What are the recommended management options for hemorrhoids in pregnancy?

Ongoing Management of Hemorrhoids in Pregnancy

Start with dietary fiber (30g/day) and adequate hydration as first-line therapy, add psyllium husk if ineffective after one week, and use topical hydrocortisone for symptomatic relief—reserving surgical intervention only for acutely incarcerated, thrombosed, or extensively prolapsed hemorrhoids that fail conservative management. 1, 2

Conservative Management (First-Line Approach)

Dietary and lifestyle modifications form the foundation of treatment:

• Increase dietary fiber intake to approximately 30g/day through fruits, vegetables, whole grains, and legumes to promote regular bowel movements and prevent constipation 1, 2
• Aim for 3-4 servings each of fruits and vegetables daily 2
• Ensure adequate fluid intake, particularly water, to soften stools and ease bowel movements 1, 2
• Avoid straining during bowel movements by allowing ample time, using relaxation techniques, and optimizing diet and hydration 1, 2

This conservative approach represents a strong recommendation based on moderate-quality evidence 3, and should be maintained throughout pregnancy as the cornerstone of management.

Pharmacological Management

If dietary modifications prove ineffective after one week, escalate to bulk-forming agents:

• Add psyllium husk (Metamucil) or methylcellulose as bulk-forming agents, which are safe during pregnancy due to minimal systemic absorption 1, 2
• Soluble fiber like psyllium improves stool viscosity and transit time in addition to increasing bulk 1

For persistent constipation contributing to hemorrhoid symptoms:

• Polyethylene glycol (PEG) 17g daily can be safely administered as a preferred osmotic laxative 1, 2
• Lactulose is also safe but may cause more bloating than PEG 1
• Magnesium hydroxide 400-500mg daily is safe and effective 2
• Avoid stimulant laxatives because safety data during pregnancy are conflicting 1

Topical and Symptomatic Relief

For perianal irritation, itching, and inflammation:

• Topical hydrocortisone cream or foam provides symptomatic relief and has been shown safe in the third trimester in a prospective study of 204 patients with no adverse events compared to placebo 1, 2
• Limit topical corticosteroids to short-term use (≤7 days) to avoid thinning of perianal and anal mucosa 1
• Sitz baths (using warm water with 20g commercial salt, three times daily) provide symptomatic relief and are safe during pregnancy 2, 4

A comparative study found sitz baths achieved 100% complete healing versus 84.8% with topical cream alone 4, suggesting sitz baths should be incorporated as an essential component of conservative management.

Management of Thrombosed External Hemorrhoids

Timing determines the treatment approach:

• 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 with stool softeners and topical analgesics 1
• The decision between non-operative management and early surgical excision should be based on local expertise and patient preference 3
• Avoid incision and drainage of the thrombus alone, as this approach is not recommended 3

Management of Incarcerated and Prolapsed Hemorrhoids

Severity-based surgical indications:

• Fourth-degree hemorrhoids (cannot be reduced, incarcerated, thrombosed) require surgical intervention 1
• Third-degree hemorrhoids (require manual reduction) should receive a trial of conservative management first, with surgery reserved for treatment failure 1
• Approximately 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids 1
• Surgical options include hemorrhoidectomy or excision of the external component with rubber band ligation of internal hemorrhoids 1
• Manual dilatation of the anus is contraindicated due to risk of sphincter injury and incontinence 1

Flavonoids and Phlebotonics

While flavonoids show promise, their use requires caution:

• Flavonoids may relieve symptoms in complicated hemorrhoids (weak recommendation based on moderate-quality evidence) 3
• Oral rutosides appear effective in reducing signs and symptoms of hemorrhoidal disease 5
• However, their use cannot be routinely recommended until new evidence reassures about safety during pregnancy, as one fetal death and one congenital malformation were reported in studies (though possibly unrelated to exposure) 5

Critical Pitfalls to Avoid

Do not assume all anorectal symptoms are hemorrhoids:

• Up to 20% of patients may have coexisting conditions like anal fissures 1, 2
• Perform careful anorectal evaluation to differentiate hemorrhoids from other pathology 2
• Pain is generally not associated with uncomplicated hemorrhoids unless thrombosis has occurred, so persistent pain suggests alternative diagnosis 2
• If bleeding persists despite treatment, further evaluation is needed to rule out other causes 2

Avoid prolonged use of potent corticosteroid preparations as they may cause tissue thinning 1, 2

Monitoring and Follow-Up

Reassess treatment response systematically:

• Evaluate 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 2
• Adjust treatment based on response, escalating through the algorithm as needed 2

For most women, symptoms resolve spontaneously soon after birth, and corrective treatment is usually deferred to postpartum 5, 6. In one study, 45% of patients' symptoms resolved within days postpartum, 27% within weeks, and 28% within months 7.