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PROPOSAL FOR ARTICLE UPDATES We propose to add more information regarding the definition of Bloody Show and the specifics of its development in pregnancy. In addition, we will add a further distinction between the Bloody show and mucus plugs and we plan to contrast Bloody Show to other types of vaginal bleeding. Our group plans to utilize systematic reviews and clinical studies that reference the words "Bloody Show" to support our edits.

- Group Comment on Bloody Show talk page

FYI: Sign/Symptom Article Template can be found here Template:Article templates/Sign or symptom

ORIGINAL ARTICLE TEXT FOR REFERENCE

Bloody show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It is caused by the detachment of the cervical mucus plug that seals the cervix during pregnancy, and is one of the signs that labor may be imminent. Although the bloody show is a common and harmless cause of bleeding in late pregnancy, there are many other possible causes for vaginal bleeding, some of which may indicate serious medical problems such as miscarriage or placental abruption, and vaginal bleeding should not be ignored as a possible sign of serious complications.

Article Draft

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Bloody show or show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It is caused by thinning and dilation of the cervix, leading to detachment of the cervical mucus plug that seals the cervix during pregnancy and tearing of small cervical blood vessels,[1] and is one of the signs that labor may be imminent.[2] The bloody show may be expelled from the vagina in pieces or altogether[3] and often appears as a jelly-like piece of mucus stained with blood.[4] Although the bloody show may be alarming at first, it is not something to be alarmed about.

Differential Diagnoses

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Overview of Vaginal Bleeding

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Vaginal bleeding may occur at any point during pregnancy. Vaginal bleeding is common in early pregnancy (first 20 gestational weeks), occurring in about 20% of confirmed pregnancies. Vaginal bleeding may be accompanied by low birth weight for a newborn, preterm birth, or stillbirth.[5] Common causes of bleeding in the first trimester include ectopic pregnancy, implantation bleeding, molar bleeding, or miscarriage.[6] In the second trimester, around 22% of pregnant women reported vaginal bleeding.[7] While less common in late pregnancy, vaginal bleeding may still occur for 3-4% of late pregnancies.[8] During late pregnancy, bleeding may be normal but may also indicate a more serious underlying problem such as miscarriage, placenta previa, or placental abruption.[6][9][10][11] Heavy bleeding within the last two trimesters is affiliated with a higher risk of preterm birth.[12] The diagnostic examinations and tools used by healthcare providers to determine the type of vaginal bleed depend on a combination of the following: gestation age, history of pregnancy and bleeding, past medical history, physical examination, and laboratory work.[5][8]

Diagnosis and Assessment of Vaginal Bleeding in Late Pregnancy (≥ 20 gestational weeks)

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Bloody show is the most common cause of bleeding during late pregnancy and often presents as minor bleeding mixed with mucus alongside other signs of labor initiation (contractions, cervical dilation, cervical effacement).[8] While not considered as serious bleeding or deadly, the passage of a bloody show signals that labor is beginning or will begin soon.[13] In addition, diagnosis of bloody show is generally an exclusion from other potentially serious causes of bleeding in late pregnancy.[8]

While bloody show is not considered as vaginal bleeding requiring medical intervention, other more serious types of bleeding may visibly present as minor bleeding.[8] As such, if any of the following are observed, a more thorough examination is warranted to rule out serious causes of bleeding:[8][14]

  • Maternal hypotension
  • Tense and/or tender uterus
  • Fetal distress - deceleration, bradycardia, loss of heart sounds
  • Cessation of labor and/or inability of uterus to contract

Examination and assessment of vaginal bleeding occurs through a combination of the following:

  • History of current pregnancy - estimated due date, risk factors for complications, abdominal pain, uterine contractions[8][14]
  • History of previous pregnancies - number of confirmed pregnancies, number of late-term deliveries, number of abortions, risk factors for major bleeding (e.g. prior cesarean section)[8]
  • Character of the bleeding - color, appearance, onset time, presence of pain[8]
  • Physical examination - vital signs (including blood pressure), abdominal palpitation, speculum or digital cervical examination[8][14]
  • Ultrasound and/or magnetic resonance imaging - assessment of uterus location and shape[15][16]
  • Laboratory tests - complete blood count, coagulation tests[8]

A healthcare provider, such as an OBGYN, will consider all of the above in order to determine the cause of bleeding and if applicable, their plan for treatment.[17] Bloody show itself is a diagnosis of exclusion, that is it rules out other causes of vaginal bleeding.[8] Other causes of vaginal bleeding in late pregnancy include placental abruption, placeta previa, vasa previa, uterine rupture, and non-obstetric causes.[8]

Mechanism

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Physiology and Biochemistry

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Labor begins with the suppression of the inhibitory effects on myometrium contraction, leading to dilation of the cervix and pushing the fetus through the birth canal.[18] This occurs as intrauterine biochemical events lead to the softening and dilation of the cervix. Decidual cells, which play a nutritional role in the formation of the placenta, promote the synthesis and release of prostaglandins and proinflammatory cytokines. Prostaglandins are key in the onset of childbirth, as they synchronize uterine activation and cervical ripening. [19] In some pregnant individuals, hemorrhaging of blood vessels in the cervix may lead to a premature release of prostaglandins. Alongside prostaglandin, placental oxytocin is another key naturally occurring neuropeptide released at the onset of labor. Oxytocin can induce myometrial contractions, as it is a common tool used for augmentation of contractions after the onset of labor. Healthcare providers may utilize oxytocin in varying doses to induce labor in pregnant individuals in order to encourage contractions.[20] Pregnant individuals are highly sensitive to oxytocin because there is an increase in the concentration of myometrial oxytocin receptors (OXTR) in comparison with non-pregnant individuals.

Cyclic nucleotides, including cyclic guanosine monophosphate (cGMP) and cyclic adenosine monophosphate (cAMP), activate specific protein kinases to provide rapid intracellular responses to these neuropeptides. Cyclic GMP mediates nitric oxide in the myometrium, allowing the relaxation of the uterus. Cyclic AMP influences the relaxation of myometrial smooth muscle by complexing with adenylyl cyclase (ADCY), protein kinase A (PKA), and phosphodiesterases.[21]

Through this biochemical cascade, a pregnant individual is prepared for childbearing. Vaginal mucus, or vaginal discharge, may increase in quantity as pregnancy progresses.[22] While vaginal mucus is considered normal in individuals with female genitalia, pregnant individuals may notice streaks of blood or a red hue in their vaginal mucus. As the cervix effaces and dilates in preparation for childbearing, small blood vessels in the cervix may tear and bleed, leading to blood mixed with vaginal mucus from the displaced mucus plug.[17][23] A mucus plug[24] is a blockage of the cervix made up of mucus which acts as a physical barrier against infectious agents that may cause bacterial vaginosis or harm to the fetus. It also contains many antimicrobial agents, similarly to the mucus found in the nasal cavity. The mucus plug develops during pregnancy to provide a pathogen-free uterus to house the fetus.[25] When a mucus plug detaches, a bloody show can be initiated.[26] As the blood vessels in the cervix dilate, this leads to ruptures of membranes that allow blood and amniotic fluid to gather in the posterior vaginal canal.[27] Pregnant individuals may present to an obstetrical triage with this phenomenon of blood-tinged vaginal leakage.

Diagnostic Evaluation

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Bloody show is recognized through the presence of mucus and blood that is combined and discharged from the cervix before labor occurs.[28] Bloody show is sometimes used as an indication of active labor, and can occur as a result of the onset of labor.[29] Bloody show can also occur with other symptoms of onset of labor, including painful contractions, degree of cervical effacement, and/or spontaneous membrane rupture.[30] Usually those symptoms are more commonly found than bloody show.

Bloody show may occur before labor, sometimes as early as three days before the actual delivery date.[28] When bloody show occurs, pregnant individuals are encouraged to see a midwife or doctor as this may be an indication of active labor.[13] Bloody show may occur gradually or all at once, however, it will indicate the pregnant person will go into labor soon.[31]

Treatment/Management

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Bloody show is not considered abnormal within the context of pregnancy, therefore, no treatment is required.[17] It is also not recommended to keep the bloody show for any reason (for example, to show to a healthcare provider) as it is unnecessary and normal to have a bloody show. If a bloody show occurs too early during a pregnancy, there are a few options to counteract the increased risk of infection and premature labor.[3] Preterm labor is when your cervix opens after week 20 of pregnancy and before week 37.[32] These options include de-stressing such as bed rest, avoiding hardcore activities, monitoring for signs of active labor, and stitching the cervix close. Stitching the cervix close will help prevent infection or pathogenic harm to the fetus while it develops. Management of the beginning of labor, after the bloody show, can include breathing techniques and hydration to maintain relaxation before delivering the baby.[33] Other symptoms that pregnant individuals may experience towards the end of pregnancy include gas, bloating, back pain, vaginal discharge or spotting, breast leakage, or Braxton Hicks contractions. Focusing on posture, trying pelvic tilts, and swimming could be ways to decrease severity of back pain that is experienced during the third trimester. Walking, eating smaller meals, and avoiding foods that cause gas can decrease bloating and the uncomfortable pain of gas buildup. For breast leakage, using nursing pads and massaging the area may help. Although there are no treatments for Braxton Hicks contractions or vaginal discharge and spotting, being aware of the symptoms and their timing is important for a healthy pregnancy and delivery.[31]

Epidemiology

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Although the bloody show can occur as part of the natural progression of labor, activities such as sexual intercourse, pressure on the pelvis, or trauma can initiate the occurrence of bloody show and labor.[17] Risk factors that can increase the chance of preterm labor and of having a bloody show include preeclampsia[34] and birth complications that risk the health of the mother or fetus.[35] Risk factors for preterm pregnancy such as high blood pressure, blood clotting issues, diabetes, sexually transmitted infections, or other vaginal infections may also put the mother at a high risk of an early bloody show.[36]

History

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Bloody show was first mentioned in an article back in 1995.[37] It was not considered to be a sign of bleeding. Its topic has been talked about more within 2021-2023.

References

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  1. ^ "Vaginal birth - series—Indications: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2018-10-17.
  2. ^ "Am I in labor?: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2018-10-17.
  3. ^ a b "What Does the Bloody Show Look Like?". MedicineNet. Retrieved 2023-07-31.
  4. ^ "Cervical Effacement: Causes, Measuring & What It Means". Cleveland Clinic. Retrieved 2023-07-31.
  5. ^ a b "Vaginal Bleeding During Early Pregnancy - Gynecology and Obstetrics". Merck Manuals Professional Edition. Retrieved 2023-07-31.
  6. ^ a b "Bleeding During Pregnancy". www.acog.org. Retrieved 2023-07-31.
  7. ^ Strobino B, Pantel-Silverman J. (April 1989). "Gestational vaginal bleeding and pregnancy outcome". PMID 2923126. Retrieved 31 July 2023. {{cite journal}}: Cite journal requires |journal= (help)
  8. ^ a b c d e f g h i j k l m "Vaginal Bleeding During Late Pregnancy - Gynecology and Obstetrics". Merck Manuals Professional Edition. Retrieved 2023-07-31.
  9. ^ McKennett, M; Fullerton, JT (1995). "Vaginal bleeding in pregnancy". American Family Physician. 51 (3): 639–46. ISSN 0002-838X. PMID 7863960.
  10. ^ "Vaginal bleeding in pregnancy". nhs.uk. 2017-12-21. Retrieved 2018-10-17.
  11. ^ "Bleeding during pregnancy". Mayo Clinic. Retrieved 2023-07-31.
  12. ^ Cite error: The named reference :0 was invoked but never defined (see the help page).
  13. ^ a b "Signs that labour has begun". nhs.uk. 2020-12-01. Retrieved 2023-07-27.
  14. ^ a b c Sakamoto, Jeffrey; Michels, Collin; Eisfelder, Bryn; Joshi, Nikita (2019). "Trauma in Pregnancy". Emergency Medicine Clinics of North America. Obstetric and Gynecologic Emergencies. 37 (2): 317–338. doi:10.1016/j.emc.2019.01.009. ISSN 0733-8627.
  15. ^ Sakornbut, Ellen; Leeman, Lawrence; Fontaine, Patricia (2007-04-15). "Late Pregnancy Bleeding". American Family Physician. 75 (8): 1199–1206.
  16. ^ Edmonds, D. Keith; Lees, Christoph; Bourne, Tom, eds. (2018-09-14). Dewhurst's Textbook of Obstetrics & Gynaecology. Chichester, UK: John Wiley & Sons, Ltd. doi:10.1002/9781119211457. ISBN 978-1-119-21145-7.
  17. ^ a b c d "Bloody Show: Symptoms & Signs of Labor". Cleveland Clinic. Retrieved 2023-07-30.
  18. ^ Liao, John B.; Buhimschi, Catalin S.; Norwitz, Errol R. (2005). "Normal labor: mechanism and duration". Obstetrics and Gynecology Clinics of North America. 32 (2): 145–164, vii. doi:10.1016/j.ogc.2005.01.001. ISSN 0889-8545. PMID 15899352.
  19. ^ Bernal, A.L. and Norwitz, E.R. (2018). Normal Mechanisms in Labour. In Dewhurst's Textbook of Obstetrics & Gynaecology. pp. 283–306. Retrieved 31 July 2023.{{cite book}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link)
  20. ^ Bernal, A.L. and Norwitz, E.R. (2018). Induction and Augmentation of Labor. In Dewhurst's Textbook of Obstetrics & Gynaecology. pp. 283–306. Retrieved 31 July 2023.{{cite book}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link)
  21. ^ Bernal, A.L. and Norwitz, E.R. (2018). Normal Mechanisms in Labour. In Dewhurst's Textbook of Obstetrics & Gynaecology. pp. 283–306. Retrieved 31 July 2023.{{cite book}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link)
  22. ^ https://www.nhs.uk/pregnancy/related-conditions/common-symptoms/vaginal-discharge/#:~:text=It%20is%20normal%20to%20have,%2C%20jelly%2Dlike%20pink%20mucus.
  23. ^ Hutchison, Julia; Mahdy, Heba; Hutchison, Justin (2023), "Stages of Labor", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 31335010, retrieved 2023-07-25
  24. ^ "Mucus Plug: What It Is, Looks Like & Means". Cleveland Clinic. Retrieved 2023-07-25.
  25. ^ Lacroix, Guillaume (2020). "The Cervicovaginal Mucus Barrier". International Journal of Molecular Sciences.
  26. ^ Williams obstetrics (24th ed.). New York: McGraw-Hill education. 2014. ISBN 978-0-07-179893-8.
  27. ^ Hutchison, Julia; Mahdy, Heba; Hutchison, Justin (2023), "Stages of Labor", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 31335010, retrieved 2023-07-27
  28. ^ a b Togioka, Brandon M.; Tonismae, Tiffany (2023), "Uterine Rupture", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32644635, retrieved 2023-07-27
  29. ^ Hanley, Gillian E.; Munro, Sarah; Greyson, Devon; Gross, Mechthild M.; Hundley, Vanora; Spiby, Helen; Janssen, Patricia A. (2016). "Diagnosing onset of labor: a systematic review of definitions in the research literature". BMC Pregnancy and Childbirth. 16: 71. doi:10.1186/s12884-016-0857-4. ISSN 1471-2393. PMC 4818892. PMID 27039302.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  30. ^ "Strategies To Reduce Cesarean Birth in Low-Risk Women | Effective Health Care (EHC) Program". effectivehealthcare.ahrq.gov. Retrieved 2023-07-27.
  31. ^ a b "37 Weeks Pregnant: Symptoms, Baby Movement & More". BabyCenter. Retrieved 2023-07-31.
  32. ^ "Preterm labor - Symptoms and causes". Mayo Clinic. Retrieved 2023-07-31.
  33. ^ Herbert, Clare; midwife, Senior; Leader |, Team. "How long after the mucus plug comes out does labour start?". BabyCentre UK. Retrieved 2023-07-31.
  34. ^ Rana, Sarosh; Lemoine, Elizabeth; Granger, Joey P.; Karumanchi, S. Ananth (2019-03-29). "Preeclampsia: Pathophysiology, Challenges, and Perspectives". Circulation Research. 124 (7): 1094–1112. doi:10.1161/CIRCRESAHA.118.313276. ISSN 0009-7330.
  35. ^ Romero, Roberto; Dey, Sudhansu K.; Fisher, Susan J. (2014). "Preterm labor: one syndrome, many causes". Science (New York, N.Y.). 345 (6198): 760–765. doi:10.1126/science.1251816. ISSN 1095-9203. PMC 4191866. PMID 25124429.
  36. ^ "What are the risk factors for preterm labor and birth? | NICHD - Eunice Kennedy Shriver National Institute of Child Health and Human Development". www.nichd.nih.gov. 2023-05-09. Retrieved 2023-07-31.
  37. ^ Salafia, C. M.; López-Zeno, J. A.; Sherer, D. M.; Whittington, S. S.; Minior, V. K.; Vintzileos, A. M. (1995). "Histologic evidence of old intrauterine bleeding is more frequent in prematurity". American Journal of Obstetrics and Gynecology. 173 (4): 1065–1070. doi:10.1016/0002-9378(95)91327-0. ISSN 0002-9378. PMID 7485294.
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