What is the recommended treatment for external hemorrhoids during the 1st trimester of pregnancy?

From the Guidelines

The recommended treatment for external hemorrhoids during the 1st trimester of pregnancy focuses on conservative measures to minimize risk to the fetus while alleviating symptoms. The most recent and highest quality study, 1, published in 2024, emphasizes the importance of dietary changes, including increased fiber intake and adequate hydration, to soften stools and reduce straining. Key recommendations include:

• Increasing dietary fiber intake to approximately 30g daily
• Consuming an adequate amount of fluids, particularly water, to help soften stools and ease bowel movements
• Using bulk-forming agents, such as psyllium husk or methylcellulose, which are safe to administer in pregnancy due to the lack of systemic absorption
• Avoiding stimulant laxatives because safety data on these medications are conflicting

Additionally, over-the-counter treatments considered safe include witch hazel pads applied directly to the area and glycerin-based suppositories as needed for discomfort. Topical creams containing 1% hydrocortisone may be used sparingly for short periods (3-7 days) to reduce inflammation and itching, as supported by 1. It is essential to avoid prolonged sitting and straining during bowel movements and to engage in regular physical activity, like walking, to improve circulation and reduce symptoms. If severe pain, bleeding, or thrombosis occurs, consulting a healthcare provider is necessary for more targeted interventions.

From the Research

Treatment Options for External Hemorrhoids in the 1st Trimester

• The treatment for external hemorrhoids during pregnancy is mainly directed towards relieving symptoms, especially pain control 2.
• Conservative management includes dietary modifications, stimulants or depressants of the bowel transit, local treatment, and phlebotonics 2.
• A study comparing Sitz bath with ano-rectal cream for treating hemorrhoids during pregnancy found that Sitz bath was more effective in achieving complete healing 3.
• Another study found that conservative measures such as increased dietary fiber, increased fluid intake, and bath salts were effective in relieving symptoms for the majority of patients 4.
• Topical antihemorrhoidal agents, although not formally assessed for safety in pregnancy, are unlikely to harm the fetus and can be used to relieve symptoms 5.
• Medical treatment with local treatment, defecation regulation, and paracetamol is recommended for external hemorrhoids thrombosis, with surgery being an exception 6.

Safety Considerations

• Most symptoms of external hemorrhoids will resolve spontaneously soon after giving birth, and any corrective treatment is usually deferred to some time after birth 2, 5.
• NSAID can be used after delivery in the absence of breastfeeding, but should be avoided during pregnancy 6.
• Local excision is not possible in most cases due to inflammation, and surgery should be an exception 6.

Recommendations

• Increase dietary fiber and fluid intake to relieve symptoms 4, 5.
• Use Sitz bath or ano-rectal cream as part of a conservative treatment protocol 3.
• Consider using topical antihemorrhoidal agents, but consult with a healthcare provider first 5.
• Avoid NSAID during pregnancy, unless advised by a healthcare provider 6.