's chart at the time of the newborn examination can help to differentiate them later from other lesions such as those caused by sexual abuse.5,6
Perineal lesions usually do not require aggressive treatment. Pressure with a moist saline pack often can control small vulvar hematomas. Analgesics are sometimes required. Topical bacteriostatic and anesthetic ointments are rarely needed.
Ana Carceller Claire Dansereau Department of Pediatrics Hervé Blanchard Department of Surgery Hôpital Sainte-Justine Montreal, Que.
References
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- 3.Sahaffer AJ. Diseases of the newborn. 2nd ed. Philadelphia: WB Saunders; 1966.
- 4.Spitz L, Steiner GM, Zachary RB. Color atlas of pediatric surgical diagnosis. Chicago: Year Book Medical Publishers; 1981.
- 5.Heger A, Emans SJ, Muram D, et al, editors. Evaluation of the sexually abused child. A medical textbook and photographic atlas. 2nd ed. New York: Oxford University Press; 2000.
- 6.Emans SJH, Laufer MR, Goldstein DP, editors. Pediatric and adolescent gynecology. 4th ed. Philadelphia: Lippincott–Raven; 1998.