Hemorrhoids are swollen veins located in the rectum and around the anus, similar to varicose veins. This condition is common during pregnancy, affecting 25% to 50% of expectant mothers, with the highest incidence in the third trimester.
The increased risk is largely due to the mechanical pressure exerted by the growing uterus on the pelvic veins, which impedes blood return and causes the vessels to swell. Hormonal shifts also play a part, as elevated progesterone levels cause vein walls to relax and become prone to enlargement.
Pregnancy often involves chronic constipation, and the straining associated with difficult bowel movements puts excessive pressure on the anal cushions. These factors cause the anal vasculature to become distended, leading to the pain, itching, and occasional bleeding characteristic of the condition.
Conservative Management Strategies
For most pregnant patients, the first and most effective line of defense against hemorrhoidal discomfort is a combination of lifestyle changes and non-invasive remedies. Medical consensus favors these conservative measures, as the condition frequently resolves spontaneously after delivery when hormonal and pressure factors subside. The goal is to alleviate symptoms and reduce the likelihood of further irritation until the body naturally recovers.
A high-fiber diet is foundational to this approach, with a recommended intake of approximately 30 grams of fiber per day from sources like whole grains, fruits, and vegetables. This modification, coupled with drinking plenty of water, works to soften stools and prevent the constipation that leads to straining. If diet alone is insufficient, bulk-forming agents like psyllium husk or osmotic laxatives such as polyethylene glycol are considered safe options during gestation to promote easier bowel movements.
Patients should focus on proper toilet habits by avoiding prolonged sitting, which increases pressure on the anal veins. External symptoms can be soothed with warm water sitz baths, soaking the anal area for 10 to 15 minutes, two to three times daily. Topical treatments provide temporary relief from pain and itching, using low-dose hydrocortisone creams, local anesthetics, or witch hazel pads under medical guidance.
Pain management is important, and simple analgesics like acetaminophen are considered safe for use during pregnancy. Applying a cold compress or ice pack to the affected area helps temporarily reduce swelling and discomfort. These measures are successful in managing the majority of cases, making invasive procedures unnecessary while pregnant.
Risks and Contraindications of Surgical Intervention
Surgical removal of hemorrhoids, such as a formal hemorrhoidectomy or procedures like banding or stapling, is strongly discouraged and typically contraindicated during pregnancy. The inherent risks associated with any major operative procedure are magnified when a fetus is involved, prompting providers to avoid intervention unless necessary. A concern is the potential impact of anesthesia, especially general anesthesia, which carries risks of adverse reactions and breathing complications for the mother.
The risk of uterine irritation is a major factor, as any procedure near the rectum and anus could stimulate the uterus, increasing the risk of premature labor or other complications. Recovery from a hemorrhoidectomy is often painful and requires significant time and medication, which is challenging for an expectant mother. Post-operative pain management might necessitate stronger medications, which carry potential risks to the developing fetus.
Furthermore, the increased blood volume and pelvic congestion that caused the hemorrhoids are still present during pregnancy, meaning surgical success may be compromised. The swollen veins may not heal optimally, or new hemorrhoids could form soon after the procedure. Since the condition is expected to improve or resolve entirely once the baby is delivered, the potential risks of surgery are not justified for a problem that is often transient.
Timing of Definitive Treatment
Definitive surgical intervention is reserved for severe cases where conservative management has failed and the patient experiences intractable symptoms. These rare exceptions include a severely thrombosed external hemorrhoid, involving a blood clot causing excruciating pain, or profuse, continuous bleeding leading to anemia. In these acute situations, a surgeon may perform a local excision of the clot under local anesthesia to provide immediate relief, which is less invasive than a full hemorrhoidectomy.
When severe symptoms persist, the consensus is to postpone any definitive, involved procedures until after the patient has given birth. Surgeons recommend a waiting period of 6 to 12 weeks postpartum before evaluating the need for further treatment. This timeframe allows the body’s physiology to normalize: the uterus shrinks, blood volume returns to pre-pregnancy levels, and hormonal influences subside. During the postpartum period, the hemorrhoids frequently diminish in size or disappear without the need for surgery. If symptoms like pain, prolapse, or bleeding remain bothersome after this initial healing period, the patient can be safely assessed for procedures like rubber band ligation or a hemorrhoidectomy.