Bloody show

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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 a concern of patient health after 37 weeks gestation. [5]

Contents

Signs and symptoms

Bloody show is recognized through the presence of mucus and blood that is combined and discharged from the cervix before labor occurs. [6] Bloody show is sometimes used as an indication of active labor, and can occur as a result of the onset of labor. [7] Bloody show can also occur with other symptoms of onset of labor, including painful contractions, degree of cervical effacement, and/or spontaneous membrane rupture. [8] Severity of symptoms differs from person to person and 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. [6] When bloody show occurs, pregnant individuals are encouraged to see a midwife or doctor as this may be an indication of active labor. [9] Bloody show may occur gradually or all at once, however, it will indicate the pregnant person will go into labor soon. [5]

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). [10] While not considered as serious bleeding or deadly, the passage of a bloody show signals that labor is beginning or will begin soon. [9]

Diagnosis

The diagnostic examinations and tools used to determine the type of vaginal bleeding depend on a combination of gestation age, history of pregnancy and bleeding, past medical history, physical examination, and laboratory work. [10]

Differential diagnoses

Vaginal bleeding may occur at any point during pregnancy. [14] During late pregnancy, bleeding may be normal but may also indicate a more serious underlying problem such as miscarriage, placenta previa, or placental abruption. [15] [16] [17] [18] Bloody show itself is an exclusionary diagnosis, that is, it rules out other causes of vaginal bleeding. [10] Other causes of vaginal bleeding in late pregnancy include placental abruption, placenta previa, vasa previa, uterine rupture, and non-obstetric causes. [10]

While bloody show is not considered as vaginal bleeding requiring medical intervention, other more serious types of bleeding may visibly present as minor bleeding. [10] As such, if any of the following are observed, a more thorough examination is warranted to rule out serious causes of bleeding: [10] [11]

Management

Bloody show is not considered abnormal within the context of pregnancy, therefore, no treatment is required. [5]

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 occurs when the cervix opens after week 20 of pregnancy and before week 37. [19] These options include de-stressing such as bed rest, avoiding intense activities, monitoring for signs of active labor, and stitching the cervix closed. Sometimes, the cervix will be stitched closed to 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. [20]

Mechanism

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. [21] 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. [22] 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. [23]

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. [22]

Through this biochemical cascade, a pregnant individual is prepared for childbearing. Vaginal mucus, or vaginal discharge, may increase in quantity as pregnancy progresses. [24] 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. [25] The mucus plug [26] 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 human nasal cavity. The mucus plug develops during pregnancy to provide a pathogen-free uterus to house the fetus. [27] When a mucus plug detaches, a bloody show can be initiated. [28] 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. [25]

Epidemiology

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. [5] Risk factors that can increase the chance of preterm labor and of having a bloody show include preeclampsia [29] and birth complications that risk the health of the mother or fetus. [30] 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. [31]

History

Bloody show was first mentioned in an article back in 1995. [32]

See also

Related Research Articles

<span class="mw-page-title-main">Cervix</span> Lower part of the uterus in the human female reproductive system

The cervix or cervix uteri is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long and roughly cylindrical in shape, which changes during pregnancy. The narrow, central cervical canal runs along its entire length, connecting the uterine cavity and the lumen of the vagina. The opening into the uterus is called the internal os, and the opening into the vagina is called the external os. The lower part of the cervix, known as the vaginal portion of the cervix, bulges into the top of the vagina. The cervix has been documented anatomically since at least the time of Hippocrates, over 2,000 years ago.

<span class="mw-page-title-main">Misoprostol</span> Medication to induce abortion and treat ulcers

Misoprostol is a synthetic prostaglandin medication used to prevent and treat stomach and duodenal ulcers, induce labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus. It is taken by mouth when used to prevent gastric ulcers in people taking nonsteroidal anti-inflammatory drugs (NSAID). For abortions it is used by itself or in conjunction with mifepristone or methotrexate. By itself, effectiveness for abortion is between 66% and 90%. For labor induction or abortion, it is taken by mouth, dissolved in the mouth, or placed in the vagina. For postpartum bleeding it may also be used rectally.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.

Rupture of membranes (ROM) or amniorrhexis is a term used during pregnancy to describe a rupture of the amniotic sac. Normally, it occurs spontaneously at full term either during or at the beginning of labor. Rupture of the membranes is known colloquially as "breaking [one's] water," especially when induced rather than spontaneous, or as one's "water breaking". A premature rupture of membranes (PROM) is a rupture of the amnion that occurs at full term and prior to the onset of labor. In cases of PROM, options include expectant management without intervention, or interventions such as oxytocin or other methods of labor induction, and both are usually accompanied by close monitoring of maternal and fetal health. Preterm premature rupture of membranes (PPROM) is when water breaks both before the onset of labor and before the pregnancy's 37 week gestation. In the United States, more than 120,000 pregnancies per year are affected by a premature rupture of membranes, which is the cause of about one third of preterm deliveries.

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Antepartum bleeding, also known as antepartum haemorrhage (APH) or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery.

Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically or medically.

<span class="mw-page-title-main">Uterine rupture</span> Medical condition

Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the mother or baby may result.

Dilation and evacuation (D&E) is the dilation of the cervix and surgical evacuation of the uterus after the first trimester of pregnancy. It is a method of abortion as well as a common procedure used after miscarriage to remove all pregnancy tissue.

<span class="mw-page-title-main">Prelabor rupture of membranes</span> Medical condition

Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.

<span class="mw-page-title-main">Cervical effacement</span>

Cervical effacement or cervical ripening refers to the thinning and shortening of the cervix. This process occurs during labor to prepare the cervix for dilation to allow the fetus to pass through the vagina. While this a normal, physiological process that occurs at the later end of pregnancy, it can also be induced through medications and procedures.

<span class="mw-page-title-main">Cervical cerclage</span> Obstetrics medical procedure

Cervical cerclage, also known as a cervical stitch, is a treatment for cervical weakness, when the cervix starts to shorten and open too early during a pregnancy causing either a late miscarriage or preterm birth. In women with a prior spontaneous preterm birth and who are pregnant with one baby, and have shortening of the cervical length less than 25 mm, a cerclage prevents a preterm birth and reduces death and illness in the baby.

Cervical weakness, also called cervical incompetence or cervical insufficiency, is a medical condition of pregnancy in which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term. Definitions of cervical weakness vary, but one that is frequently used is the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester. Cervical weakness may cause miscarriage or preterm birth during the second and third trimesters. It has been estimated that cervical insufficiency complicates about 1% of pregnancies, and that it is a cause in about 8% of women with second trimester recurrent miscarriages.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, with lower morbidity and mortality than caesarean sections (C-sections).

A cervical mucus plug (operculum) is a plug that fills and seals the cervical canal during pregnancy. It is formed by a small amount of cervical mucus that condenses to form a cervical mucus plug during pregnancy.

Early pregnancy bleeding refers to vaginal bleeding before 14 weeks of gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain.

<span class="mw-page-title-main">Prolonged labor</span> Medical condition

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. Failure to progress can take place during two different phases; the latent phase and active phase of labor. The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. The active phase of labor, on the other hand, if prolonged, can result in long term complications.

<span class="mw-page-title-main">Emergency childbirth</span>

Emergency childbirth is the precipitous birth of an infant in an unexpected setting. In planned childbirth, mothers choose the location and obstetric team ahead of time. Options range from delivering at home, at a hospital, a medical facility or a birthing center. Sometimes, birth can occur on the way to these facilities, without a healthcare team. The rates of unplanned childbirth are low. If the birth is imminent, emergency measures may be needed. Emergency services can be contacted for help in some countries.

References

  1. ↑ "Vaginal birth - series—Indications". MedlinePlus Medical Encyclopedia. U.S. National Library of Medicine. Retrieved 2018-10-17.
  2. ↑ "Am I in labor?". MedlinePlus Medical Encyclopedia. U.S. National Library of Medicine. Retrieved 2018-10-17.
  3. 1 2 Brennan D. "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. 1 2 3 4 "Bloody Show: Symptoms & Signs of Labor". Cleveland Clinic. Retrieved 2023-07-30.
  6. 1 2 Togioka BM, Tonismae T (2023). "Uterine Rupture". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   32644635 . Retrieved 2023-07-27.
  7. ↑ Hanley GE, Munro S, Greyson D, Gross MM, Hundley V, Spiby H, Janssen PA (April 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 . PMC   4818892 . PMID   27039302.
  8. ↑ "Strategies To Reduce Cesarean Birth in Low-Risk Women". Effective Health Care (EHC) Program. Retrieved 2023-07-27.
  9. 1 2 "Signs that labour has begun". National Health Service, UK. 2020-12-01. Retrieved 2023-07-27.
  10. 1 2 3 4 5 6 7 8 9 10 11 "Vaginal Bleeding During Late Pregnancy – Gynecology and Obstetrics". Merck Manuals Professional Edition. Retrieved 2023-07-31.
  11. 1 2 Sakamoto J, Michels C, Eisfelder B, Joshi N (May 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. PMID   30940375. S2CID   88034782.
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  15. ↑ "Bleeding During Pregnancy". American College of Obstetricians and Gynecologists. Retrieved 2023-07-31.
  16. ↑ McKennett M, Fullerton JT (February 1995). "Vaginal bleeding in pregnancy". American Family Physician. 51 (3): 639–646. PMID   7863960.
  17. ↑ "Vaginal bleeding in pregnancy". National Health Service, UK. 2017-12-21. Retrieved 2018-10-17.
  18. ↑ "Bleeding during pregnancy". Mayo Clinic. Retrieved 2023-07-31.
  19. ↑ "Preterm labor - Symptoms and causes". Mayo Clinic. Retrieved 2023-07-31.
  20. ↑ "Coping Skills for Labor without Medication". Cleveland Clinic. Retrieved 2023-08-01.
  21. ↑ Liao JB, Buhimschi CS, Norwitz ER (June 2005). "Normal labor: mechanism and duration". Obstetrics and Gynecology Clinics of North America. 32 (2): 145–64, vii. doi:10.1016/j.ogc.2005.01.001. PMID   15899352.
  22. 1 2 Bernal AL, Norwitz ER (2018). "Normal Mechanisms in Labour". In Edmonds DK, Lees C, Bourne T (eds.). Dewhurst's Textbook of Obstetrics & Gynaecology. John Wiley & Sons Ltd. pp. 283–306. doi:10.1002/9781119211457.ch22. ISBN   978-1-119-21145-7. S2CID   91492214.
  23. ↑ Norman JE, Stock SJ (2018). "Induction and Augmentation of Labor". In Dewhurst's Textbook of Obstetrics & Gynaecology. John Wiley & Sons Ltd. pp. 326–355. doi:10.1002/9781119211457.ch24. ISBN   978-1-119-21145-7.
  24. ↑ "Vaginal discharge in pregnancy". National Health Service, UK. 3 December 2020.
  25. 1 2 Hutchison J, Mahdy H, Hutchison J (2023). "Stages of Labor". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   31335010 . Retrieved 2023-07-25.
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  27. ↑ Lacroix G (2020). "The Cervicovaginal Mucus Barrier". International Journal of Molecular Sciences. 21 (21): 8266. doi: 10.3390/ijms21218266 . PMC   7663572 . PMID   33158227.
  28. ↑ Williams Obstetrics (24th ed.). New York: McGraw-Hill education. 2014. ISBN   978-0-07-179893-8.
  29. ↑ Rana S, Lemoine E, Granger JP, Karumanchi SA (March 2019). "Preeclampsia: Pathophysiology, Challenges, and Perspectives". Circulation Research. 124 (7): 1094–1112. doi: 10.1161/CIRCRESAHA.118.313276 . PMID   30920918. S2CID   242400796.
  30. ↑ Romero R, Dey SK, Fisher SJ (August 2014). "Preterm labor: one syndrome, many causes". Science. 345 (6198): 760–765. Bibcode:2014Sci...345..760R. doi:10.1126/science.1251816. PMC   4191866 . PMID   25124429.
  31. ↑ "What are the risk factors for preterm labor and birth?". NICHD - Eunice Kennedy Shriver National Institute of Child Health and Human Development. 2023-05-09. Retrieved 2023-07-31.
  32. ↑ Salafia CM, López-Zeno JA, Sherer DM, Whittington SS, Minior VK, Vintzileos AM (October 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. PMID   7485294.
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