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Journal of Obstetrics and Gynaecology, April 2010; 30(3): 231–237

REVIEW

Haemorrhoids during pregnancy

A. F. AVSAR & H. L. KESKIN

Department of Obstetrics and Gynecology, Atatürk Education and Research Hospital, Ankara, Turkey
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Summary
Haemorrhoids are varicose veins of the rectum covered by mucosa at or near the anal canal. They are normally
asymptomatic, can occur at any age and affect both males and females. In this review, we address the issue of the approach of
the obstetrician to haemorrhoids and their management. Haemorrhoids are common in young women and commoner during
pregnancy and the puerperium. Obstetricians and gynaecologists should be familiar with haemorrhoids, a proctological
disease, diagnosis and their treatment, but they have little experience regarding the impact of pregnancy on haemorrhoids.
The obstetrician must be able to relieve symptoms in patients who are pregnant, or who have just delivered.

Keywords
Haemorrhoids, pregnancy, postpartum

Multiple aetiological factors have been incriminated in


The definition, incidence and physiopathology
For personal use only.

the development of haemorrhoids. They include chronic


of haemorrhoids
constipation, hard stools, prolonged straining, straining at
Haemorrhoids are a common disease of the anal canal, defaecation, vascular engorgement because of increased
which recur, may recover spontaneously and have acute intra-abdominal pressure, absence of valves in haemor-
episodes in addition to chronic symptoms. They are a rhoidal vessels and draining vessels, persistent lack of
common problem in the general population. The incidence support to the pelvic floor, impairment of the internal anal
of haemorrhoids is quite high, being higher in the sphincter, genetic factors and pregnancy. The majority
reproductive age group and particularly during pregnancy. occur due to a patient’s poor bowel habit. The most
This disease affects 4–10% of the population (Saenz et al. consistently demonstrated physiological abnormality is
2006), and has been reported to be as high as 24.8% in increase in maximum anal pressure at rest (Loder et al.
women (Hyams and Philpot 1970). 1994).
Although the pathogenesis is not completely understood Haemorrhoids can be either internal or external and both
and the underlying mechanisms are far from clear, types may occur together. Haemorrhoids above the dentate
haemorrhoidal disease may be the consequence of distal line, arising from the superior haemorrhoidal plexus and
displacement of anal cushions, which are normal structures being covered by poorly innervated mucous membrane
with an important role in continence. The pathogenesis of with columnar epithelium and draining into portal circula-
haemorrhoids involves a degeneration of anchoring sup- tion are referred to as internal haemorrhoids, whereas those
porting tissue of the anal cushions and their descent with found distal to the dentate line, in the zone of the anoderm,
venous distention and engorgement plus stasis owing to arising from inferior haemorrhoidal plexus of the rectum
lack of support (Haas et al. 1984). Haemorrhoidal tissue, and draining into the vena cava and covered by squamous
normally found at the distal end of the rectum inside the epithelium are referred to as external haemorrhoids.
anal canal, prolapses from anal canal cushions, which are External haemorrhoids are vascular complexes under the
composed of redundant rectal mucosa, smooth muscle, anoderm of the anal canal. Internal haemorrhoids, covered
connective tissue and blood vessels (Medich and Fazio by mucosa characteristically bleed or prolapse but they are
1995). The pathophysiology of symptomatic haemorrhoids usually painless. Patients usually complain of rectal full-
is related to the engorgement of the vascular pedicles in the ness, mucous discharge and dripping of bright red blood.
haemorrhoidal complexes, these then dilate, stretch and On occasion, internal haemorrhoids incarcerate in the
cause the cushions to enlarge. Inflammation plays an outer ring of the anal canal thrombosis and necrosis
important part in the process and bleeding occurs following develops. They are classified according to the severity of
erosion and oedema in the anal mucosa. They do not the examination findings. Classification is as below:
constitute a disease unless they become symptomatic.
Bleeding occurs from presinusoidal arterioles. The main . Grade I: Haemorrhoid is small, protrudes into but does
cushions lie at the left lateral and right posterolateral not prolapse out of anal canal and can be visualised
portions of the anal canal. merely by anoscopy and characterised only by bleeding.

Correspondence: H. L. Keskin, Birlik mah. 130.sok. 3/5 Çankaya, 06610 Ankara, Turkey. E-mail: hlkeskin@yahoo.com
ISSN 0144-3615 print/ISSN 1364-6893 online Ó 2010 Informa Healthcare USA, Inc.
DOI: 10.3109/01443610903439242
232 A. F. Avsar & H. L. Keskin

. Grade II: Haemorrhoid protrudes during defaecation or


Constipation
straining, but spontaneously reduces and returns to
internal position upon the cessation of straining. Constipation is a quite common problem during preg-
. Grade III: Haemorrhoids prolapse constantly but can nancy. If already present, its frequency may increase, it may
be pushed back manually with exertion of little effort. be exacerbated, or it may develop during pregnancy owing
. Grade IV: Haemorrhoids prolapse permanently and to physiological changes or concurrent conditions asso-
cannot be reduced. ciated with pregnancy.
Constipation results from several factors, including
mechanical obstruction due to compression of the lower
bowel by the uterus, decreased motility or prolonged transit
Symptoms
time in association with smooth muscle relaxation and
Clinical manifestations appear when prolapse gives rise to increase in water absorption from the colon.
congestion, engorgement and bleeding. Symptoms include
rectal bleeding, prolapse of haemorrhoidal veins, mucoid
Mechanical factors
discharge, mucosal or faecal soiling, itching, rectal dis-
comfort and occasionally pain. Bleeding develops due to Venous stasis and congestion secondary to mechanical
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local trauma to the haemorrhoid complex, usually during compression on the superior rectal vein and to vena cava
defaecation. and portal vein obstruction by the enlarged gravid uterus
External haemorrhoids are generally painful and become are probably the most significant mechanical factors. At the
red and tender when inflamed. If they become thrombosed, same time, during pregnancy the expanding uterus brings
they can cause severe pain and be felt as a tender mass in about a rise in intra-abdominal pressure and with the
the anal area. Internal haemorrhoids are usually painless. mechanical pressure of pregnancy, venous blockage and
Both internal and external haemorrhoids can bleed, but by arteriovenous shunting develop in the internal sphincter.
definition, internal haemorrhoids ‘prolapse’ and ‘external’ The circulating blood volume increases by 25–40%,
haemorrhoids ‘thrombose’. contributing to venous dilatation and engorgement.
Decreased blood flow in the anal mucosa and trauma have Stagnation of blood in the lower extremities and pelvis
been suggested as being involved in thrombosed external during later pregnancy can be ascribed to the enlarged
haemorrhoids (Loder et al. 1994). External haemorrhoids uterus. This sluggish flow and increased lower extremity
For personal use only.

under the anal skin can enlarge with time as a consequence of and pelvic venous pressure are of great importance. As the
dilatation or repeated thrombosis. Thrombosed external connective tissue (Parks ligament) is weak, these changes
haemorrhoids covered with squamous epithelium occur as a contribute to the development of varicose veins as well as
blue swelling with or without oedema and are located under haemorrhoids.
the linea pectinea. The overlying skin may stretch, and
become a skin tag. Old external haemorrhoids are anal tags.
Hormonal factors
They do not constitute a risk for subsequent thrombosis.
Haemorrhoids which remain prolapsed may develop throm- Hormonal factors may play a role. Gastrointestinal motility
bosis and gangrene. Acute haemorrhoidal crisis can occur is believed to be inhibited during pregnancy. This
with irreducible prolapse, thrombosis and sustained pain. inhibition may directly promote constipation or indirectly
Associated symptoms range from rectal itching, through exacerbate underlying disorders of bowel habit. Oro-caecal
light or heavy bleeding to severe pain in a thrombosed transit is significantly slower (by approximately one-third)
haemorrhoid. Occasionally, a clot within an external in the third trimester of pregnancy, when oestradiol and
haemorrhoid causes severe pain and may bleed if the clot progesterone levels are elevated, as compared with the
erodes through the overlying skin. Bleeding is rare unless postpartum period (Wald et al. 1982). In the postpartum
thrombosis leads to the necrosis of overlying skin. period, when progesterone and oestrogen return to pre-
Unlike external haemorrhoids, internal haemorrhoids pregnant levels, gastrointestinal motility returns to normal
usually bleed without pain and if they prolapse through the as well (Lawson et al. 1985). Oestrogens are associated
anus, they may present with the feeling of discomfort, with an enlargement of venous walls.
itching and, if incarcerated, with pain. Progesterone tends to lower the strength of venous wall
muscle, decrease circular and longitudinal smooth muscle
contractility and slow gastrointestinal transit. This inhibi-
Factors influencing the development of
tion contributes to constipation, which indirectly predis-
haemorrhoids during pregnancy
poses to the development of haemorrhoids. This may be
Pregnancy is a facilitating factor for the development of reduced with the increase in the concentration of calcium.
varicose veins and tends to exacerbate any predisposition Plasma motilin levels are reversibly depressed during
towards venous disorders and is the most common cause of pregnancy, perhaps via inhibition by progesterone (Chris-
symptomatic haemorrhoids. Varicosities of the rectal veins tofides et al. 1982). During pregnancy, hormonal changes
may arise de novo during pregnancy or more often may cause the vascularity of skin and muscles and
pregnancy causes an exacerbation or recurrence of previous hyperaemia to increase and connective tissue to soften
haemorrhoids. Their development or aggravation during and become laxer.
pregnancy is no doubt related to increased pressure in Decreased fluid intake and iron supplementation
rectal veins caused by restriction of venous return by the may also cause constipation. Straining during defa-
enlarged uterus as well as by constipation related to ecation, impairment of defaecation habits during preg-
pregnancy. In terms of aetiology, mechanical and hormonal nancy, decrease in physical activity and psycho-social
factors have been proposed to account for the relationship stress may also tendency to constipation and hence
(Medich and Fazio 1995; Wald 2003). haemorrhoids.
Haemorrhoid during pregnancy 233

only one had been delivered by caesarean section.


Haemorrhoid incidence during pregnancy
Caesarean section appears to protect against this problem
and the puerperium
(MacArthur et al. 1991; Abramowitz et al. 2002).
Haemorrhoids are present in 85% of women during the Birth weight also appears to be related to the rate of
second and third stages of pregnancy (Gojnic et al. 2005). thrombosed external haemorrhoids. The rate of anal
In the last 3 months of pregnancy, the thrombosed lesions and haemorrhoids was significantly higher in those
haemorrhoid rate is 7.9% (Abramowitz et al. 2002). who gave birth to heavier infants (MacArthur et al. 1991;
MacArthur et al. (1991) reported that the haemorr- Abramowitz et al. 2002).
hoid rate was 5.3% and 6.9% among primigravidae. Late delivery is also a risk factor for postnatal anal disease
Abramowitz et al. (2002) reported that 91% of thrombosed (OR: 1.4). Patients who delivered after 40 weeks of
haemorrhoids emerge on the first day postpartum and in pregnancy were more likely to have anal disease than those
14.5% of cases they appear de novo after delivery. The rate who delivered before that time. Although the reason why
within 2 months postpartum is 20%. Parity has no effect on late delivery is a risk factor for anal disease is not clear, the
this, although as parity increases, the risk of new symptoms exposure of perineum to the effects of pregnancy for longer
decreases (MacArthur et al. 1991). period and prolongation of hormonal effects may predis-
Haemorrhoids will often regress after delivery but usually pose women to anal diseases (Abramowitz et al. 2002).
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will not disappear completely. The incidence of haemorrhoids


has been reported to be 8–24% within 3 months postpartum,
Diagnosis
24%, between 3–6 months and 15–16% after 6 months
(Glazener et al. 1995; Brown and Lumley, 1998; Gunn et al. The diagnosis is made by examining the anus and anal
1998; Saurel-Cubizolles et al. 2000; Borders, 2006). canal with inspection, digital rectal examination and
endoscopy (sigmoidoscopy and colonoscopy). It is im-
portant to rule out more serious causes of bleeding, such as
Haemorrhoid symptoms in pregnancy
inflammatory bowel disease, anal fissure and carcinoma of
Pregnancy and the puerperium predispose to symptomatic the colon, rectum, or anus. No relationship between
haemorrhoids, which is the most common anorectal haemorrhoids and cancer has been found.
disease at this time. Haemorrhoids, which are present The causes and treatment of constipation during
previously, may also be symptomatic for the first time in pregnancy are similar to those of chronic constipation in
For personal use only.

pregnancy and present with bleeding, pain and itch. the general population. Extensive investigation of constipa-
Haemorrhoidal symptoms are common in the second and tion is usually unnecessary in pregnant women (Singer and
third trimesters of pregnancy and after delivery. Brandt 1991). Endoscopic examination is the most
Clinical symptoms and signs, as in non-pregnant patients definitive tool in diagnosis, even although it is sometimes
are: red bleeding without pain; the prolapse becomes more thought that it should not be carried out during pregnancy,
marked during activity and on increasing intra-abdominal except when very necessary.
pressure with defaecation, sneezing, coughing or walking; Complications unique to the pregnant woman and her
mucoid anal canal discharge; chronic irritation from a fetus during endoscopy were initially thought to result
moist anus with anal itching in 50% of cases; pain in acute either directly from colonic intubation itself or from the use
thrombosed or irreducible prolapse; feeling of fullness in of sedatives. Insertion of the sigmoidoscope or colonoscope
perineum and anus; tenesmus, and impairment of rectal into the colon could theoretically cause premature labour
emptying and intestinal function. Symptoms are usually by neuro-humoral responses to colonic distention or by
mild and transient with intermittent bleeding from the anus physically causing uterine rupture, placental abruption, or
and pain. Quality of life is affected; pain varying from mild fetal compression. Special care should be given not only
discomfort to severe causing real difficulty in dealing with because of the effects of the actual procedures on the
the activities of everyday life. Dyschezia is very common mother and fetus, but also for the potential adverse effects
during pregnancy (Calhoun 1992) affecting 23% in the last of medications used (Siddiqui and Proctor 2006). For-
3 months of pregnancy and a third in the postpartum tunately medication-related problems usually relate to
period. In 21.8% of those who complain from dyschezia sedation during endoscopy and for assessment of haemor-
during pregnancy, thrombosed external haemorrhoids rhoids, sedation is not usually required.
occurred (Abramowitz et al. 2002). Lower gastrointestinal endoscopy should be avoided for
weak indications during pregnancy and should be delayed
until after the first trimester, or better if feasible, until the
Association between delivery and
postpartum period (Siddiqui and Proctor 2006). For
haemorrhoids
stronger indications, however, including significant rectal
Prolonged straining during spontaneous delivery and bleeding causing lowering of mean haematocrit or requir-
assisted vaginal births predisposes to the development of ing blood transfusion, a fall in arterial pressure etc.,
haemorrhoids. Prolongation of the second stage of labour is a endoscopy is indicated during pregnancy.
risk factor for the formation of haemorrhoids (MacArthur Sigmoidoscopy does not induce labour or result in
et al. 1991). congenital malformations, Sigmoidoscopy is not contra-
Traumatic delivery appears to be an important risk factor indicated during pregnancy, and sigmoidoscopy may be
for thrombosed external haemorrhoids, which occur beneficial in pregnant patients with significant lower
immediately after delivery (Abramowitz et al. 2002). gastrointestinal bleeding. Colonoscopy during pregnancy
Haemorrhoids occur more frequently after assisted vaginal should be considered for life-threatening lower gastro-
deliveries (MacArthur et al. 1991; Glazener et al. 1995; intestinal bleeding or when the only alternative is surgery
Thompson et al. 2002). Abramowitz et al. (2002) reported (Cappell et al. 1996; Cappell 1998; Abramowitz et al.
that of 33 cases with thrombosed external haemorrhoids, 2002). If sedation is needed during colonoscopy or rarely
234 A. F. Avsar & H. L. Keskin

during sigmoidoscopy diazepam, midazolam, meperidine with decreased bowel transit time, and stools may be
and fentanyl can be used. hardened. Terminal constipation is the most important risk
Gojnic et al. (2005) emphasised that differential diag- factor for anal lesions in pregnant women, which suggests
noses should be based on complete examination of that dietary modification with increased bulk such as with
haemorrhoids during pregnancy, because they detected fresh fruit and vegetables and plenty of water should be
rectal carcinoma in three out of 50 cases between 36 and 38 used during childbirth and in the postpartum period in all
years old whom they examined with an anoscope and patients with terminal constipation during late pregnancy.
rectoscope during their second trimester (Gojnic et al. These preventive methods usually help significantly.
2005). Avoidance of constipation is the most important method
Based on the previous data, it appears that performing an for prevention of haemorrhoids during pregnancy.
unsedated flexible sigmoidoscopy in a pregnant woman is In order to prevent constipation, pregnant women
quite safe (Siddiqui and Proctor 2006). In addition, the should ideally be instructed on bowel habit. Patients are
timing of the procedure does not seem to matter given that advised to perform moderate exercises such as walking, to
sigmoidoscopies were safely performed during all three avoid straining, and to take advantage of postprandial
trimesters (Siddiqui and Proctor 2006). When sigmoido- increases in colonic motility by defaecating in the morning
scopy is performed during pregnancy, technologically and after meals, when colonic activity is highest.
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advanced instruments should be used, the monitoring of Although the evidence appears to be inconclusive,
patients should be improved and greater awareness of the reviews and clinical practice guidelines recommend the
safety of procedure is necessary. The procedure must be use of laxatives and fibre for the treatment of haemorrhoids
performed as quickly as possible by the most experienced and relief of symptoms. They are safe and cheap.
endoscopist. Progesterone-induced relaxation of the intestinal smooth
muscle slows peristalsis and increases bowel transit time.
Dietary management of this common condition includes
Management and treatment of haemorrhoids
increased fluids and liberal intake of high-fibre foods.
during pregnancy
Psyllium draws fluid into the intestine and promotes a
Should haemorrhoids be treated during pregnancy and if more rapid transit time. The use of fibre shows a consistent
so, how should they be treated? beneficial effect for relieving overall symptoms and
The aim of treatment is to reduce both acute and chronic bleeding in the treatment of symptomatic haemorrhoids
For personal use only.

symptoms, to increase the duration of time between (Alonso-Coello et al. 2005). Stool softeners work well for
attacks, to protect the perineal region which has been 1st and 2nd degree haemorrhoids.
exposed to trauma during vaginal delivery and to relieve the Increased dietary fibre and increased fluid intake can
feeling of disturbance. Treatment should not harm the prevent constipation and are the most physiological and
mother or fetus and should relieve the patient at least until safest recommendations for constipation during pregnancy
the end of the puerperium. together with reasonable amounts of daily exercise. Dietary
Treatment during pregnancy is mainly directed to the fibre is that portion of plant food that escapes digestion.
relief of symptoms, especially pain control. Non-surgical This regimen may be supplemented when necessary by a
management includes dietary modification, stimulants or mild laxative, such as prune juice, milk of magnesia, bulk-
depressants of bowel transit, local treatment and phlebo- producing substances, or stool-softening agents.
tonics (drugs that cause decreased capillary fragility, Wheat bran is a highly effective fibre laxative. Patients
improving the microcirculation in venous insufficiency). with poor dietary habit may add 2–6 spoons of bran to each
For many women, symptoms will resolve spontaneously meal, followed by liquid. Vegetables and fruit contain
soon after birth, and so any corrective treatment is usually soluble fibre but are not always adequate substitutes for
deferred to some time after birth. With internal haemor- bran. Pregnant women should be warned that consuming a
rhoids, a conservative approach is used. External haemor- large amount of bran can cause abdominal bloating or
rhoids do not require treatment unless they have become flatulence and that sufficient fluids should be consumed
thrombosed and if pain does occur conservative treatment with bran which should be consumed in small amounts
may be given. Treatment is not required unless acute increased gradually.
thromboses develop. If the diet cannot be modified in this way, adding bulk
Treatment is based on the degree of haemorrhoidal laxatives such as psyllium, methylcellulose, polycarbophil
prolapse and the severity of symptoms and may be divided or surface-active agents such as docusate are recom-
into three main groups: mended; they can prevent worsening of the condition.
Laxatives are rarely necessary (Wald 2003).
. Conservative methods
. Medical therapy
Preferred laxatives during pregnancy
. Surgical interventions:
. Elastic ligation . Bulk-forming laxatives:
. Photocoagulation . Natural (e.g. psyllium)
. Sclerosis . Synthetic (e.g. methylcellulose, polycarbophil).
. Cryosurgery and direct-current coagulation . Hyperosmolar laxatives:
. Excisional haemorrhoidectomy. . Polyethylene glycol
. Lactulose
. Sorbitol (70%)
Conservative methods
. Glycerine.
Treatment is usually non-operative. The best treatment is . Diphenylmethane
prevention. Constipation is physiological during pregnancy . Bisacodyl.
Haemorrhoid during pregnancy 235

. Anthraquinones Oral treatment may be administered by flavonoids, which


. Senna are phlebotonic-trophic drugs. Micronised flavonoids are an
. Cascara sagrada. important and efficient option in the treatment of haemor-
rhoids in pregnancy and is reliable in the third trimester,
Mineral oil softens stools as a result of its emollient action. which is important for use in pregnancy. Flavonoid
Aspiration, resulting in lipoid pneumonia, is a hazard of compounds derived from citrus fruits have been used in
oral administration, especially in patients with impaired haemorrhoid treatment during pregnancy since the 1970s.
swallowing. Repeated use is associated with decreased In haemorrhoids, with stasis there is a marginalisation and
maternal absorption of fat-soluble vitamins, neonatal trapping of white cells on the luminal surface of the vein,
hypoprothrombinaemia, and haemorrhage. release of inflammatory substance such as prostaglandins
Stimulant laxatives may be considered in patients who fail and free radicals, and increased permeability and fragility of
to respond to bulk or osmotic laxatives. These agents affect the vessel wall leading to its necrosis. Micronised flavonoids
fluid and electrolyte transport, gastrointestinal motility, or exert their effects by preventing these pathologies, increasing
both. In general, stimulant laxatives should be reserved for venous tonus for venous contraction, suppressing inflam-
patients who do not respond to simple initial measures matory mediators in order to decrease capillary hyperperme-
(Wald 2000). Bisacodyl, although safe for use in pregnancy, ability and fragility with anti-inflammatory effect and by
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tends to produce more colic than anthraquinone laxatives, increasing lymphatic drainage and improve acute symptoms.
especially when administered orally. The overall symptom score and acute haemorrhoidal
Laxatives to be avoided during pregnancy include castor episodes were significantly lower in the flavonoid treated
oil, because it may initiate premature uterine contractions group (Godeberge 1994).
and saline agents such as magnesium laxatives and Micronised purified flavonoid fraction (MPFF) signifi-
phospho-soda because they promote sodium and water cantly reduced pain and bleeding in patients with acute
retention, which is inadvisable during pregnancy (Lewis haemorrhoids, and was well tolerated (Jiang and Cao
and Weingold 1985). Enemas and strong cathartics should 2006).
be avoided. In a safety and efficacy study of micronised diosmin 90%
Giving laxative treatment to all patients who have and hesperidin 10% for the treatment of internal haemor-
dyschezia during childbirth and the postpartum period rhoids of pregnancy, Buckshee et al. (1997) showed that
should significantly decrease the occurrence of anal lesions treatment was safe, acceptable and effective. A total of 66%
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in the postpartum period. of the patients had relief from acute symptoms (bleeding,
Frequently what appears to be severe perineal pain and pain, rectal exudation, rectal discomfort and endoscopi-
swelling is, in fact, the pain of prolapsed haemorrhoids. cally visualised rectal inflammation) by the fourth day;
Witch hazel compresses, suppositories containing corticos- 53.6% fewer patients relapsed during the antenatal period.
teroids, or topically applied local anaesthetics, warm soaks, It was established that maintenance treatment markedly
and stool-softening agents may be helpful. decreased both the frequency and duration of symptoms in
There are numerous sprays, emollients creams and the antenatal period (8 weeks before birth). No significant
suppositories that can relieve anal irritation and pain, but decrease was observed in thrombosis and prolapse.
they rarely provide long-term benefit. Occasionally a Treatment was well accepted, and did not affect
thrombus will occur in a prolapsed haemorrhoid. It is a pregnancy, fetal development, birth weight, infant growth
simple task to remove the thrombus through a small scalpel and feeding. No fetal risk has been established with
incision using local anaesthetic. flavonoids and Daflon1 500 mg.
Minor symptoms such as anal pruritus may be treated by Wijayanegara et al. (1992) suggest that O-(beta-hydroxy-
various products after each defaecation and by topical local ethyl)rutoside, an over the counter drug, provides safe and
anaesthetics containing benzocaine, dibucaine or pramox- effective treatment for women with haemorrhoids in
ine (Wald 2003). However, creams containing a topical pregnancy. However, Quijano and Abalos (2005) suggest
anaesthetic may induce sensitisation and are not recom- that, although this seems promising for symptomatic relief
mended. in 1st and 2nd degree haemorrhoids, its use cannot be
Warm baths may be used to decrease internal sphincter recommended until new evidence reassures women and
tone or to improve venous congestion. Inflamed haemor- their clinicians about their safety.
rhoids often respond well to warm sitz baths and a topical Uokawa et al. (2007), faced with the difficulty of a triplet
anti-inflammatory cream designed to reduce inflammation pregnancy in the 25th week, with severe pain due to
and itching. A cream containing hydrocortisone may help haemorrhoids, used caudal epidural block with first 0.25%
relieve pruritus in more severe cases. bupivacaine 20 ml and morphine hydrochloride 2 mg once
Epinephrine or phenylephrine containing products a day without inserting a catheter and after that 0.125%
which decrease haemorrhoidal swelling with their vessel bupivacaine 1–2 ml/h via a catheter up to the day of
contracting effects should be used very cautiously in caesarean section successfully and safely for relief of pain.
pregnancy particularly in hypertensive patients.
Constipation is aggravated by the use of iron supple-
Surgical management
ments; if dietary iron is insufficient pregnant women given
oral iron should change to a slow-release form which may Failure of medical therapy is an indication for mechanical
be less constipating. intervention. When haemorrhoidal symptoms do not
respond to medical treatment and intractable pain pre-
dominates, surgeons may be reluctant to operate due to
Medical therapy
potential complications.
Medical therapy often is the only requirement for non- In 1980, the conventional treatment choices for inter-
thrombosed haemorrhoids. nal haemorrhoids occurring in pregnancy were surgical
236 A. F. Avsar & H. L. Keskin

outpatient measures: injection, rubber band ligation and 109 postpartum women with severe haemorrhoidal symp-
infrared coagulation, or haemorrhoidectomy were regarded toms and reported the long-term effects to be excellent.
as contraindicated. Only in one case did symptoms occur (O’Connor 1980).
It has also been reported that with surgical treatment for If haemorrhoids are severely prolapsed and incarcerated
haemorrhoids during pregnancy, postoperative bleeding is or have associated ulceration, severe bleeding, fissure, or
a greater problem and haemorrhoidectomy carries hypo- fistula and symptoms fail to respond to conservative
tensive risks both for the mother and the fetus (3.3–6.7%) measures or office-based procedures, surgical haemorrhoi-
(Ho et al. 1995). Sphincterotomy was considered risky as it dectomy should be considered for more definitive control
was expected to cause premature labour and have problems of symptoms, but this is seldom needed if conservative
with wound healing. Therefore, usually conservative treat- treatment is used scrupulously. Haemorrhoidectomy is
ment was preferred even if acute haemorrhoidal symptoms necessary when clots repeatedly form in external haemor-
occurred. rhoids, ligation fails to treat internal haemorrhoids, the
However, at present, surgical intervention can be made protruding haemorrhoid cannot be reduced, or there is
more effectively and reliably because of developments in persistent bleeding. Haemorrhoidectomy is done under
surgical technique and with office procedures. general anaesthetic and may require admission to hospital.
Treatments for symptomatic internal haemorrhoids are Thrombosis or clots in the vein lead to severe symptoms.
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many. The method is designed to match the severity of The current surgical approach to haemorrhoidal disease is
prolapse. Rubber band ligation sometimes produces mild conservative, with simple outpatient treatment preferred,
discomfort and bleeding, but it is generally the first particularly during pregnancy and the puerperium. Throm-
choice for patients who have haemorrhoids and for whom bosed external haemorrhoid occurs during and immedi-
haemorrhoidectomy is considered too radical, or when the ately after delivery and external haemorrhoids require
patient specifically wishes to avoid surgical excision. Other treatment predominantly for acute thrombosis. Thrombo-
methods which can be used in cases with refractory symptoms sis of a rectal vein can cause considerable pain, but the clot
include injection, sclerotherapy, dilation of the anus, sphinc- may usually be evacuated by incising the vein wall under
terotomy and infrared photocoagulation (Smith 1983). topical anaesthesia. Dramatic relief of pain usually follows.
For patients with grade I or grade II haemorrhoids or This procedure is reliable and effective in pregnancy
who have larger haemorrhoids and wish to avoid surgical (Medich and Fazio 1995).
treatment, outpatient procedures, such as sclerotherapy, If thrombosed, external haemorrhoids remain tender and
For personal use only.

photocoagulation, rubber band ligation, and cryotherapy, resist conservative treatment; they may be treated with
may be appropriate. An ulcer forms above the haemor- simple clot extraction or by excision, which reduces the
rhoidal tissue after each of these treatments. As the wound chance of recurrence (Parangi et al. 2007). It has been
heals, fibrosis results in mucosal fixation. It is thus essential reported that only clot incision and removal is inadequate
that local treatments be applied to the mucosa above the as the thrombosis usually recurs (Saleeby et al. 1991).
haemorrhoids; if applied too low, they may cause excessive Thrombosis of external or prolapsing internal haemor-
pain. rhoids may require haemorrhoidectomy. If this is done,
Rubber band ligation works effectively on internal only symptomatic quadrants should be excised for the
haemorrhoids that protrude during defaecation, and in safety of the mother and the baby, irrespective of the need
experienced hands, complications are few. Rubber band for further treatment. Operative haemorrhoidectomy using
ligation, which is an easy and inexpensive office procedure, local anaesthesia in selected pregnant patients and post-
is used to treat 2nd degree haemorrhoids. Surgery is often partum women can be accepted as a safe and effective
necessary for 3rd and 4th degree haemorrhoids. There is a procedure (Saleeby et al. 1991). They can be infiltrated
small risk of acute necrotising perianal sepsis. Injection with 1% lidocaine and a small incision made to extract the
sclerotherapy using 5% phenol in almond oil, quinine, clot.
sodium morrhuate, or ethanolamine oleate, is safe and Saleeby et al. (1991) carried out selective operative
effective during pregnancy with rare recurrences (Medich haemorrhoidectomy on 25 cases with 3rd trimester and
and Fazio, 1995). postpartum acute haemorrhoidal attack (intractable pain,
Infrared photocoagulation or laser coagulation is safe protrusion, bleeding, thrombosed or gangrenous haemor-
and effective in non-pregnant patients and theoretically is rhoids). Only in one case was a haemostatic pack necessary
safe in pregnant women (Medich and Fazio 1995). due to persistent rectal bleeding postoperatively. No other
Cryotherapy is less effective and more painful. Excessive fetal complication occurred and no adverse effect of
activity of the internal anal sphincter is often associated surgical procedure was seen on labour.
with bleeding; for such patients gentle anal dilatation under Finally, it should be emphasised that prevention is the
general anaesthesia is advisable. It is important to recognise best approach; both office procedures and haemorrhoidec-
that stretching the sphincter inevitably weakens the external tomies need skilled operators.
sphincter as well as the internal. Spasms of the internal
sphincter may be relieved by injections of botulinum toxin Declaration of interest: The authors report no conflicts
or topical application of nitroglycerine ointment. If of interest. The authors alone are responsible for the
symptoms recur after topical treatment, the patient can content and writing of the paper.
be treated with Lord’s procedure, which has long been
used reliably in the postpartum period for the treatment of
symptomatic haemorrhoids. In Lord’s procedure, the References
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