Best Treatment for Chronic Hemorrhoids in Pregnancy
Conservative management with dietary fiber (30g/day), adequate hydration, and bulk-forming agents like psyllium husk represents the first-line treatment for chronic hemorrhoids during pregnancy, with topical hydrocortisone foam reserved for symptomatic relief when needed. 1, 2
First-Line Conservative Approach
The cornerstone of hemorrhoid management in pregnancy is non-pharmacological intervention, which should be maintained throughout pregnancy:
Increase dietary fiber to approximately 30g/day through fruits (3-4 servings), vegetables (3-4 servings), whole grains, and legumes to promote regular bowel movements and prevent constipation 1, 2
Ensure adequate fluid intake, particularly water, to soften stools and ease bowel movements 1, 2
Avoid straining during bowel movements by providing ample time, using relaxation techniques, and adjusting diet and hydration 1, 2
Sitz baths provide symptomatic relief and are safe during pregnancy—one study showed 100% complete healing with salty warm sitz baths three times daily compared to 84.8% with topical creams 2, 3
Pharmacological Management When Conservative Measures Fail
If dietary modifications are ineffective after 1 week, escalate treatment systematically:
Bulk-forming agents (psyllium husk or methylcellulose) are safe during pregnancy due to minimal systemic absorption and should be added next 1, 2
Osmotic laxatives (polyethylene glycol 17g daily or lactulose) can be safely administered for persistent constipation 1, 2
Topical hydrocortisone foam has been shown safe in the third trimester with no adverse events compared to placebo in a prospective study of 204 patients 1
Limit topical corticosteroids to ≤7 days to avoid thinning of perianal and anal mucosa 1, 4
Critical Pitfall to Avoid
Avoid stimulant laxatives as safety data during pregnancy are conflicting 1
Management of Thrombosed External Hemorrhoids
For acute thrombosis, timing determines the approach:
Within 72 hours of symptom onset: Surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates 1, 4
Beyond 72 hours: Conservative management is preferred with stool softeners and topical analgesics 1, 4
Surgical Intervention During Pregnancy
Surgery is rarely needed but has specific indications:
Approximately 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids 1
Fourth-degree hemorrhoids (cannot be reduced, incarcerated, thrombosed) require surgical intervention 1
The American Gastroenterological Association recommends that patients with acutely prolapsed, incarcerated, and thrombosed hemorrhoids should undergo either hemorrhoidectomy or excision of the external component with rubber band ligation of internal hemorrhoids when conservative management fails 1
Evidence Quality Considerations
While oral rutosides (flavonoids) showed promise in a Cochrane review for symptom relief, their use cannot be recommended until safety is better established in pregnancy 5. The most commonly used approaches—dietary modifications and local treatments—have strong guideline support but limited high-quality pregnancy-specific trials 1, 2, 6.
Important Clinical Pearl
Do not assume all anorectal symptoms are due to hemorrhoids—anal fissures may coexist in up to 20% of patients and require different management 1, 2