by Michele Brown
Today's pregnancy health topic is a bit delicate, but we have never been shy about discussing important health issues for pregnant women and we won't tip-toe around hemorrhoids, either. Fortunately there is nothing life threatening about hemorrhoids, but don't tell that to a pregnant woman who has developed symptoms. You may be risking a bloody nose.
The problem is two fold: Many women are embarrassed to admit, even to their doctor, that they have excruciating pain "down there." But pregnancy can exacerbate an existing condition or cause hemorrhoids to appear for the first time.
Approximately 40% of pregnant women develop hemorrhoids but only 10% require some form of therapy. They are more common in the second and third trimester of pregnancy, more common in women who have been pregnant several times and increase in severity with each subsequent pregnancy.
What Are Hemorrhoids?
Hemorrhoids, also known as piles, are a conglomeration of swollen blood vessels in and around the anus and lower rectum.
Hemorrhoids can be classified into two kinds, internal and external. Internal hemorrhoids lie inside the anus or lower rectum, beneath the anal or rectal lining and generally present with bleeding and discomfort due to prolapse. External hemorrhoids lie outside the anal opening and present with irritation and discomfort. Both kinds can be present at the same time.
What Causes Hemorrhoids?
The causes of hemorrhoidal disease are similar to those which cause varicose veins, i.e., genetic weakness of the veins, excessive venous pressure, low fiber diets (associated with constipation and increase straining), prolonged standing or sitting, and heavy lifting are considered factors.
The physical and hormonal changes associated with pregnancy tend to make women more prone to develop hemorrhoids or worsen existing hemorrhoidal symptoms.
Those changes include:
- Increased abdominal pressure caused by the pregnant uterus
- Straining at defecation and constipation often accompanying pregnancy
- Dilation and engorgement of the veins due to increased blood volume
- Hormonal changes leading to increased laxity of connective tissue
The symptoms most often associated with hemorrhoids include itching, burning, pain, inflammation, irritation, swelling, bleeding and seepage. Itching is often due to the mucous discharge from prolapsing internal hemorrhoids.
Pain does not occur unless there is acute inflammation of external hemorrhoids. As there are no sensory nerves ending above the anorectal line, uncomplicated internal hemorrhoids rarely cause pain.
Bleeding is almost always associated with internal hemorrhoids and may occur before, during or after excretion. When bleeding occurs from an external hemorrhoid, it is due to rupture of an acute thrombotic hemorrhoid. Bleeding hemorrhoids can produce severe anemia due to chronic blood loss.
Therapy and Prevention
As with all diseases, the primary treatment of hemorrhoids is prevention. This involves reducing those factors which may be responsible for increasing pelvic congestion such as straining during defecation, and sitting or standing for prolonged periods or time.
A high-fiber diet is crucial for the maintenance of proper bowel activity. Spicy foods should be avoided.
Specific treatment of hemorrhoids should be tailored to the severity of the symptoms. In pregnancy special consideration should be made to the developing fetus. Drugs should therefore be used sparingly and surgery only done when absolutely necessary.
Hemorrhoids are rarely seen in countries where high fiber, unrefined diets are consumed. A low fiber diet, high in refined foods, contributes greatly to the development of hemorrhoids.
Individuals consuming a low fiber diet tend to strain more during bowel movements since their smaller and harder stools are difficult to pass. This straining increases the pressure in the abdomen, which obstructs venous return. The increased pressure will increase pelvic congestion and may significantly weaken the veins, causing hemorrhoids to form.
A high fiber diet is perhaps the most important component in the prevention of hemorrhoids. Diets rich in vegetables, fruits, and legumes help keep the feces soft and easy to pass. The net effect of a high fiber diet is significantly less straining during defecation.
Bulking agents: Natural bulking compounds can be used to reduce fecal straining. They are the first basic step in your preventative strategy. These fibrous substances, particularly Psyllium seed, possess mild laxative action due to their ability to attract water and form a gelatinous mass.
Hydrotherapy: The warm sitz bath is an effective non-invasive treatment for uncomplicated hemorrhoids. A sitz bath is a partial immersion bath of the pelvic region. The Temperature of the water in the warm sitz bath should be 100–104 °F.
Topical therapy: Topical therapy, in most circumstances, will only provide temporary relief. Topical treatment involves the use of suppositories, ointments and anorectal pads. Many over-the-counter products for hemorrhoids contain primarily natural ingredients, such as witch hazel, shark liver oil, cod oil, cocoa butter, Peruvian balsam, zinc oxide, live yeast cell derivative and allantoin.
Surgical Intervention: In severe cases where conservative therapy was unsuccessful, consideration should be given to surgical treatment. These patients should consult a colorectal surgeon to determine the procedure of choice. Procedures such as elastic band ligation, injection sclerotherapy, (5% phenol in almond oil) and infrared photocoagulation have been performed successfully in pregnancy. Infection and bleeding in the peri-anal area is the major risk factor. Surgical hemorrhoidectomy has been performed in pregnancy successfully in severe cases where office based procedures have failed. Some patients have required further therapy postpartum.
Hemorrhoids are a common problem during pregnancy. Treatment should focus on prevention and particularly high fiber diet and proper hydration.
When conservative measures fail, consulting a colorectal surgeon and discussing surgical options may be indicated.
Dr. Brown, founder of Beauté de Maman, is a board-certified member of the American College of Obstetrics and Gynecology, a member of the American Medical Association, the Fairfield County Medical Association, Yale Obstetrical and Gynecological Society and the Women's Medical Association of Fairfield County. She is a magna cum laude graduate of Tufts University, completed her medical training at George Washington University Medical Center and completed her internship and residency in obstetrics and gynecology at Yale-New Haven Hospital. Dr. Brown has a busy obstetrical practice in Stamford, Connecticut and, as a clinical attending, actively teaches residents from Stamford Hospital and medical students from Columbia Presbyterian Hospital in New York.
Copyright © Michele Brown. Permission to republish granted to Pregnancy.org, LLC.