Hemorrhoids during pregnancy are varicose veins of the hemorrhoidal plexus, the occurrence or exacerbation of which is provoked by gestation. It is manifested by itching, burning, discomfort, pain in the anus, bloody and mucous discharge from the anus, loss of nodes. It is diagnosed using finger rectal examination, anoscopy, rectoromanoscopy. Dietary therapy, herbal laxatives, phlebotonics, candles and ointments with anti-inflammatory, analgesic, hemostatic effects, minimally invasive interventions, radical hemorrhoidectomy are used for treatment.
O22.4 Hemorrhoids during pregnancy
Hemorrhoids are one of the most common extragenital diseases diagnosed during pregnancy. In the 1st trimester, it is detected in 33% of patients, in the 2nd – in 35%, in the 3rd — in 42%. The disease is diagnosed in 41% of maternity patients. Although the prevalence of pathology in general does not depend on gender, most cases of its occurrence in women are associated with gestation. According to research in the field of proctology, the incidence of hemorrhoids in patients who have given birth to at least one child is 5 times higher than in unborn patients, while the disorder occurs more often in the second half of pregnancy or in childbirth. The probability of hemorrhoidal vascular damage during gestation increases with increasing age of a woman.
Hemorrhoids during pregnancy are caused by pathological changes in the hemorrhoidal veins against the background of changed conditions of functioning of the body. In most cases, the disease occurs during gestation, less often the existing pathology clinically debuts or worsens due to physiological changes occurring in the body. According to experts in the field of modern proctology, the development of hemorrhoids in pregnant women is promoted by:
- The effect of progesterone. Under the influence of the hormone, the tone of smooth muscle fibers decreases, connective tissue loosens. Due to the relaxation of the walls of venous vessels and the weakening of elastic fiber components, blood is deposited in the hemorrhoidal plexus, typical cavernous corpuscles are formed. The situation is aggravated by a decrease in peristalsis, leading to constipation.
- Stagnant phenomena. As pregnancy progresses, the level of intra-abdominal pressure gradually increases, which leads to disruption of the digestive organs and blood outflow. The growing uterus squeezes the inferior vena cava, causing stagnation of blood in the lower extremities, genitals, hemorrhoidal plexus. Under the influence of increased pressure, venous vessels dilate.
- Lifestyle changes. Some women perceive pregnancy as a painful condition and intentionally reduce physical activity. Against the background of hypodynamia, the overall tone decreases and intestinal motility worsens, which increases constipation caused by the action of progesterone. When straining, the intra-abdominal pressure increases even more, the cavernous sinuses of the rectum overflow with blood.
- Childbirth. The starting point in the manifestation of hemorrhoids can be the load during labor. During the attempts, there is an increase in intra-abdominal pressure, when the head is lowered into the pelvis, the rectal veins are squeezed. Weakened parts of the vascular wall bulge out. In addition, when the head is eruption, it is possible to shift the existing hemorrhoids outwards and rupture them.
Additional provoking factors are an increase in the volume of circulating blood, changes in the coagulation and anticoagulation systems of the blood, enhanced synthesis of various mediators. After childbirth, hemorrhoids that have arisen during gestation undergo involution or continue to progress. An important role in the development of the disease after pregnancy is played by a constitutional predisposition in the form of innervation disorders and subclinical connective tissue dysplasia with a violation of the collagen structure and the failure of the middle shell of venous vessels.
There is a universal mechanism for the development of hemorrhoids during pregnancy, independent of the immediate provoking cause and due to the anatomical features of rectal cavernous bodies. Unlike conventional rectal veins, hemorrhoidal plexus vessels have direct arteriovenous anastomoses connecting the whorl arteries and cavernous veins. Hyperplasia of the cavernous corpuscles is observed with increased arterial blood flow against the background of increased intra-abdominal pressure and worsening venous outflow due to compression of the inferior vena cava and portal veins by the pregnant uterus.
Relaxation of the smooth muscle layer of the venous wall and softening of connective tissue fibers under the influence of progesterone contribute to the rapid formation of baggy (nodular) formations during pregnancy. Varicose veins are more pronounced in women with hereditary collagenopathies. With the progression of the process with the destruction of the ligaments of the Parks and the muscles of the Treitz supporting the apparatus of the internal hemorrhoidal plexus, the formed nodes may bulge, and then become inflamed and pinched. The mucosa covering their wall is injured, ulcerated, begins to bleed.
Taking into account the localization in relation to the dentate line of the rectum, the nodes are external (subcutaneous), internal (submucosal), combined. Usually, during pregnancy, hemorrhoids occur chronically with a minimally pronounced pain syndrome. Less often there is an acute process with intense painful sensations, inflammation of the surrounding tissues and subsequent necrosis of the thrombosed areas. There are four stages in the development of anorectal disorder, the first and second are more often observed in pregnant women:
- Stage I. Anatomical localization of hemorrhoids is not disturbed. There may be burning, itching, other uncomfortable sensations in the anus, periodic release of small amounts of scarlet blood with an increase in pressure in the abdominal cavity.
- Stage II. Swollen cavernous corpuscles fall out of the anus during bowel emptying, straining, significant physical exertion, and then spontaneously set. Bloody and mucous rectal secretions are noted.
- Stage III. Enlarged nodes fall out even with minor loads. Due to the impossibility of self-adjustment, they have to be adjusted manually. The mucosa may ulcerate. Bleeding occurs during and after defecation.
- Stage IV. The loss of nodes and the adjacent mucosa of the rectum is noted even without loads, their manual reduction becomes impossible. Relaxation of the sphincter can be determined. Dystrophic and erosive processes occur in the epithelium.
The initial stages of hemorrhoids during pregnancy are characterized by complaints of burning, slight itching, uncomfortable sensations in the perianal zone, usually occurring after defecation. In women with external hemorrhoids, soft, elastic, warty-type formations on a wide base are detected near the anal opening. The internal nodes are not visible at first. As the pathological process progresses, mucus begins to be released from the anus, and after emptying the intestines, a small amount of scarlet blood begins to flow. In some pregnant women, blood flows in a trickle when straining. Due to constant irritation, the skin turns red, macerated, itchy.
At the next stage, there is a loss of nodes located in the folds of the rectal mucosa. With their possible thrombosis or infringement, there is a sharp intense pain that increases in an upright position and while walking. The affected nodes become purplish-cyanotic, the anoderm swells, thickens. Subsequently, a white fibrinous plaque, ulceration, and areas of necrosis appear on the crimson mucous membrane of the nodes. The temperature rises. Signs of general intoxication appear and increase — weakness, bruising, headaches, lack of appetite, itching. With chronically uncomplicated hemorrhoids, pain syndrome is usually absent.
In the absence of adequate medical care, thrombosis and infringement of hemorrhoids on the background of hemorrhoids during pregnancy are complicated by the spread of destructive necrotic processes to surrounding tissues and infection. The patient develops thrombophlebitis of rectal veins, paraproctitis, and the risk of intrauterine infection of the fetus increases. Usually hemorrhoids do not affect the course of gestation and do not provoke obstetric complications, although with constant feeding it can aggravate the course of anemia during pregnancy. During the laborious period of labor, anal bleeding may occur.
With an asymptomatic course or insignificant severity of symptoms, hemorrhoids during pregnancy often become an accidental finding during a routine examination or manifest clinically during childbirth. In patients with characteristic symptoms, the disease does not present any difficulties in diagnostic terms. External and dropped nodes are detected already at the stage of visual examination and palpation of the perineum. The most informative methods of diagnosing internal hemorrhoids during pregnancy are:
- Finger examination of the rectum. During palpation, the relief of the mucosa is changed. In its folds, tight elastic formations with a wide base and a smooth surface are determined, which fall off when pressed, and when coughing and straining, they bulge out, become tense.
- Anoscopy. During a visual examination using an anoscope, the condition of the dentate line, anal crypts, and epithelial membrane is assessed. Internal nodes are identified, their localization, size, and structure are determined. During anoscopy, the rectum is examined to a depth of 8-12 cm.
- Rectoromanoscopy. This method confirms and supplements the data of anoscopic examination. It is performed without fail to exclude processes localized in the distal parts of the sigmoid colon and accompanied by bloody discharge from the anus.
- Additional research. If necessary, with the help of sphincterometry and electromyography, the locking function of the anus is evaluated. As additional laboratory methods, a general blood test is shown, which allows to assess the effect of hemorrhoids on anemia during pregnancy, and a coagulogram, the indicators of which change with thrombosis of hemorrhoids.
Differential diagnosis is carried out with a crack of the anus, bleeding polyps, rectal cancer, diverticulosis, diseases of other parts of the large intestine, pathologies that are accompanied by anal itching — diabetes mellitus, helminthiasis (enterobiosis, ascariasis), candidiasis. The patient is recommended to consult a proctologist, a surgeon’s examination, if necessary, an oncologist, an endocrinologist, an infectious disease specialist.
The choice of medical tactics depends on the presence and severity of clinical symptoms, the severity of the course of the disease. An integrated approach to the management of pregnant women with hemorrhoids involves correcting the diet, providing hygienic care, performing a special set of exercises, medication and surgical treatment. Specialists in the field of obstetrics distinguish three groups of patients. The first group consists of patients with asymptomatic hemorrhoids. Such women are recommended dynamic monitoring and prevention of further progression of the disease. The leading one is diet therapy with sufficient water intake, aimed at preventing constipation and softening fecal masses.
It is permissible to use fermented dairy products, vegetable oils, lean meat, eggs, cereals, fruits, berries, beets, cabbage, carrots, pumpkins, and other vegetables containing fiber. Fresh bread, muffins, flour, fatty meat, salinities, smoked meats, marinades, mushrooms, legumes, semolina and rice porridge, strong broths, fruits with astringent effect (quince, pear), products that enhance fermentation (grapes, radishes, garlic, onions), strong tea, coffee are prohibited. Exercise therapy, dosed walks, care of the perianal area after defecation are effective. It is possible to prescribe herbal preparations with a laxative effect.
The second group includes patients with the initial stages of hemorrhoids in the presence of indications for conservative drug therapy. The selection of a specific drug is determined by the clinical variant and the features of the course of the disease. In addition to the above therapeutic and preventive measures , pregnant women are prescribed warm sedentary baths with decoctions of astringent plants and the following groups of medicines:
- Combined candles, ointments. The ingredients included in their composition effectively eliminate itching and pain, prevent infection of tissues, contribute to the reduction of edema and healing of erosions. They also have a hemostatic, drying, antioxidant, regenerating effect.
- Phlebotonics and phleboprotectors. They increase the tone of the smooth muscle muscles of the cavernous sinuses, make the vascular wall less permeable, restore microcirculation. Due to the increased resistance of hemorrhoidal veins to high intra-abdominal pressure, the nodes are reduced in size.
- Anticoagulants. Recommended for increased bleeding. Accelerate the resorption of existing blood clots and prevent the formation of new ones. They have an anti-inflammatory, decongestant effect. Regeneratively affect the connective tissue. They are used with caution at the end of pregnancy.
It is possible to prescribe funds to improve microcirculation and rheology of blood, vitamin and mineral complexes with a high content of ascorbic acid and rutin. To soften the stool, remove local irritation, eliminate inflammation, microclysms with oils and decoctions of medicinal herbs are used (the volume of liquid is up to 40 ml). In case of infection and pain, antibiotics and nonsteroidal anti-inflammatory drugs are used.
Surgical treatment is recommended for patients with frequent exacerbations of hemorrhoids, node prolapse, intense pain syndrome, complicated by the course of the disease. Minimally invasive techniques are preferred during pregnancy:
- latex ligation;
- radio wave excision;
- injectable sclerotherapy;
- dearterization of dilated cavernous sinuses or a combination of procedures.
With external thrombosis, a thrombectomy (evacuation of a thrombotic clot) is performed. Women with severe recurrent course of the disease, abundant anemizing bleeding are shown radical operations for hemorrhoids — submucosal, open, closed hemorrhoidectomy, transanal resection of the mucosa according to Longo. If possible, interventions are carried out in the early stages of pregnancy or transferred to the postpartum period.
Pregnant patients with hemorrhoids are usually observed on an outpatient basis. Emergency hospitalization is performed in case of infringement and necrosis of nodes, the occurrence of massive hemorrhoidal bleeding. The presence of hemorrhoids does not affect the choice of delivery method. Pregnancy usually ends with natural childbirth. Caesarean section is performed in the presence of obstetric indications.
Prognosis and prevention
Timely diagnosis and treatment of hemorrhoids during pregnancy in the early stages of the disease can stabilize the process. Surgical treatment usually leads to a complete recovery. For preventive purposes, pregnant women who have subclinical signs of connective tissue dysplasia and are prone to constipation are recommended to be regularly monitored by an obstetrician-gynecologist, moderate motor activity, a diet with an increased content of dietary fiber and vegetable fats, sufficient water intake, restriction of the use of products that can have a strengthening effect.