Treatment Options for Hemorrhoids in Pregnancy
The first-line treatment for hemorrhoids in pregnancy includes dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, and topical treatments such as hydrocortisone foam, which has been shown to be safe in the third trimester. 1
Epidemiology and Presentation
- Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester due to compression of the rectum by the gravid uterus 1
- Most symptoms develop in the third trimester (55%), though they can appear in the first (15%) or second trimester (30%) 2
- Symptoms include bleeding, protrusion, itching, and pain 3
Conservative Management (First-Line)
- Increasing dietary fiber intake to approximately 30 g/day (fruits, vegetables, whole grains, legumes) helps promote regular bowel movements and prevents constipation 1
- Adequate fluid intake, particularly water, helps soften stools and ease bowel movements 1
- Bulk-forming agents such as psyllium husk (5-6 teaspoonfuls with 600 mL water daily) are safe during pregnancy due to lack of systemic absorption 1, 3
- Soluble fiber like psyllium husk improves stool viscosity and transit time in addition to increasing bulk 1
- Avoiding straining during bowel movements by using relaxation techniques and adjusting diet and hydration is helpful 1
Pharmacological Management
- Osmotic laxatives such as polyethylene glycol or lactulose can be safely administered during pregnancy 1
- Note: Excessive use of osmotic laxatives like lactulose can cause maternal bloating 1
- Topical treatments for symptom relief:
- Hydrocortisone foam has been shown to be safe for hemorrhoids in the third trimester with no adverse events compared to placebo in a prospective study of 204 patients 1, 3
- Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa 3, 4
- Topical analgesics can provide symptomatic relief of local pain and itching 3, 5
- Stimulant laxatives should be avoided because safety data on these medications during pregnancy are conflicting 1
Management of Thrombosed External Hemorrhoids
- For thrombosed hemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates 3, 4
- For presentations beyond 72 hours, conservative management is preferred, with treatment including stool softeners and topical analgesics 3
- In case of massive bleeding, anal packing could be a simple and useful maneuver 6
Natural Course and Prognosis
- In most women, symptoms will resolve spontaneously soon after giving birth 5
- Approximately 45% of patients' symptoms resolve within days after delivery, 27% within weeks, and 28% within months 2
Important Considerations and Pitfalls
- Hemorrhoidectomy is reserved for strangulated or extensively thrombosed hemorrhoids, and hemorrhoids with intractable bleeding 6
- In the absence of acute conditions, surgical treatment of hemorrhoids is typically delayed until after pregnancy, childbirth, and lactation 7
- Avoid assuming all anorectal symptoms are due to hemorrhoids, as other conditions like anal fissures may coexist 3
- Concerningly, the majority of patients (64%) self-diagnose and manage the condition without seeking medical guidance 2