Management of Hemorrhoid Symptoms in the Third Trimester of Pregnancy
For hemorrhoid symptoms during the third trimester of pregnancy, treatment should focus on conservative measures including dietary modifications, sitz baths, topical treatments, and proper bowel habits to reduce discomfort and prevent complications. 1
Understanding Hemorrhoids in Pregnancy
Hemorrhoids are extremely common during pregnancy, affecting approximately 80% of pregnant women, with increased prevalence in the third trimester due to:
- Compression of the rectum by the gravid uterus
- Hormonal changes affecting vascular tone
- Constipation due to slowed GI motility 1
First-Line Management Approach
Dietary and Lifestyle Modifications
- Increase dietary fiber intake to approximately 30g/day through fruits, vegetables, whole grains, and legumes 1
- Ensure adequate fluid intake, particularly water, to soften stools 1
- Avoid prolonged sitting and straining during bowel movements 2
- Regular physical activity to promote bowel regularity 2
Constipation Management
- Bulk-forming agents such as psyllium husk or methylcellulose are safe during pregnancy due to lack of systemic absorption 1
- Soluble fiber (psyllium) improves stool viscosity and transit time in addition to increasing bulk
- Osmotic laxatives such as polyethylene glycol (PEG) or lactulose can be safely administered 1
- Caution: May cause maternal bloating
- Stool softeners like docusate sodium can prevent dry, hard stools 3
- Avoid stimulant laxatives as safety data during pregnancy are conflicting 1
Topical Treatments
- Sitz baths with warm water 2-3 times daily
- A prospective study showed sitz baths with commercial salt (20g) three times daily achieved complete healing in 100% of pregnant patients compared to 84.8% with topical creams 4
- Topical hydrocortisone preparations
- A prospective study of 204 patients treated with hydrocortisone foam for hemorrhoids in the third trimester showed no adverse events compared to placebo 1
- Topical anesthetics can provide temporary pain relief 5
Second-Line Management
For Persistent Symptoms
- Manual repositioning for prolapsed hemorrhoids under mild sedation when appropriate 2
- Phlebotonics (drugs that improve microcirculation) may be considered, though evidence for safety during pregnancy is limited 6
For Thrombosed External Hemorrhoids
- Acetaminophen for pain management 5
- Local treatments with corticosteroids and anesthetics 5
- Avoid NSAIDs during pregnancy, though they may be used postpartum if not breastfeeding 5
Special Considerations
Monitoring for Complications
- Bleeding: Distinguish hemorrhoidal bleeding (bright red) from other sources
- Pain: Assess severity and impact on quality of life
- Thrombosis: Evaluate for external hemorrhoidal thrombosis, which affects 8% of women during the last trimester 5
When to Consider Additional Evaluation
- Persistent bleeding or blood mixed with stool may suggest a more proximal source of bleeding 2
- Severe pain unresponsive to conservative measures
- Signs of infection or other complications
When to Refer
- Hemorrhoids with intractable bleeding
- Strangulated or extensively thrombosed hemorrhoids unresponsive to conservative management 6
- Symptoms severely affecting quality of life despite conservative measures
Post-Delivery Considerations
- For many women, symptoms will resolve spontaneously soon after birth 7
- Continue conservative management during the puerperium
- Corrective treatments may be deferred until some time after delivery 7
Most pregnant women with hemorrhoids can be successfully managed with conservative approaches, avoiding the need for procedural or surgical interventions during pregnancy.