Hemorrhoids during pregnancy

Haemorrhoids during pregnancy: Why do they occur, and what can you do?

Haemorrhoids are one of the most common - and least talked about - complaints during pregnancy and the postnatal period. Many women have symptoms in the third trimester, and complaints are also common in the first weeks after childbirth. How often this happens varies considerably between series, which are mixed and often small, so there is no reliable figure [1,2]. The course varies from woman to woman, and many manage with conservative treatment. What is relevant for you is assessed together with your midwife or doctor.

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Why do pregnant women get haemorrhoids more often?

Three factors work together:

• Increased pressure in the pelvic veins. The growing womb presses on the vena cava and pelvic veins, making it harder for blood to flow back from the vessels in the rectum. That is the usual explanation, but the causes of haemorrhoids are not fully established [3].
• Hormonal changes. Progesterone is thought to relax the smooth muscle of the bowel and slow it down – a commonly cited mechanism behind the increased risk of constipation in pregnancy, though this is not conclusively established.
• Pressure during childbirth. In a French prospective study of women before and after delivery, thrombosed external haemorrhoids and anal fissures were more frequent shortly after a vaginal delivery, particularly with a longer pushing stage or a large baby [2,5]. The study followed women around a single delivery and says nothing about longer-term risk.

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Symptoms to be aware of

• Fresh, bright red blood on the toilet paper or in the toilet bowl
• Itching, burning, or a feeling of "something bulging out"
• A tender lump at the anal opening (typically thrombosed haemorrhoids)
• Discomfort when sitting down, especially after childbirth

Heavy or persistent bleeding, fever, feeling generally unwell or severe and increasing pain need urgent assessment. Contact your GP the same day, the out-of-hours service (1813 in the Capital Region) outside opening hours, and call 112 if you are severely affected. The same applies in order to rule out other causes such as an anal fissure or an abscess.

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Treatment during pregnancy and breastfeeding

Advice usually starts with diet, habits and local treatment, and procedures are in many cases postponed until after childbirth. The specific choice rests on an individual assessment by a midwife or doctor, and you should not start, stop or change prescribed medication without agreeing it first.

Conservative measures:

• Fibre and fluid: Dietary fibre and fluid according to individual need. The amount depends on your current diet, fluid losses and any other conditions, and is increased gradually. Psyllium husk and other fibre supplements may be considered, but use during pregnancy should be agreed with your midwife, doctor or pharmacist.
• Laxatives: If diet is not enough, a laxative may be considered [7]. The choice, dose and duration during pregnancy and breastfeeding are agreed with your midwife, doctor or pharmacist.
• Topical treatment: Local anaesthetic and corticosteroid ointments are used only after assessment by a midwife, doctor or pharmacist, who decides on the product, amount and duration in pregnancy and breastfeeding.
• Sitz baths in warm water can relieve itching and pain. Frequency and duration are adjusted to what helps you.
• Avoid straining and avoid sitting on the toilet for long periods.

What about surgery?

Surgery is rarely recommended during pregnancy. For an acute thrombosed external haemorrhoid, surgical treatment may be considered in selected cases. The method and timing are assessed clinically from symptoms and findings [8]. Formal surgical treatment for haemorrhoids or McGivney banding treatment is usually postponed until after the postnatal period. The timing is assessed individually based on symptoms, findings and the delivery.

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Prevention after childbirth

• Continue with a high-fibre diet and fluid suited to your needs, especially if you are breastfeeding
• Stool softeners after delivery are used after agreement with a midwife, doctor or pharmacist, who also decides how long to continue
• Pelvic floor exercises are recommended for pelvic floor function and continence. They are not an established treatment for haemorrhoids or venous disease

The course after delivery varies from woman to woman [2]. If your symptoms persist, you are welcome to contact the clinic. Whether a referral and public cover are possible, and any waiting time, depend on the specific service and the rules in force, and are clarified before treatment.

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References

1. Poskus T, et al. Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study. BJOG 2014;121(13):1666-71.
2. Quijano CE, Abalos E. Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium. Cochrane Database Syst Rev 2005;(3):CD004077.
3. Sandler RS, Peery AF. Rethinking what we know about hemorrhoids. Clin Gastroenterol Hepatol 2019;17(1):8-15.
4. Vazquez JC. Constipation, haemorrhoids, and heartburn in pregnancy. BMJ Clin Evid 2010;2010:1411.
5. Abramowitz L, et al. Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum 2002;45(5):650-5.
6. McRorie JW, Chey WD. Laxative effects of wheat bran and psyllium: resolving enduring misconceptions about fiber in treatment guidelines for chronic idiopathic constipation. J Am Assoc Nurse Pract 2020;32(1):15-23. PubMed
7. Rungsiprakarn P, et al. Interventions for treating constipation in pregnancy. Cochrane Database Syst Rev 2015;(9):CD011448.
8. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Dis Colon Rectum 2018;61(3):284-292. PubMed