Hemorrhoids are one of the most common anorectal problems affecting pregnant women, and influence the quality of life negatively. Pregnancy is a well-known risk factor that may predispose women to increase severity of hemorrhoids. Increased blood volume, the hormonal and mechanical changes, and increased intra-abdominal pressure by the enlarging gravid uterus are associated with the development of internal and external hemorrhoids. Due to excessive straining in constipation during pregnancy, hemorrhoids may become more complicated (1). It has been reported that 25% to 35% of pregnant women are suffered from hemorrhoids (2). However, trimester-based changes of the frequency of hemorrhoids have not been clarified yet. The aim of the present study was to determine the presence of hemorrhoids and their symptoms in the first, second, and third trimester.

This was an observational and descriptive study of pregnant women. Fifty-one primigravid pregnant women were recruited from the outpatient gynaecology and obstetrics clinic of university between January 2016 and May 2018. The inclusion criteria were as follows: being singleton pregnancy and having no previous history of anorectal diseases before the current pregnancy. Pregnant women having any gastrointestinal diseases, pelvic or anal surgery, diabetes mellitus, and hypertension were excluded from the study. Sociodemographics, physical characteristics, medical and clinical history of the pregnant women were recorded. Symptoms including perianal discomfort, mucous discharge, itching, burning, perianal pain, dyschezia, protrusion, constipation, bleeding, and anal fissure were evaluated by self-developed questionnaire in accordance with previous study (3). The presence of chronic constipation was assessed using the Rome III Diagnostic Criteria. All evaluations were performed in the first (11-14th gestational week), second (14-24th gestational week), and third trimester (24-37th gestational week) of pregnancy. The normality distribution of data was checked using visual and analytical methods. Descriptive statistics of each parameter were presented as mean ± standard deviation, median (25 % - 75 %), or number (percentage). Cochran’s Q and Friedman tests were used to determine the differences in outcomes among three trimesters. When an overall significance was found, the post-hoc comparisons were performed by the Wilcoxon test using the Bonferroni correction. The level of statistical significance was assumed at p<0.05.

The mean age of 51 pregnant women was 31.4±3.6 years (range: 24-39). The mean Body Mass Index (BMI) of pregnant women in each trimester was 24.44±2.99 kg/m2, 26.31±3.11 kg/m2, and 27.91±3.22 kg/m2, respectively. Hemorrhoids were present in 13 (25.5%), 14 (27.5%), and 22 (43.1%) women and constipation was present in 8 (16.3%), 11 (22.4%), and 15 (30.6%) women in the 11–14th, 14-24th, and 24-37th gestational weeks, respectively. There were significant differences in the percentage rates of hemorrhoids (p<0.05), severity of hemorrhoids (p<0.05), constipation (p=0.03), and perianal pain (p=0.03) among trimesters (Table1). It was found to be statistically significant (p<0.05) and highest in the third trimester in terms of the presence rate of hemorrhoids, constipation, perianal pain and severity of hemorrhoids.

The finding of the present study revealed that the presence of hemorrhoids, constipation, perinanal pain and, severity of hemorrhoids increased proportionally to the gestational week. The risk factors for the development of anorectal problems during pregnancy are increased intra-abdominal pressure by the enlarging gravid uterus causing vascular engorgement and venous stasis. Furthermore, especially in the third trimester increased pressure on the recto-sigmoid colon related to the gravid uterus may aggravate the symptoms of constipation and perianal pain. In the late pregnancy, most pregnant women can avoid from pushing during defecation because of fearing of stimulate preterm labour. This may be the explanation of why the dyschezia tend to decrease during pregnancy.

Hemorrhoids and hemorrhoids-related anorectal problems tend to worsen as pregnancy progresses. Therefore, conservative therapeutic approaches should be given by health professionals before pregnancy or in early pregnancy to prevent the occurrence and progression of such anorectal problems.

Staroselsky A, Nava-Ocampo AA, Vohra S, Koren GJCFP. Hemorrhoids in pregnancy. 2008;54(2):189-90.
Longo SA, Moore RC, Canzoneri BJ, Robichaux AJCic, surgery r. Gastrointestinal conditions during pregnancy. 2010;23(2):80.
Vazquez, J. C. (2010). Constipation, hemorrhoids, and heartburn in pregnancy. BMJ clinical evidence, 2010.