Treatment Options for Hemorrhoids in Pregnancy

Epidemiology and Presentation

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester due to compression of the rectum by the gravid uterus 1, 2
• Symptoms include bleeding, protrusion, itching, and pain 3

Conservative Management (First-Line)

• Increasing dietary fiber intake to approximately 30 g/day helps promote regular bowel movements and prevents constipation 1, 2
• Adequate fluid intake, particularly water, helps soften stools and ease bowel movements 1, 2
• Bulk-forming agents such as psyllium husk are safe during pregnancy due to lack of systemic absorption 1, 2, 3
• Soluble fiber like psyllium husk improves stool viscosity and transit time in addition to increasing bulk 1, 2
• Avoiding straining during bowel movements by using relaxation techniques and adjusting diet and hydration is helpful 1, 2

Pharmacological Management

• Osmotic laxatives such as polyethylene glycol or lactulose can be safely administered during pregnancy 1, 2
• Topical treatments for symptom relief: Hydrocortisone foam has been shown to be safe for hemorrhoids in the third trimester with no adverse events compared to placebo in a prospective study of 204 patients 1, 2, 3
• Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa 3, 4
• Stimulant laxatives should be avoided because safety data on these medications during pregnancy are conflicting 1, 2

Management of Thrombosed External Hemorrhoids

• For thrombosed hemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates 3, 4
• For presentations beyond 72 hours, conservative management is preferred, with treatment including stool softeners and topical analgesics 3

Important Considerations and Pitfalls

• Avoid assuming all anorectal symptoms are due to hemorrhoids, as other conditions like anal fissures may coexist 3

Management of Incarcerated and Prolapsed Hemorrhoids in Pregnancy

Acute Surgical Management

• 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 the internal hemorrhoids, particularly in pregnancy when conservative management fails or when there is acute incarceration with thrombosis 5, 6
• Approximately 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids 7
• Manual dilatation of the anus is not recommended due to the associated risk of sphincter injury and incontinence 5, 6

Severity-Based Approach

• Fourth-degree hemorrhoids (cannot be reduced, incarcerated, thrombosed) require surgical intervention 5, 6, 8
• Third-degree hemorrhoids (require manual reduction) should be treated with a trial of conservative management first, and surgery if failed 5, 6

Critical Pitfalls to Avoid

• The American Gastroenterological Association advises against assuming all anorectal symptoms are due to hemorrhoids, as other conditions like anal fissures may coexist in up to 20% of patients 8
• Prolonged use of potent corticosteroid preparations should be avoided as they may be harmful and cause tissue thinning 5, 6

Ongoing Management of Hemorrhoids in Pregnancy

Conservative Management

• The World Journal of Emergency Surgery recommends a conservative approach as the cornerstone of management, which represents a strong recommendation based on moderate-quality evidence, and should be maintained throughout pregnancy 9

Management of Thrombosed External Hemorrhoids

• The decision between non-operative management and early surgical excision for thrombosed hemorrhoids should be based on local expertise and patient preference, according to the World Journal of Emergency Surgery 9
• Incision and drainage of the thrombus alone is not recommended for thrombosed external hemorrhoids, as stated by the World Journal of Emergency Surgery 9

Flavonoids and Phlebotonics

• Flavonoids may relieve symptoms in complicated hemorrhoids, which is a weak recommendation based on moderate-quality evidence, according to the World Journal of Emergency Surgery 9

Evidence‑Based Management of Hemorrhoids During Pregnancy

Conservative and Symptomatic Care

• Topical analgesic preparations can be applied to relieve perianal skin irritation caused by mucus discharge or fecal seepage in pregnant patients with hemorrhoids. 10
• Pain from a thrombosed external hemorrhoid typically resolves within 7–10 days when managed conservatively with stool softeners and topical analgesics. 10

Timing‑Based Approach to Thrombosed External Hemorrhoids

• When a thrombosed external hemorrhoid presents within 72 hours of symptom onset, surgical excision performed under local anesthesia leads to faster symptom resolution and lower recurrence compared with delayed treatment. 10
• If presentation occurs after 72 hours, a conservative regimen—using stool softeners and topical analgesics—is preferred. 10

Indications for Surgical Intervention

• Acutely prolapsed, incarcerated, or thrombosed hemorrhoids in pregnancy should be treated with either a hemorrhoidectomy or excision of the external component combined with rubber‑band ligation of internal hemorrhoids. 10
• Manual dilatation of the anal canal is contraindicated during pregnancy because it carries a risk of sphincter injury and subsequent fecal incontinence. 10

Caution with Potent Corticosteroids

• Prolonged use of high‑potency topical corticosteroid preparations should be avoided in pregnant patients, as they may cause detrimental thinning of perianal and anal mucosa. 10

First‑ and Second‑Degree Hemorrhoid Management Algorithm

• First‑degree hemorrhoids (bleeding only, no prolapse): Initiate dietary fiber supplementation (~30 g/day) and ensure adequate fluid intake. 10
• Second‑degree hemorrhoids (prolapse with spontaneous reduction): Apply the same conservative measures as for first‑degree disease. 10