External hemorrhoids in pregnancy

The formation of hemorrhoidal nodes around the rectum is called hemorrhoids, and a distinction is made between internal and external. The latter involves pathological changes in the form of expansion of the veins of the external rectal plexus located around the anus. Pregnancy contributes to the development of the disease. [ 1 ]

Epidemiology

It has been estimated that 25% to 35% of pregnant women suffer from this condition.[ 2 ],[ 3 ] In some populations, up to 85% of pregnant women suffer from hemorrhoids in the third trimester.[ 4 ]

Causes of external hemorrhoids in pregnancy

Carrying a child is accompanied by a large load on the vascular system. During this period, the volume of circulating blood increases by a third. The causes of hemorrhoids are as follows:

• the growing uterus presses on the pelvic veins, thereby worsening blood circulation and contributing to the stretching of the veins of the rectum;
  • hormonal changes (increased progesterone relaxes the smooth muscles of the intestines and veins);
• reduced motor and physical activity in the third trimester of pregnancy leads to venous congestion;
• Frequent constipation, typical of this period, reduces the tone of the walls of the terminal section of the large intestine.

Risk factors

Risk factors for the development of hemorrhoids include long-term regular use of hormonal contraceptives before pregnancy, excess weight, and poorly organized nutrition. Spicy dishes with abundant spices, alcohol, and hypertension also contribute to the pathology. [ 5 ]

Pathogenesis

The pathogenesis of hemorrhoidal nodes is associated with the proliferation of cavernous tissue of the veins, which occurs due to abundant blood flow through the arteries of the rectum or difficulty in outflow from its veins. It goes through several stages from the internal form, the manifestations of which do not bother the patient much, to the external, very painful with dangerous consequences. [ 6 ]

Symptoms of external hemorrhoids in pregnancy

At first, a woman may not even understand that troubles are brewing related to her health. The first signs are expressed in some discomfort in the anus, painful defecation appears, during which the feces contain fragments of scarlet blood.

Ignoring the problem and refusing to visit a proctologist worsens the symptoms. Itching in the anus occurs, mucous discharge appears, and hemorrhoids prolapse.

Then the pain increases during bowel movements and walking, and external hemorrhoids begin to bleed.

It is no less likely that such a scenario will develop after childbirth, which only confirms the fact that there was a pathology during the gestation period. The pushing only caused the nodes to fall out. [ 7 ]

Complications and consequences

Hemorrhoids are a rapidly progressing disease. If left untreated, they can cause profuse bleeding, anemia, and complications such as thrombosis of hemorrhoids. Often, the disease causes inflammation, which is dangerous due to the development of acute purulent paraproctitis. Cracks and edema may develop. [ 8 ]

Diagnostics of external hemorrhoids in pregnancy

Pregnant women undergo a proctological examination by a proctologist, which involves an external visual examination and a digital examination, carried out on a special proctological chair.

In diagnostics of the disease, it is impossible to do without instrumental methods, since external hemorrhoids come from problems inside the anus. Anoscopy examines this area, rectoscopy - 20 cm of the rectum. With the help of a special sensor, the condition of the mucous membrane and the nodes themselves is determined. Both procedures can be carried out up to 24 weeks of pregnancy, after this period only anoscopy.

Hemorrhoids are differentiated from polyps, other neoplasms, and rectal prolapse. [ 9 ]

Treatment of external hemorrhoids in pregnancy

First of all, the doctor will advise the pregnant woman to pay attention to nutrition: increase raw vegetables and fruits in the diet, switch to a dietary method of cooking, increase the drinking regime to 2 liters per day. Medicinal enemas based on vegetable oils, softening the fecal lump, are also effective.

A recent systematic review of both published and unpublished randomized controlled trials involving over 350 patients found that fiber laxatives have a beneficial effect in the treatment of symptomatic hemorrhoids.[ 10 ] Reducing straining during bowel movements constricts the internal hemorrhoidal veins, resulting in a reduction in symptoms. Bathing in warm water (40–50°C for 10 min) usually relieves anorectal pain.[ 11 ]

Topical preparations with analgesic and anti-inflammatory effects provide short-term local relief of discomfort, pain, and bleeding. Because of their low doses and limited systemic absorption, they can be used in pregnant women; however, the safety of any of them in pregnancy has not been adequately documented.

You can remove nodes, relieve inflammation and pain with the help of ointments and suppositories that are safe for the fetus. [ 12 ]

Medicines

The best way to treat external hemorrhoids during pregnancy is to use ointments. Before using them, you need to empty your bowels, wash yourself and wipe yourself dry. They are applied in a thin layer around the anus. [ 13 ] Among them are the following:

• posterisan - the main active ingredient is microbial cells of E. coli killed by phenol. It is applied to the surface twice a day and after defecation using an applicator. The phenol in its composition can cause allergic reactions, there are no other contraindications;
• troxevasin ointment - has a good antioxidant effect, eliminates pain, swelling, venous insufficiency. Apply to the affected area in the morning and evening. Contraindicated for patients with serious renal dysfunction, very rarely causes skin reactions.

Rectal suppositories are also prescribed in combination with ointments:

• natalsid - suitable for the treatment of bleeding hemorrhoids. It is obtained from brown seaweed. It is inserted into the anus twice a day (unless the doctor has prescribed another regimen) after bowel movement. Contraindicated in case of individual intolerance to the components. Indispensable for long-term treatment;
• Sea buckthorn suppositories – heal well, relieve inflammation, soften. Apply 1 to 3 times a day. The average course of treatment is 7-10 days. Side effects may include an allergic reaction to the plant;
• Relief (suppositories and ointment) – anti-inflammatory, immunomodulatory, healing agent. It is based on cocoa butter and shark liver. It is not prescribed for diabetes, diseases of the circulatory system, allergies to its components. It is used for pregnant women only with the permission of a doctor. Suppositories, like ointment, should be used 4 times a day.

Vitamins

Chronic pathology can lead to iron deficiency anemia. Therefore, along with vitamins that increase the body's resistance, especially C, strengthening blood vessels (A, C, E, K, P, group B), iron must be present, as well as copper and zinc, necessary for its synthesis.

Foods containing them may not be enough, so you need to take vitamin and mineral complexes (Aevit, Ascorutin).

Folk remedies

There are some folk wisdoms that allow you to relieve pain and ease the patient's condition. One of them is raw potato candles. Their size should be within 3-4 cm in length and 1-1.5 cm in diameter. Starch and vitamin C, which are part of it, promote healing and tone blood vessels.

You can also make your own anus lubricating compound: finely chop garlic, mix with sea buckthorn oil, and freeze slightly. Honey, propolis, and butter are used for this purpose.

It is also useful to drink carrot and beetroot juice, taking equal proportions of ingredients. It will prevent constipation.

Herbal treatment

From herbs for the treatment of hemorrhoids, decoctions and infusions are prepared for poultices, using such plants as blueberry leaves, strawberry, chamomile, calendula, aloe, oak bark. A bandage folded in several layers is dipped in liquid, slightly squeezed out and applied to the anus for 10 minutes.

Homeopathy

The list of homeopathic remedies for the treatment of external hemorrhoids includes:

Fleming's ointment - has an antiseptic, anti-inflammatory and drying effect. Apply with a tampon three times a day for a week. The drug may cause allergies, other side effects have not been identified;

• esculus - an ointment based on horse chestnut fruits. Reduces swelling, accelerates tissue regeneration. Apply to a tampon, which is inserted into the rectum 1-2 times a day. Contraindicated in case of individual sensitivity and may cause an allergic reaction;
• Nova Vita – rectal suppositories containing sea buckthorn oil, propolis, and ginseng. Has anti-inflammatory and antimicrobial effects;
• anti-K – suppositories containing fir and tea tree oil, yarrow, wormwood, and thuja. They relieve itching, dry out ulcers, and prevent purulent complications.

Surgical treatment

Surgical treatment of external hemorrhoids in pregnant women is resorted to only in cases of urgent need. There are several minimally invasive surgical procedures that are not dangerous for women: sclerotherapy and cauterization with laser or infrared rays. [ 14 ]

Prevention

Preventive measures include an active lifestyle, a balanced daily diet, frequent but fractional meals, and prevention of constipation. It is also important to perform special exercises for pregnant women that help improve blood circulation, increase muscle tone, and reduce pressure on the pelvic organs.

Forecast

The success of treatment of external hemorrhoids depends on the timeliness of treatment, which does not allow the disease to progress to the next more serious stage. [ 15 ] Under certain circumstances, exacerbations may recur.