From the Guidelines
For thrombosed hemorrhoids at 28 weeks pregnant, I strongly recommend starting with conservative treatments, prioritizing non-operative management as the first-line therapy, with dietary and lifestyle changes, as suggested by the most recent guidelines 1. The goal of treatment is to alleviate symptoms, minimize risks to the pregnancy, and improve quality of life.
- Conservative treatments include:
- Sitz baths 2-3 times daily for 10-15 minutes using warm water
- Application of witch hazel pads or cold compresses to reduce swelling
- Increasing fiber intake to 25-30 grams daily along with drinking 8-10 glasses of water to soften stool
- Over-the-counter topical treatments containing 1% hydrocortisone can be used for short periods (up to 7 days) to reduce inflammation and pain, as supported by a prospective study 1.
- Avoid straining during bowel movements and try not to sit for prolonged periods.
- For pain management, acetaminophen (Tylenol) is considered safe during pregnancy at regular doses (up to 3000 mg daily in divided doses). If symptoms are severe or don't improve within a few days, it is essential to consult your obstetrician, as surgical excision may be considered in extreme cases, though this is typically avoided during pregnancy when possible, as noted in the guidelines 1. Pregnancy-related increased blood volume and pressure from the growing uterus contribute to hemorrhoid development, making management rather than complete cure the realistic goal until after delivery. It is crucial to prioritize the most recent and highest-quality studies, such as those published in 2021 and 2024 1, to ensure the best possible outcome for both the mother and the fetus.
From the Research
Treatment Options for Thrombosed Hemorrhoids at 28 Weeks Pregnant
- Fiber supplement, stool softener, and mild laxatives are generally safe for pregnant women 2
- Topical medication or oral phlebotonics may be used with special caution because the strong evidence of their safety and efficacy in pregnancy is lacking 2
- In case of massive bleeding, anal packing could be a simple and useful maneuver 2
- Hemorrhoidectomy is reserved for strangulated or extensively thrombosed hemorrhoids, and hemorrhoids with intractable bleeding 2, 3
- Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 3
Considerations for Pregnant Women
- Medical management, dietary modifications, and behavioral therapies are the mainstays of initial therapy 3, 4
- The use of tribenoside and lidocaine in the local treatment of hemorrhoids has been shown to be effective and safe in clinical studies, including in women with hemorrhoids as a consequence of pregnancy or delivery 5
- Alternative treatments, like Myrrh sitz baths, may be of growing interest due to their potential wound-healing properties, but cautious usage must be considered due to the higher complication rate 6
Important Factors to Consider
- The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes 3
- The degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued 3
- The efficacy and safety of medical treatments for hemorrhoids in pregnancy are still controversial, and further research is needed to provide comprehensive evaluation and guidance for clinical practices 2, 4