What are the recommended treatments for hemorrhoids in pregnant women?

Treatment of Hemorrhoids in Pregnancy

For pregnant women with hemorrhoids, start with dietary fiber (30g/day) and adequate hydration, add bulk-forming agents like psyllium husk if needed, and use topical hydrocortisone foam for symptom relief—all of which are safe throughout pregnancy. 1

First-Line Conservative Management

Dietary and lifestyle modifications should be implemented immediately:

• Increase dietary fiber intake to approximately 30 grams daily through fruits, vegetables, whole grains, and legumes 1, 2
• Ensure adequate fluid intake, particularly water, to soften stools and ease bowel movements 1
• Avoid straining during bowel movements by using relaxation techniques 1
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1, 3

A prospective study of 495 pregnant women found that sitz baths achieved 100% complete healing compared to 84.8% with topical creams, representing a statistically significant difference. 3

Pharmacological Management

Bulk-Forming Agents (Safest Option)

• Psyllium husk (5-6 teaspoonfuls with 600 mL water daily) is the safest pharmacological option due to lack of systemic absorption 1
• Soluble fiber like psyllium improves stool viscosity and transit time 1

Osmotic Laxatives

• Polyethylene glycol or lactulose can be safely administered during pregnancy 1
• These are preferred over stimulant laxatives, which should be avoided due to conflicting safety data 1

Topical Treatments for Symptom Relief

Hydrocortisone foam is the best-studied topical agent in pregnancy:

• A prospective study of 204 pregnant patients in the third trimester showed hydrocortisone foam was safe with no adverse events compared to placebo 1
• Short-term topical corticosteroids (≤7 days maximum) can reduce local inflammation 1
• Never use corticosteroid preparations for more than 7 days to avoid thinning of perianal and anal mucosa 1

Alternative topical agents:

• Topical lidocaine 1.5-2% ointment provides symptomatic relief of local pain and itching 1, 4
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks shows 92% resolution rate for thrombosed hemorrhoids 4
• No systemic side effects have been observed with topical nifedipine 4

Important caveat: Although topical antihemorrhoidal agents have not been formally assessed for safety in pregnancy, the constituent parts (anesthetics, corticosteroids) are unlikely to harm the third-trimester infant 5

Management of Thrombosed External Hemorrhoids

Timing determines the approach:

• For presentation within 72 hours of symptom onset: Surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates 1
• For presentation beyond 72 hours: Conservative management is preferred with stool softeners and topical analgesics 1
• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1, 4

Management of Incarcerated/Prolapsed Hemorrhoids

Approximately 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids 1

Surgical intervention is indicated when:

• Fourth-degree hemorrhoids (cannot be reduced, incarcerated, thrombosed) are present 1
• Conservative management has failed for third-degree hemorrhoids 1
• There is acute incarceration with thrombosis 1

Oral Phlebotonics (Flavonoids)

• Flavonoids may relieve symptoms in complicated hemorrhoids, though this is a weak recommendation based on moderate-quality evidence 1
• Use with special caution as strong evidence of safety and efficacy in pregnancy is lacking 6
• Symptom recurrence reaches 80% within 3-6 months after cessation 4

Critical Pitfalls to Avoid

Do not assume all anorectal symptoms are hemorrhoids:

• Other conditions like anal fissures may coexist in up to 20% of patients 1
• Hemorrhoids alone do not cause positive stool guaiac tests 4
• Anemia from hemorrhoids is rare (0.5 per 100,000 population) 4

Avoid these medications/interventions:

• Stimulant laxatives (conflicting safety data) 1
• Prolonged corticosteroid use (>7 days causes tissue thinning) 1
• Manual anal dilatation (52% incontinence rate at long-term follow-up) 4

Postpartum Considerations

Most hemorrhoid symptoms resolve spontaneously soon after giving birth 5

In the absence of acute conditions, surgical treatment should be delayed until after pregnancy, childbirth, and lactation 7

Tribenoside + lidocaine combination (rectal cream 5%/2% or suppository 400mg/40mg) can be safely administered in postpartum women and pregnant women after the first trimester, with fast onset of symptom relief from 10 minutes lasting up to 10-12 hours 8