What is the management for an incarcerated and prolapsed hemorrhoid in pregnancy?

Management of Incarcerated and Prolapsed Hemorrhoids in Pregnancy

For acutely prolapsed, incarcerated, and thrombosed hemorrhoids in pregnancy, proceed with either hemorrhoidectomy or excision of the external component with rubber band ligation of the internal hemorrhoids. 1

Acute Surgical Management

Patients with acutely prolapsed, incarcerated, and thrombosed hemorrhoids should undergo either hemorrhoidectomy or excision of the external component with rubber band ligation of the internal hemorrhoids. 1 This recommendation from the American Gastroenterological Association applies to the general population but is particularly relevant in pregnancy when conservative management fails or when there is acute incarceration with thrombosis.

Surgical Indications in Pregnancy

• Hemorrhoidectomy is reserved for strangulated or extensively thrombosed hemorrhoids and hemorrhoids with intractable bleeding. 2
• Approximately 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids. 1
• For thrombosed hemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates. 3

Important Surgical Considerations

• There is an increased risk of anal stenosis after acute surgery in pregnancy. 4
• The risks of sepsis and sphincter damage are less significant than previously thought. 4
• Manual dilatation of the anus is not recommended due to the associated risk of sphincter injury and incontinence. 1

Conservative Management (When Appropriate)

For presentations beyond 72 hours or when symptoms are resolving, conservative management is preferred. 3

First-Line Conservative Measures

• Increasing dietary fiber intake to approximately 30 g/day helps promote regular bowel movements and prevents constipation. 3
• Bulk-forming agents such as psyllium husk are safe during pregnancy due to lack of systemic absorption. 3
• Osmotic laxatives such as polyethylene glycol or lactulose can be safely administered during pregnancy. 3
• Adequate fluid intake, particularly water, helps soften stools and ease bowel movements. 3

Topical and Pharmacological Treatment

• 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. 3
• Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa. 3
• Sitz bath three times per day using warm salty water (20g of commercial salt) achieved complete healing in 100% of pregnant patients compared to 84.8% with ano-rectal cream. 5

Medications to Avoid

• Stimulant laxatives should be avoided because safety data on these medications during pregnancy are conflicting. 3

Clinical Decision Algorithm

Timing-Based Approach

1. If presenting within 72 hours of symptom onset with acute thrombosis/incarceration: Proceed with surgical excision under local anesthesia 3
2. If presenting beyond 72 hours: Conservative management with stool softeners and topical analgesics 3
3. If conservative management fails or there is intractable bleeding/strangulation: Proceed with hemorrhoidectomy 2

Severity-Based Approach

• Fourth-degree hemorrhoids (cannot be reduced, incarcerated, thrombosed): Surgical intervention indicated 1
• Third-degree hemorrhoids (require manual reduction): Trial of conservative management first, surgery if failed 1
• Massive bleeding: Anal packing could be a simple and useful maneuver 2

Critical Pitfalls to Avoid

• Do not assume all anorectal symptoms are due to hemorrhoids, as other conditions like anal fissures may coexist in up to 20% of patients. 1, 3
• Do not delay surgical intervention when there are signs of strangulation or extensive thrombosis, as these require urgent treatment. 2
• The majority of patients (who are treated conservatively) will still require definitive treatment at a later date after delivery. 4
• Avoid prolonged use of potent corticosteroid preparations as they may be harmful and cause tissue thinning. 1

Postpartum Considerations

• For many women, symptoms will resolve spontaneously soon after birth, and corrective treatment is usually deferred to some time after delivery. 6
• In the absence of acute conditions, surgical treatment of hemorrhoids is delayed after pregnancy, childbirth, and lactation. 7