Introduction: This study aimed to evaluate the impact of third-trimester post-coital bleeding (PCB) on pregnancy outcomes. Methods: A retrospective cohort study was conducted at two tertiary medical centers, including all pregnant women between 24 and 34 weeks of gestation referred due to vaginal bleeding over an 11-year period. The study population includes all singleton deliveries; within this population, women were further classified into three groups: those admitted due to vaginal bleeding related to PCB, those admitted due to vaginal bleeding not related to PCB, and those who did not report vaginal bleeding. The primary outcome measure was delivery prior to 37 weeks of gestation, while secondary outcome measures included maternal and neonatal complications. Baseline characteristics of the two groups were compared. Results: During the study period, there were a total of 51,698 deliveries. Among these, 230 cases involved bleeding between 24 and 34 weeks of gestation, 34 (14.8%) were identified as PCB, and 196 as bleeding unrelated to intercourse. In addition, 51,468 pregnancies without bleeding were analyzed as the general population for comparison. The incidence of preterm labor before 37 weeks of gestation was notably higher in both women with PCB (14.7%) and those with bleeding unrelated to coitus (20.9%) compared to the general population (5.6%); however, there was no statistically significant difference between the two bleeding groups (p = 0.403) while both were significantly different from the general population (p < 0.001). The odds ratio for preterm birth before 37 weeks of gestation after PCB was 3.29 (95% CI: 1.26–8.56, p = 0.0149). There were no significant differences between the PCB and bleeding unrelated to intercourse groups in terms of maternal and neonatal complications. Conclusion: This study found that third-trimester PCB is a risk factor for preterm delivery, with rates similar to other causes of third-trimester bleeding but significantly higher than the general population without bleeding. These findings challenge the assumption that PCB is benign.

Vaginal bleeding during the third trimester of pregnancy is a common and often concerning occurrence, with a reported prevalence of approximately 2% [1‒4]. When this bleeding episode follows sexual intercourse and is not accompanied by clinical symptomatology or findings suggesting common etiologies such as placenta previa or abruption, it is defined as post-coital bleeding (PCB) [5, 6]. Despite the high prevalence of PCB, there are limited studies describing its clinical significance and currently no evidence-based guidelines for its management [7‒11].

The etiology of PCB is thought to be minor cervical or vaginal trauma, leading to the assumption that it is a benign condition [5]. However, the impact of PCB on pregnancy outcomes, including preterm delivery and maternal and neonatal complications, is not well understood. Previous research on PCB has been limited to case reports, small case series, and retrospective studies, making it difficult to draw definitive conclusions about its clinical significance and the potential risks it may pose [6, 8, 11‒14].

The aim of this study was to investigate the potential association between third-trimester PCB and pregnancy outcomes using a retrospective cohort design. By evaluating the relationship between PCB and pregnancy outcomes, our study aimed to contribute to the limited literature on this condition and inform clinical practice. The findings of this study have the potential to guide the development of evidence-based guidelines for the management of PCB in pregnancy and improve the care of women experiencing this common episode.

Study Design and Population

This was a retrospective cohort study conducted over an 11-year period in the maternal-fetal unit of two campuses of a tertiary care university teaching hospital with approximately 12,000 deliveries annually [15]. The study population included pregnant women between 24 + 0/7 and 33 + 6/7 weeks of gestation who were admitted to the high-risk antenatal ward for vaginal bleeding. The study group consisted of those admitted with third-trimester PCB, and the comparison group consisted of those admitted with vaginal bleeding unrelated to intercourse. A separate sample from a previously collected database of 51,468 singleton pregnant women without bleeding was used to represent the general population.

Data Collection

The primary outcome measure was delivery prior to 37 weeks of gestation, while secondary outcome measures were maternal and neonatal complications, including rates of fetal distress, neonatal intensive care unit (NICU) admission, and neonatal morbidity. Baseline characteristics were compared between the PCB and control groups. Preterm birth rates were compared among the study group (PCB), control group (vaginal bleeding unrelated to intercourse), and general population.

For this study, a variety of other clinical data were collected from the electronic medical records of the study participants. The data included maternal demographics, such as age and religion, as well as information on smoking habits and obstetrical history, including any previous preterm deliveries. Information before, during, and after birth events was also collected, as well as pregnancy outcomes. The data were collected by research staff, and the midwives and obstetricians who were providing care to the patients during labor were unaware of the study, in order to minimize any potential bias.

The antepartum evaluation included data on the episodes of bleeding, including the gestational age at the onset of bleeding, the length of bleeding and hospitalization, the amount of bleeding, any accompanying symptoms, and any treatment received during hospitalization. The intrapartum information included the gestational age at delivery, the onset of labor (whether it was spontaneous, induced, or augmented), the mode of delivery, and any intrapartum complications such as fever, post-partum hemorrhage, genital lacerations, or the need for manual removal of the placenta. The pregnancy outcomes evaluated included both maternal outcomes: presence of placental abruption (either clinically or as identified by placental pathology, if the placenta was sent for examination) and the length of hospitalization after delivery and neonatal outcomes: preterm birth, birth weight, gender assigned at birth, Apgar score at 5 min, admission to the NICU, and length of neonatal hospitalization.

History of preterm delivery was operationalized as any previous birth occurring before 37 weeks of gestation. The volume of bleeding was categorized as either less than, equivalent to, or exceeding the amount typical of menstrual bleeding. A low-lying placenta was characterized as a placenta situated within 2 cm of the cervical os. Trauma encompassed instances of blunt force with or without direct injury to the abdomen, including incidents such as motor vehicle accidents, falls, or physical abuse; however, cases involving penetrating abdominal trauma were excluded. Clinical signs indicative of placental abruption in proximity to delivery were identified as hospitalizations complicated by bleeding, with delivery occurring during the same hospital stay in the absence of alternative reasons for delivery, or substantial bleeding near the time of delivery.

Statistical Analysis

Differences between the PCB and comparison groups in terms of the primary and secondary outcome measures were analyzed. To evaluate the association between two categorical variables, the χ2 test or Fisher’s exact test were applied. For comparison of a quantitative variable between two independent groups, the two-sample t test or the non-parametric Mann-Whitney test were applied in cases of non-normally distributed data. All statistical tests were two tailed, and a p value ≤0.05 was considered statistically significant. The data collected for this study were entered into an electronic spreadsheet and analyzed using statistical software (IBM-SPSS statistical package v.24 for Windows, Armonk, NY, USA).

Ethical Considerations

The study received ethical approval from the local Ethics Committee and informed consent was waived by the Institutional Review Board (IRB N°: 0211-14-HMO). All personal and identifying information was removed before analysis to ensure confidentiality.

Study Population

The study population consisted of 230 singleton pregnancies, 34 (14.8%) of which were referred with PCB and composed the study group, while 196 (85.2%) were referred with vaginal bleeding unrelated to intercourse and served as the control group. A separate sample of 51,468 pregnancies without bleeding represented the background population. The characteristics of the study population and the group assignments are presented in Figure 1.

Fig. 1.

Study design flowchart: this figure shows the study design used in this research.

Fig. 1.

Study design flowchart: this figure shows the study design used in this research.

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Demographic characteristics of the study population were compared between the two groups, including maternal age, nulliparity, and smoking status are presented in Table 1. The results revealed that the mean maternal age was significantly lower in the PCB group (mean 27.65 years) compared to the bleeding unrelated to coitus group (mean 31.36 years, p = 0.001). Additionally, a higher proportion of nulliparous women were present in the group with bleeding unrelated to coitus (71.9%) compared to the group with PCB (41.2%, p < 0.001). The prevalence of smoking did not differ significantly between the two groups, with a slightly higher proportion of women in the bleeding unrelated to coitus group reporting this characteristic (6.6% compared to 11.8% in the PCB group, p = 0.289). The amount of bleeding was similar between the two groups, with the majority of women in both groups reporting bleeding less than their menstrual period. Induction was more common in the group with PCB (35.3%) compared to the group with bleeding unrelated to coitus (25.5%).

Table 1.

Comparison of demographic characteristics between PCB and bleeding unrelated to coitus groups

CharacteristicPCB (n = 34)Bleeding unrelated to coitus (n = 196)p value
Maternal age, mean±SD, years 27.65±5.81 31.36±6.14 0.001 
Gestational age at bleeding, mean±SD, weeks 30.0±2.1 29.1±2.9 0.074 
Nulliparous, N (%) 14 (41.2) 141 (71.9) <0.001 
Smoking, N (%) 4 (11.8) 13 (6.6) 0.289 
Cervical length, mean±SD, mm 34.4±9.6 33.6±11.9 0.651 
Amount of bleeding, N (%)   0.09 
 Less than menstrual period 21 (61.7) 122 (62.2)  
 Equal to menstrual period 5 (14.7) 52 (26.5)  
 More than menstrual period 4 (16.8) 15 (7.7)  
 Unknown 4 (16.8) 7 (3.6)  
Low-lying placenta, N (%) 1 (2.9) 20 (10.2) 0.328 
Ectropion, N (%) 6 (17.6) 9 (4.6) 0.013 
Trauma, N (%) 0 (0) 5 (2.6) 
CharacteristicPCB (n = 34)Bleeding unrelated to coitus (n = 196)p value
Maternal age, mean±SD, years 27.65±5.81 31.36±6.14 0.001 
Gestational age at bleeding, mean±SD, weeks 30.0±2.1 29.1±2.9 0.074 
Nulliparous, N (%) 14 (41.2) 141 (71.9) <0.001 
Smoking, N (%) 4 (11.8) 13 (6.6) 0.289 
Cervical length, mean±SD, mm 34.4±9.6 33.6±11.9 0.651 
Amount of bleeding, N (%)   0.09 
 Less than menstrual period 21 (61.7) 122 (62.2)  
 Equal to menstrual period 5 (14.7) 52 (26.5)  
 More than menstrual period 4 (16.8) 15 (7.7)  
 Unknown 4 (16.8) 7 (3.6)  
Low-lying placenta, N (%) 1 (2.9) 20 (10.2) 0.328 
Ectropion, N (%) 6 (17.6) 9 (4.6) 0.013 
Trauma, N (%) 0 (0) 5 (2.6) 

Primary Outcome

The primary outcome measure, delivery prior to 37 weeks of gestation, was observed in 5 (14.7%) women in the PCB group and 41 (20.9%) in the control group. The difference between the two groups was not statistically significant (p = 0.403). There were no significant differences between the PCB and control groups in terms of maternal and neonatal complications, including rates of fetal distress, NICU admission, and neonatal morbidity.

As shown in Figure 2, when comparing the rate of preterm delivery among all three groups in this study (PCB group, control group, and general population without bleeding), a significant difference was observed. The rate of preterm delivery in the PCB group was 14.7%, while the rate in the control group was 20.9%. These rates were significantly higher than the rate of 5.6% observed in the general population without bleeding (p < 0.001 for both comparisons). These findings suggest that third-trimester PCB is a risk factor for preterm delivery, with rates similar to other causes of third-trimester bleeding but significantly higher than the general population without bleeding. Women with PCB were found to have more than three times the odds of experiencing preterm birth compared to the general population. The odds ratio was 3.29 (95% CI: 1.26–8.56, p = 0.0149), which indicates a statistically significant increased risk of preterm birth in the PCB group.

Fig. 2.

Preterm birth rates in PCB, control, and general population groups. This figure illustrates the rates of preterm delivery in three different groups: PCB group, comparison group, and parturient population without bleeding. The PCB group had a significantly higher rate of preterm delivery compared to the population without bleeding (p < 0.001). The comparison group also had a significantly higher rate of preterm delivery compared to the parturient population without bleeding (p < 0.001).

Fig. 2.

Preterm birth rates in PCB, control, and general population groups. This figure illustrates the rates of preterm delivery in three different groups: PCB group, comparison group, and parturient population without bleeding. The PCB group had a significantly higher rate of preterm delivery compared to the population without bleeding (p < 0.001). The comparison group also had a significantly higher rate of preterm delivery compared to the parturient population without bleeding (p < 0.001).

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Secondary Outcomes

Table 2 presents a comparative analysis of maternal and neonatal outcomes across three groups: women experiencing PCB, those with vaginal bleeding not associated with coitus, and the general population without vaginal bleeding, revealing several significant patterns and observations. In the comparison between women with PCB and those with bleeding unrelated to coitus, there was no statistically significant difference in the rate of induction of labor (35.3% vs. 25.5%, p = 0.104), post-partum hemorrhage (2.9% vs. 10.7%, p = 0.214), or NICU admission (2.9% vs. 12.2%, p = 0.139). However, there was a statistically significant difference in the mode of delivery between the two groups (p = 0.028), with a higher rate of vaginal delivery in the PCB group (82.4%) compared to the bleeding unrelated to coitus group (62.8%).

Table 2.

Comparison of maternal and neonatal outcomes

CharacteristicGeneral population (N = 51,468)PCB (n = 34)Bleeding unrelated to coitus (n = 196)p valueap valueb
Preterm labor < 37 weeks, N (%) 2,846 (5.6) 5 (14.7) 41 (20.9) 0.403 <0.001 
Induction of labor, N (%) 7,841 (15.4) 12 (35.3) 50 (25.5) 0.104 <0.001 
Post-partum hemorrhage, N (%) 2,223 (5.5) 1 (2.9) 2 (10.7) 0.214 <0.001 
Mode of delivery, N (%)    0.028 <0.001 
 Vaginal delivery 37,552 (74.4) 28 (82.4) 123 (62.8)   
 Operative delivery 3,680 (7.3) 1 (2.9) 11 (5.6)   
 Planned cesarean delivery 3,927 (7.8) 0 (0) 19 (9.7)   
 Unplanned cesarean delivery 5,307 (10.5) 5 (14.7) 43 (21.9)   
 Third and fourth perineal lacerations, N (%) 156 (0.3) N/S <0.001 
Birth weight, mean±SD 3,249±489 3,050±491 3,030±594 0.852 <0.001 
Neonate hospitalization period, mean±SD, days  4.5±4.0 5.9±5.4 0.17 <0.001 
NICU admission, N (%) 1,303 (2.6) 1 (2.9) 24 (12.2) 0.139 <0.001 
CharacteristicGeneral population (N = 51,468)PCB (n = 34)Bleeding unrelated to coitus (n = 196)p valueap valueb
Preterm labor < 37 weeks, N (%) 2,846 (5.6) 5 (14.7) 41 (20.9) 0.403 <0.001 
Induction of labor, N (%) 7,841 (15.4) 12 (35.3) 50 (25.5) 0.104 <0.001 
Post-partum hemorrhage, N (%) 2,223 (5.5) 1 (2.9) 2 (10.7) 0.214 <0.001 
Mode of delivery, N (%)    0.028 <0.001 
 Vaginal delivery 37,552 (74.4) 28 (82.4) 123 (62.8)   
 Operative delivery 3,680 (7.3) 1 (2.9) 11 (5.6)   
 Planned cesarean delivery 3,927 (7.8) 0 (0) 19 (9.7)   
 Unplanned cesarean delivery 5,307 (10.5) 5 (14.7) 43 (21.9)   
 Third and fourth perineal lacerations, N (%) 156 (0.3) N/S <0.001 
Birth weight, mean±SD 3,249±489 3,050±491 3,030±594 0.852 <0.001 
Neonate hospitalization period, mean±SD, days  4.5±4.0 5.9±5.4 0.17 <0.001 
NICU admission, N (%) 1,303 (2.6) 1 (2.9) 24 (12.2) 0.139 <0.001 

aComparison between the PCB and bleeding unrelated to coitus groups.

bComparison between the general population and the bleeding groups.

When comparing these groups to the general population, both bleeding groups had significantly higher rates of induction of labor (15.4% in the general population, p < 0.001), and NICU admission (2.6% in the general population, p < 0.001). Additionally, the post-partum hemorrhage rate was significantly higher in the bleeding unrelated to coitus group compared to the general population (p < 0.001). The mode of delivery also differed significantly between the bleeding groups and the general population (p < 0.001). Birth weights were significantly lower in both bleeding groups compared to the general population (3,249 ± 489 g in the general population, p < 0.001). Third and fourth-degree perineal lacerations were rare and not significantly different between the two bleeding groups but significantly higher in the general population (0.3%, p < 0.001).

In analyzing the outcomes among women with PCB compared to the general population, the odds of induction of labor were significantly higher with an odds ratio of 3.03 (95% CI: 1.50–6.13, p = 0.002). However, the odds ratios for unplanned cesarean delivery (1.67, 95% CI: 0.64–4.36, p = 0.2923), postpartum hemorrhage (0.67, 95% CI: 0.09–4.91, p = 0.6946), and NICU admission (1.17, 95% CI: 0.16–8.54, p = 0.8793) were not statistically significant. This suggests that women with PCB have a higher likelihood of requiring induction of labor, but no significant differences were observed in the rates of unplanned cesarean delivery, postpartum hemorrhage, or NICU admissions compared to the general population.

The present retrospective cohort study aimed to evaluate the impact of third-trimester PCB on pregnancy outcomes. The results of this study suggest that third-trimester PCB is a risk factor for preterm delivery, with rates similar to other causes of third-trimester bleeding but significantly higher than the parturient population without bleeding. These findings challenge the assumption that PCB is benign and underscore the need for further research on its clinical significance and management.

The mechanisms behind the increased risk of preterm delivery in the presence of PCB are not well understood. Potential contributing factors may include uterine contractions or cervical changes following sexual intercourse, or underlying uterine or cervical abnormalities that predispose to bleeding and preterm delivery. It is possible that these mechanisms may operate independently or interact with one another to increase the risk of preterm delivery in the presence of PCB. Further studies are needed to identify the specific mechanisms behind this increased risk and to determine potential strategies for mitigating it.

In our study, one key area that warrants further investigation is the role of placenta previa. The prevalence of “low-lying placenta,” which includes placenta previa, was 2.9% in the PCB group and 10.2% in the bleeding unrelated to coitus group. Although these differences were not statistically significant (p value = 0.328), the sample size was relatively small. Placenta previa could be a confounding factor.

Another noteworthy finding in our cohort was the significantly higher prevalence of ectropion and cervical lesions, in the PCB group. Specifically, ectropion was present in 17.6% of women with PCB as opposed to just 4.6% in the non-PCB group (p value = 0.013). This indicates that cervical pathology may have a substantial impact on the occurrence of PCB. Such a difference in prevalence raises questions about the etiology of PCB and suggests that cervical health should be thoroughly evaluated in these cases.

The findings of this study also suggest that women with PCB may be at higher risk for longer hospitalization periods following delivery. This finding has potential implications for postpartum care and recovery and warrants further investigation.

Strengths and Limitations

Strengths of the present study include the use of a well-defined study population and control group. The inclusion of a separate sample of pregnancies without bleeding allowed for comparison of the PCB and control groups to a general population, providing a broader context for interpreting the results. The use of a retrospective cohort design also allowed for the assessment of a wide range of maternal and neonatal outcomes, providing a comprehensive evaluation of the impact of PCB on pregnancy outcomes.

There are also a number of limitations to consider in interpreting the results of this study. One limitation is the retrospective design of the study with its inherent biases. Additionally, electronic medical records may have incomplete or inaccurate data; however, our databases are updated in the labor and delivery wards in real time and regularly vetted by trained personnel to help improve accuracy and completeness.

It is noteworthy to mention that the rate of bleeding observed in our cohort is lower than the generally cited 2% in the literature. This can be attributed to the study’s strict inclusion criteria focusing on women admitted to the high-risk pregnancy ward for vaginal bleeding between 24 and 34 weeks of gestation. Excluding cases beyond this gestational range, those delivering within 24 h of admission, and those not requiring hospital admission allowed for a more focused assessment but resulted in a narrower spectrum of cases.

Additionally, the relatively small sample size and the low number of preterm deliveries in the PCB group may have limited the statistical power of the study to detect significant differences in maternal and neonatal outcomes. Further research with larger sample sizes is needed to confirm the findings of this study and to determine the clinical significance of PCB on pregnancy outcomes.

Implications and Further Investigation

This study found that third-trimester PCB is a risk factor for preterm delivery, and these findings have important implications for the management and monitoring of pregnant women experiencing PCB, particularly in the later stages of pregnancy. One key implication of these findings is the need for healthcare providers to be aware of the potential risk of preterm delivery associated with PCB. Given the increased risk of preterm delivery observed in this study, pregnant women with PCB may require closer monitoring, particularly in the later stages of pregnancy. This may involve more frequent fetal monitoring, as well as closer monitoring of maternal and fetal well-being.

Another important implication of these findings is the need to determine the optimal management of PCB in pregnancy. While the mechanisms behind the increased risk of preterm delivery in the presence of PCB are not well understood, it is possible that addressing potential underlying causes of bleeding may help to mitigate this risk. Additionally, research is needed to determine the most effective strategies for mitigating the risk of preterm delivery in women with PCB, including pharmacological and non-pharmacological interventions.

In conclusion, this study found that third-trimester PCB is a risk factor for preterm delivery, with rates similar to other causes of third-trimester bleeding but significantly higher than the parturient population without bleeding. These findings challenge the assumption that PCB is benign and highlight the need for further research to determine the clinical significance and optimal management of PCB in pregnancy. Given the increased risk of preterm delivery observed in this study, pregnant women with PCB may require closer monitoring, particularly in the later stages of pregnancy. Further research is needed to identify the specific mechanisms behind the increased risk of preterm delivery in the presence of PCB and to determine the most effective strategies for mitigating this risk. These findings have important implications for the care and outcomes of pregnant women experiencing PCB and underscore the need for further investigation in this area.

This study protocol was reviewed and approved by Hadassah Medical Center Institutional Review Board (approval number [0211-10-HMO]). All personal and identifying information was removed before analysis to ensure confidentiality. The study received ethical approval from the local Ethics Committee and informed consent was waived by the Institutional Review Board (IRB N°: 0211-14-HMO).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

No funding was received in support of this work.

The study was conceived and designed by D.K., H.A., and Y.E., with data acquisition assistance from H.W., M.L., and R.A. The EMR database was built and the data were analyzed by D.K., M.L., and H.W., while R.H.Y. and R.A. contributed to the study design and interpretation of the results. The draft manuscript was written by D.K. and all authors reviewed and provided critical feedback on the final version. All authors bear responsibility for the accuracy and integrity of the data and analysis, and all approved the final manuscript for submission.

Additional Information

Doron Kabiri and Hagai Amsalem contributed equally to this work.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Further inquiries can be directed to the corresponding author.

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