How are hemorrhoids managed during pregnancy?

Management of Hemorrhoids During Pregnancy

Hemorrhoids occur in approximately 80% of pregnant persons, most commonly during the third trimester, and should be managed with a stepwise approach starting with conservative measures including dietary fiber, adequate hydration, and sitz baths before progressing to topical treatments. 1

Causes and Risk Factors in Pregnancy

• Hemorrhoids during pregnancy result from:
  • Compression of the rectum by the gravid uterus, especially in the third trimester
  • Hormonal changes (increased progesterone) slowing GI motility
  • Constipation (affects 20-40% of pregnant persons)
  • Increased pressure in the anal canal

Evaluation

• Detailed history focusing on:

  • Frequency and consistency of bowel movements
  • Presence of pain, itching, or bleeding during bowel movements
  • Severity of symptoms
  • Timing of symptom onset (55% develop in third trimester) 2

• Physical examination:

  • External examination to identify external hemorrhoids
  • Anoscopy for proper visualization of internal hemorrhoids (when necessary)

Treatment Algorithm

First-line: Conservative Management

1. Dietary modifications:

   • Increase dietary fiber intake to approximately 30g/day (fruits, vegetables, whole grains, legumes)
   • Ensure adequate fluid intake, particularly water 1

2. Bowel habit training:

   • Avoid straining during bowel movements
   • Use relaxation techniques
   • Provide ample time for defecation 1

3. Sitz baths:

   • Warm salty sitz baths three times daily (using 20g of commercial salt)
   • Studies show 100% healing rate with sitz baths compared to 84.8% with topical creams 3

Second-line: Medical Therapy

1. Bulk-forming agents:

   • Psyllium husk or methylcellulose (safe during pregnancy due to lack of systemic absorption)
   • Soluble fiber improves stool viscosity and transit time 1

2. Osmotic laxatives (for associated constipation):

   • Polyethylene glycol or lactulose (safe during pregnancy)
   • Caution: May cause maternal bloating 1

3. Topical treatments:

   • Hydrocortisone foam/cream for symptomatic relief
   • A prospective study of 204 pregnant patients treated with hydrocortisone foam in the third trimester showed no adverse events compared to placebo 1
   • Topical ointments are the most commonly used treatment (93.2% of pregnant women with hemorrhoids) 4

Third-line: Procedural Interventions

• Rarely needed during pregnancy (only 1.8% of pregnant women with hemorrhoids require procedures) 4
• If severe symptoms persist despite conservative and medical therapy, consider:
  • Excision of thrombosed external hemorrhoids (if diagnosed within 72 hours of symptom onset)
  • Rubber band ligation for small third-degree hemorrhoids

Special Considerations

• Avoid stimulant laxatives as safety data during pregnancy are conflicting 1

• Thrombosed hemorrhoids may require urgent evaluation and possible excision under local anesthesia if diagnosed early (within 72 hours)

• Reassurance about natural course:

  • 45% of cases resolve within days after delivery
  • 27% resolve within weeks
  • 28% resolve within months 2

Monitoring and Follow-up

• Regular assessment of symptom improvement
• Evaluate for adequate bowel movements and resolution of bleeding
• Consider referral to gastroenterology if symptoms are severe or refractory to treatment

Prevention

• Maintain adequate fiber intake throughout pregnancy
• Stay well-hydrated
• Regular physical activity as tolerated
• Address constipation promptly

Most pregnant women with hemorrhoids can be effectively managed with conservative measures, and symptoms typically resolve spontaneously after delivery. The treatment approach should focus on symptom relief while ensuring safety for both mother and fetus.