What are the treatment options for hemorrhoids during pregnancy?

Treatment Options for Hemorrhoids During Pregnancy

Conservative management is the first-line treatment for hemorrhoids during pregnancy, including dietary modifications, topical treatments, and proper toileting habits.

Epidemiology and Presentation

• Hemorrhoids occur in approximately 80% of pregnant women, more commonly during the third trimester due to compression of the rectum by the gravid uterus 1
• Symptoms include bleeding, protrusion, itching, and pain 1

First-Line Conservative Management

• Increasing dietary fiber intake to approximately 30 g/day through fruits, vegetables, and whole grains to promote regular bowel movements 1
• Ensuring adequate fluid intake, particularly water, to soften stools and ease bowel movements 1
• Using bulk-forming agents such as psyllium husk (5-6 teaspoonfuls with 600 mL water daily), which are safe during pregnancy due to minimal systemic absorption 2, 1
• Avoiding straining during bowel movements by using relaxation techniques 1
• Taking regular sitz baths (warm water soaks) to reduce inflammation and discomfort 2

Pharmacological Management

• Osmotic laxatives such as polyethylene glycol or lactulose can be safely used during pregnancy when dietary modifications are insufficient 1, 3
• 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 2, 1
  • Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa 1
  • Topical analgesics can provide symptomatic relief of local pain and itching 2
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours can be effective by relaxing internal anal sphincter hypertonicity 2

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 1
• For presentations beyond 72 hours, conservative management is preferred, including stool softeners, topical analgesics, and sitz baths 2, 1
• Simple incision and drainage of the thrombus alone is NOT recommended due to persistent bleeding and higher recurrence rates 2

Important Considerations and Pitfalls

• Most hemorrhoidal symptoms will resolve spontaneously soon after giving birth, so any corrective surgical treatment is usually deferred until after delivery 4, 5
• Avoid assuming all anorectal symptoms are due to hemorrhoids, as other conditions like anal fissures may coexist 2
• Stimulant laxatives should be used cautiously during pregnancy as safety data are conflicting 3
• Long-term use of high-potency corticosteroid preparations should be avoided 2
• If symptoms worsen or fail to improve within 1-2 weeks of treatment, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 2

Evidence Quality and Limitations

• While conservative management is widely recommended, high-quality evidence specifically for pregnant women is limited 6, 4
• Most treatments are based on general hemorrhoid management principles adapted for the pregnant population 7, 8
• The safety of many topical agents has not been rigorously tested in pregnancy, though adverse effects are considered unlikely in the third trimester 5