Treatment of Hemorrhoids in Pregnancy
First-Line Conservative Management
Dietary and lifestyle modifications are the cornerstone of hemorrhoid treatment during pregnancy and should be initiated immediately for all patients. 1
- Increase dietary fiber to approximately 30 g/day to promote regular bowel movements and prevent constipation 1
- Ensure adequate fluid intake, particularly water, to 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 and should be recommended 1, 2
- Avoid straining during bowel movements by using relaxation techniques and adjusting diet and hydration 1
These conservative measures are effective because hemorrhoids occur in approximately 80% of pregnant persons, most commonly during the third trimester due to compression of the rectum by the gravid uterus 1. The American Gastroenterological Association emphasizes that conservative management should be first-line for all hemorrhoid grades 2.
Pharmacological Management for Symptom Relief
Laxatives
- Osmotic laxatives such as polyethylene glycol or lactulose can be safely administered during pregnancy 1
- Stimulant laxatives should be avoided because safety data during pregnancy are conflicting 1
Topical Treatments
For third-trimester patients, hydrocortisone foam has been shown to be safe with no adverse events compared to placebo in a prospective study of 204 patients. 1
- Short-term topical corticosteroids (≤7 days maximum) can reduce local inflammation but must be limited to avoid thinning of perianal and anal mucosa 1, 3
- Topical analgesics provide symptomatic relief of local pain and itching 2
Important caveat: While topical antihemorrhoidal agents have not been formally assessed for safety in pregnancy, the constituent parts (anesthetics, corticosteroids, anti-inflammatory agents) are unlikely to harm the third-trimester infant 4. However, evidence for their safety and efficacy in pregnancy remains limited 5.
Oral Phlebotonics
- Oral rutosides show promise for symptom relief in first and second-degree hemorrhoids, but their use cannot be recommended until new evidence reassures about safety 6
- Flavonoid preparations may be used for thrombosed hemorrhoids, though evidence is limited 7
Management of Thrombosed External Hemorrhoids
The timing of presentation determines the treatment approach:
Early Presentation (Within 72 Hours)
Surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates 1, 2, 3
Late Presentation (Beyond 72 Hours)
Conservative management is preferred, including:
Critical pitfall: Simple incision and drainage of the thrombus is NOT recommended due to persistent bleeding and higher recurrence rates 2, 3.
Surgical Management During Pregnancy
Hemorrhoidectomy is reserved for strangulated or extensively thrombosed hemorrhoids, and hemorrhoids with intractable bleeding 5. In the absence of acute conditions, surgical treatment should be delayed until after pregnancy, childbirth, and lactation 7.
Indications for Surgery During Pregnancy:
- Strangulated hemorrhoids 5
- Extensively thrombosed hemorrhoids 5
- Intractable bleeding 5
- Massive bleeding requiring anal packing as a simple and useful maneuver 5
Important Considerations and Pitfalls
- Do not assume all anorectal symptoms are due to hemorrhoids, as other conditions like anal fissures may coexist (occurring in up to 20% of patients with hemorrhoids) 1, 2
- Most symptoms will resolve spontaneously soon after giving birth, so corrective treatment is usually deferred 4, 6
- Hemorrhoids occur in about 40% of pregnant women, usually during the third trimester and 1-2 days after giving birth 7
- Risk factors include: constipation during pregnancy, perianal diseases during previous pregnancy, instrumental delivery, straining duration >20 minutes, and newborn weight >3,800 g 7