What treatment is recommended for a 22-week gestation woman with hemorrhoids?

Management of Hemorrhoids in a 22-Week Pregnant Woman

For a 22-week pregnant woman with hemorrhoids, start with dietary modifications including 30g/day of fiber and adequate hydration, combined with bulk-forming agents like psyllium husk if dietary changes alone are insufficient, and consider topical hydrocortisone cream for symptomatic relief of pain and itching. 1, 2, 3

Initial Conservative Management

Dietary and Lifestyle Modifications

• Increase dietary fiber intake to approximately 30g/day through fruits, vegetables, whole grains, and legumes to promote regular bowel movements and prevent constipation, which worsens hemorrhoid symptoms 1, 2, 3
• Ensure adequate fluid intake, particularly water, to soften stools and ease bowel movements 1, 2
• Encourage the patient to avoid straining during bowel movements by providing ample time, using relaxation techniques, and adjusting diet and hydration 1
• Aim for 3-4 servings of fruits and 3-4 servings of vegetables daily 2

Pharmacological First-Line Treatment

• If dietary modifications are ineffective after 1 week, add psyllium husk (Metamucil) or methylcellulose as bulk-forming agents, which are safe during pregnancy due to minimal systemic absorption 1, 2, 3
• For persistent constipation contributing to hemorrhoid symptoms, polyethylene glycol (PEG) 17g daily can be safely administered 2, 3
• Magnesium hydroxide 400-500mg daily is also safe and effective if needed 2

Symptomatic Relief for Hemorrhoids

Topical Therapy

• Topical hydrocortisone cream or foam is safe and effective for managing perianal irritation, itching, and inflammation associated with hemorrhoids during pregnancy 1, 3
• In a prospective study of 204 patients treated with hydrocortisone foam for hemorrhoids in the third trimester, no adverse events were seen compared with placebo 1
• Topical corticosteroids help reduce inflammation and itching, though prolonged use of potent corticosteroid preparations should be avoided 1, 3

Additional Considerations

• Sitz baths can provide symptomatic relief and are safe during pregnancy 3
• Although topical anesthetic and anti-inflammatory agents have not been formally assessed for safety in pregnancy, they are unlikely to harm the fetus at 22 weeks gestation 4

Important Clinical Pearls

Evaluation Requirements

• Perform a careful anorectal evaluation to differentiate hemorrhoids from other conditions like anal fissures, which may present with similar symptoms 3
• Bright red rectal bleeding is the most common presenting symptom, but proper evaluation is needed to rule out other causes 3
• Pain is generally not associated with uncomplicated hemorrhoids unless thrombosis has occurred, so persistent pain suggests other pathology 3

When to Escalate Care

• Stimulant laxatives like bisacodyl or senna should be used cautiously and only for short-term relief when other methods fail, with limited doses of 5-10mg bisacodyl daily 2
• The second trimester (where this patient is) offers the safest window for more aggressive constipation management because organogenesis is complete 2
• Hemorrhoidectomy is reserved for strangulated or extensively thrombosed hemorrhoids, and hemorrhoids with intractable bleeding, but is rarely needed during pregnancy 5

Monitoring and Follow-Up

• Reassess bowel movement frequency and consistency after initiating treatment, with the goal of achieving soft, formed stools every 1-2 days 2
• Regular assessment of hemorrhoid symptoms and constipation is necessary throughout pregnancy 3
• If bleeding persists despite treatment, further evaluation may be needed to rule out other causes 3
• For most women, hemorrhoid symptoms will resolve spontaneously soon after birth 6, 4