Haemorrhoid symptoms are common in pregnancy, particularly in the second and third trimesters. Advice on avoiding constipation may assist women to prevent or lessen the effects of haemorrhoids. Topical products can be used to ease continuing symptoms.
Haemorrhoids are enlarged, swollen veins around the anus that are characterised by anorectal bleeding, painful bowel movements, anal pain and anal itching. While the mechanism is not clear, this is thought to be a result of prolapse of the anal canal cushions, which play a role in maintaining continence. Constipation (see Chapter 55) is the major precipitating factor for haemorrhoids. Pregnancy also facilitates development or exacerbation of haemorrhoids, due to increased pressure in rectal veins caused by restriction of venous return by a woman’s enlarged uterus .
57.1.1 Incidence during pregnancy
Haemorrhoids that were present previously may become symptomatic for the first time in pregnancy. Haemorrhoidal symptoms are most common in the second and third trimesters of pregnancy and after birth.
While estimates vary, it is thought that 25–35% of pregnant women are affected by haemorrhoids Staroselsky et al 2008, Abramowitz & Batallan 2003. One observational study found that 8% of pregnant women (n=165) experienced thrombosed external haemorrhoids in the last 3 months of pregnancy.
Pain with bowel movements, bleeding and itching are often the first signs and symptoms of haemorrhoids. Diagnosis is made by examining the anus and anal canal, usually by inspection. Digital rectal examination and endoscopy (sigmoidoscopy and colonoscopy) may also be used. It is important to rule out more serious causes of bleeding.
57.2 Discussing haemorrhoids
57.2.1 Effectiveness of treatments
Treatment during pregnancy aims mainly to relieve symptoms and control pain.
Most evidence for the effectiveness of haemorrhoid treatments comes from studies of non-pregnant patients. Given the overall lack of evidence, there is consensus in clinical reviews for conservative management in pregnancy including avoiding constipation, dietary modification, dietary fibre supplementation and stool softeners Avsar & Keskin 2010, Dietrich et al 2008, Wald 2003.
Topical products with analgesics and anti-inflammatory effects provide short-term local relief of symptoms. There is no evidence on the effectiveness or safety of creams used in pregnancy; however, the small doses and limited systemic absorption mean that they are unlikely to harm the baby when used in the third trimester.
While surgical removal of haemorrhoids may be a consideration in extreme circumstances, surgery is rarely an appropriate intervention for pregnant women as haemorrhoidal symptoms often resolve spontaneously after the birth.
Offer women who have haemorrhoids information about increasing dietary fibre and fluid intake. If clinical symptoms remain, advise women that they can consider using standard haemorrhoid creams.
Approved by NHMRC in June 2014; expires June 2019
57.3 Practice summary: haemorrhoids
A woman had haemorrhoids before pregnancy or has symptoms of haemorrhoids.
- Aboriginal and Torres Strait Islander Health Practitioner
- Aboriginal and Torres Strait Islander Health Worker
- multicultural health worker
- accredited dietitian.
- Provide advice
Advise women that avoiding constipation (see Chapter 55) is the best way to prevent and manage haemorrhoids during pregnancy and they should also try to avoid straining with bowel motions.
- Discuss treatments
Advise women that haemorrhoid creams can be used to further ease their symptoms.
- Take a holistic approach
Explore culturally appropriate, low cost ways for women to increase their fibre intake. Advise women who are increasing their fibre intake to make sure they drink adequate fluids.
- NHMRC (2013) Australian Dietary Guidelines. Canberra: Commonwealth of Australia.
- Abramowitz L & Batallan A (2003) Epidemiology of anal lesions (fissure and thrombosed external hemorroid) during pregnancy and post-partum. Gynecol Obstet Fertil 31(6): 546–49.
- Abramowitz L, Sobhani I, Benifla JL et al (2002) Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum 45(5): 650–55.
- Avsar A & Keskin H (2010) Haemorrhoids during pregnancy. J Obstet Gynaecol 30(3): 231–37.Buckshee K, Takkar D, Aggarwal N (1997) Micronized flavonoid therapy in internal hemorrhoids of pregnancy. Int J Gynecol Obstet 57: 145–51.
- Dietrich C, Hill C, Hueman M (2008) Surgical diseases presenting in pregnancy. Surg Clin North America 88: 403–19.
- Staroselsky A, Nava-Ocampo AA, Vohra S et al (2008) Hemorrhoids in pregnancy. Can Fam Phys 54(2): 189–90.
- Wald A (2003) Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy. Gastroenterol Clin North America 32: 309–22.