Hemorrhoids in pregnant and postpartum women: risk factors

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Introduction

Pregnancy is a unique condition for the female body, associated with the risk of developing various diseases. Gestational diabetes, gestosis, and other dangerous conditions pose a threat to the life of both mother and fetus [1]. Prevention and treatment of such pregnancy complications are the responsibility of the antenatal clinic, where, a pregnant woman will be examined by an obstetrician-gynecologist, a general practitioner, an ophthalmologist, an otolaryngologist and a dentist. Visits to other specialists are made as needed, taking into account any associated pathologies.

Hemorrhoidal disease, unlike the conditions mentioned above, can develop in anyone. Hemorrhoidal plexuses provide the primary functions of the rectum: fecal retention and defecation. The main factors that contribute to pathology during pregnancy include: hormonal imbalances (hyperprogesteronemia); functional disorders of the venous walls; increased intra-abdominal pressure; and increased circulating blood volume [2]. Hemorrhoids most often develop in the third trimester of pregnancy, as this period is characterized by the maximum impact of all pathogenesis factors. Progesterone, as the main pregnancy hormone, also affects the smooth muscles of the venous wall and intestines, causing them to relax. An increase in circulating blood volume and increased intra-abdominal pressure contribute to this. The combination of these factors negatively impacts blood circulation in the cavernous bodies [3; 4]. Hemorrhoids most often develop in the third trimester of pregnancy, as this period is characterized by the maximum impact of all links in the pathogenesis [5].

Developing hemorrhoidal hyperplasia leads to symptoms such as itching, burning, pain, bleeding, and the appearance of a tumor-like formation in the anorectal area. The physiological conditions of pregnancy and childbirth can be considered as separate risk factors for the development of hemorrhoids. Hemorrhoid symptoms are more common in pregnant women than in non-pregnant women [6].

Hemorrhoids are a common anorectal disorder, representing a serious medical and socioeconomic problem. Pregnancy, while not a primary pathogenic factor for hemorrhoids, often contributes to the underlying risk factors for hemorrhoidal disease [7–9]. According to some studies, the incidence of hemorrhoids among pregnant and postpartum women ranges from 15 to 41 %, and in some populations up to 85 %. An increase in prevalence has been noted with increasing age and parity of births [10; 11].

It should be clarified that hemorrhoids do not pose a direct threat to the life of the mother and fetus, but they can significantly worsen the quality of life of pregnant women and women in labor [12]. Constant itching, pain, and bleeding negatively affect a woman's psycho-emotional state, disrupting her moral and physical comfort and complicating her relationship with the newborn [13].

The threat to motherhood requires us to conduct a more detailed study of this issue for better diagnosis and treatment. An objective assessment of the prevalence of hemorrhoids among pregnant and postpartum women is complicated by the sensitivity and intimacy of the problem, as women often fail to mention such complaints to their physician, leading to serious consequences.

The aim of the study is to investigate the main risk factors and symptoms of hemorrhoids in women in labor in the postpartum department of the perinatal center of the Saratov region for the period 2021–2022 through an anonymous survey.

Materials and Methods

The main factors in the development of hemorrhoids during pregnancy include: hormonal imbalances (hyperprogesteronemia); functional disorders of the venous walls; increased intra-abdominal pressure; and increased circulating blood volume. It is important to note that hemorrhoids most often develop in the third trimester of pregnancy, as this period is characterized by the maximum impact of all pathogenesis factors. The study involved 214 people.

The criteria for inclusion in the study were: singleton pregnancy; absence of severe forms of extragenital pathology; absence of hemorrhoidal disease before pregnancy; patient age from 25 to 40 years; absence of gastrointestinal tract (GIT) tumors in patients; voluntary informed consent for the study.

Criteria for exclusion from the study: multifetal pregnancy; presence of severe forms of extragenital pathology; age of patients under 25 and over 40; gastrointestinal tumors in patients.

In the study, patients were divided into three groups based on whether they had received progesterone therapy during their last pregnancy. In Group I, women in labor did not receive hormonal therapy (n = 114). Group II included women in labor who received progesterone during pregnancy (n = 64). Group III includes women in labor whose pregnancy occurred as a result of IVF (n = 36). Utrozhestan and Duphaston were taken by the patients during their last pregnancy as progesterone preparations. In Group II, 71.9 % they took Utrozhestan, 28.1 % took Duphaston. In Group III, all patients took Utrozhestan. Patients in Group III received longer-term hormonal therapy (Table 1).

It's worth noting that vaginal delivery is also a predisposing factor for the development of hemorrhoids. We noted that vaginal delivery was more common in groups I and II. When examining the pathologies of the last pregnancy, we found that vomiting during pregnancy was prevalent in Group III; the threat of miscarriage was detected in all groups of patients; patients in Groups II and III received hormonal therapy.

Nonparametric analysis methods were used for statistical data processing. The Kruskal-Wallis test was used to assess the significance of differences, and the Mann-Whitney test was used for subsequent pairwise comparisons. The critical significance level (p-value) was set to 0.05. The study was conducted in accordance with Good Clinical Practice standards and the principles of the Declaration of Helsinki.

 

Table 1. The nature of hormonal therapy

Treatment of female patients
Characteristics of the course of the last pregnancy		Group 1 (n = 114), abs. (%)	Group 2 (n = 64), abs. (%)	Group 3 (n = 36), abs. (%)	p
Taking iron supplements during their last pregnancy		50 (43.8)	42 (65.6)	18 (50)	p1 = 0.006 p2 = 0.519 p3 = 0.126
Taking hormonal therapy aimed at maintaining pregnancy		0 (0)	64 (100)	36 (100)	p1 < 0.001 p2 < 0.001 p3 = 1.000
Type of hormonal therapy	Utrozhestan	0 (0)	46 (71.9)	36 (100)	p1 < 0.001 p2 = 0.001 p3 = 1.000
	Duphaston	0 (0)	18 (28.1)	0 (0)	p1 = < 0.001 p2 = 1.000 p3 = < 0.001
Trimester in which the patient received hormonal therapy	First trimester only	0 (0)	41 (64)	0 (0)	p1 = < 0.001 p2 = 1.000 p3 = < 0.001
	Second trimester only	0 (0)	15 (23.4)	0 (0)	p1 = < 0.001 p2 = 1.000 p3 = < 0.003
	Third trimester only	0 (0)	8 (13.6)	0 (0)	p1 = 0.003 p2 = 1.000 p3 = 0.086
	Through two or more trimesters	0 (0)	0 (0)	36 (100)	p1 < 0.001 p2 < 0.001 p3 < 0.001

 

Results And Discussion

As can be seen from the data in Table 2, in all three groups, the majority of women had one or two previous pregnancies and one or two previous births. When collecting the history of extragenital pathology, the presence of varicose veins of the lower extremities was emphasized. This pathology occurred in 12 women (10.5 %) in Group I, 7 women (10.9 %) in Group II, and 2 women (5.6 %) in Group III.

The characteristics of the course of the last pregnancy are presented in Table 3 and Fig. 1. In Group I, the predominant method of delivery was vaginal delivery (91.2 %), while in Group III, all patients were delivered by cesarean section (100 %).

Patients were asked to subjectively assess the presence and severity of nausea and vomiting. As shown in Table 4, symptoms were present in half of the patients in Groups I and II, as well as in almost 80 % of patients in Group III. Threatened miscarriage was reported in 12 women (10.5 %) in Group I, 28 (43.8 %) in Group II, and 10 (27.7 %) in Group III.

When assessing the risk factors for the development of hemorrhoids (Table 5), it was determined: 1) based on the data of heredity analysis, the presence of varicose veins of the lower extremities and/or hemorrhoidal disease in first-degree relatives was revealed in 78 (68.4 %) women in group I, 46 (71.9 %) in group II, and 28 (77.8 %) in group III; 2) predisposing or resolving factors for hemorrhoids are insufficient amounts of dietary fiber in the diet.

 

Table 2. Gynecological history and presence of extragenital pathology

Anamnesis of life		Group 1 (n = 114), abs. (%)	Group 2 (n = 64), abs. (%)	Group 3 (n = 36), abs. (%)	р
Gynecological history
Number of pregnancies in the medical history (including the last pregnancy)	0–1	66 (57.8)	30 (46.8)	26 (72.1)	p1 = 0.157 p2 = 0.124 p3 = 0.015
	3–4	30 (26.2)	22 (34.3)	10 (27.7)	p1 = 0.257 p2 = 0.863 p3 = 0.498
	5–6	18 (15.8)	10 (15.6)	0 (0)	p1 = 0.977 p2 = 0.012 p3 = 0.013
	7 and more	0 (0)	2 (3.1)	0 (0)	p1 = 0.058 p2 = 1.000 p3 = 0.284
Number of births (including the most recent births)	1–2	80 (70.2)	42 (65.6)	36 (100)	p1 = 0.531 p2 < 0.001 p3 < 0.001
	3–4	34 (29.7)	12 (34.3)	0 (0)	p1 = 0.036 p2 < 0.001 p3 = 0.013
Extragenital pathology
Varicose veins of the lower extremities		12 (10.5)	7 (11)	2 (5.6)	p1 = 0.933 p2 = 0.372 p3 = 0.367

 

Table 3. Characteristics of the course of the last pregnancy

Characteristics of the course of the last pregnancy		Group 1 (n = 114), abs. (%)	Group 2 (n = 64), abs. (%)	Group 3 (n = 36), abs. (%)	p
The deadline for registering at the antenatal clinic	First trimester	99 (86.8)	58 (90.6)	36 (100)	p1 = 0.453 p2 = 0.022 p3 = 0.059
	Second trimester	15 (13.2)	6 (9.4)	0 (0)	p1 = 0.453 p2 = 0.022 p3 = 0.059
	Third trimester	0 (0)	0 (0)	0 (0)	p1 = 1.000 p2 = 1.000 p3 = 1.000
Method of delivery in the last pregnancy	Cesarean section	10 (8.7)	16 (25)	36 (100)	p1 = 0.004 p2 < 0.001 p3 < 0.001
	Natural	104 (91.2)	48 (75)	0 (0)	p1 = 0.004 p2 < 0.001 p3 < 0.001

 

Fig. 1. Method of delivery in patients of groups I–III

 

The patients were asked to estimate the proportion of their daily diet consisting of fruits and vegetables. It is noteworthy that approximately half of the women in Groups I and II had no more than 10 % fiber in their diet. Meanwhile, for 72 % of patients in Group III, fruits and vegetables comprised between 10 % and 40 % of their daily diet.

Table 6 presents the risk factors for hemorrhoid development associated with defecation. About half of the patients in all three groups spent more than 5 minutes in the toilet. As a means of personal hygiene after defecation, patients in Groups I and II most often used toilet paper – 46 (40.4 %) and 32 (50 %), respectively. In group III, patients use toilet paper (14 (38.9 %)) and intimate washing (16 (44.4 %)) with almost equal frequency).

Next, the patients were asked questions to identify symptoms of hemorrhoids (Fig. 2). Regardless of the group, the most common symptom during the last pregnancy for women was a feeling of fullness in the rectum without the urge to defecate: in Group I – 42 (36.8 %) women, in Group II – 32 (50 %), in Group III - 26 (72,2 %). The second most common symptom experienced by women in labor was an extuberance in the anus: 30 (26.3 %) in Group I, 20 (31.3 %) in Group II, and 20 (55.5 %) in Group III. It's important to note that hemorrhoid symptoms were most common in patients whose pregnancies were achieved through IVF. Itching, burning, and pain in the anus were reported by 12 (33.3 %) of them, and blood on toilet paper by 10 (27,7 %).

During the study, it was also noted that these symptoms of hemorrhoids did not bother the majority of patients (in Group I there were 66 (57.9 %) women, in Group II – 38 (59.4 %), in Group III – 26 (72.2 %)) before the current pregnancy (Table 7).

 

Table 4. Pathology of the last pregnancy

Characteristics of the course of the last pregnancy		Group 1 (n = 114), abs. (%)	Group 2 (n = 64), abs. (%)	Group 3 (n = 36), abs. (%)	p
Vomiting of pregnant (according to the subjective assessment of patients)	There was no vomiting	56 (49.1)	32 (50)	8 (22.2)	p1 = 0.911 p2 = 0.005 p3 = 0.007
	Minor (nausea, vomiting 1-2 times in the morning, lasting no more than one trimester)	36 (31.6)	12 (18.8)	12 (33.3)	p1 = 0.065 p2 = 0.845 p3 = 0.102
	Moderate (nausea, vomiting 3-5 times a day, lasting no more than one trimester)	12 (10.5)	14 (21.9)	10 (27.7)	p1 = 0.040 p2 = 0.011 p3 = 0.508
	Significantly impaired quality of life (nausea, vomiting more than 5 times a day, lasting more than one trimester)	10 (8.7)	6 (9.4)	6 (16.6)	p1 = 0.893 p2 = 0.181 p3 = 0.282
Threat of termination of pregnancy		12 (10.5)	28 (43.8)	10 (27.7)	p1 < 0.001 p2 = 0.011 p3 = 0.115

 

Table 5. Risk factors for hemorrhoids occurrence

Risk factors for hemorrhoids occurrence		Group 1 (n = 114), abs. (%)	Group 2 (n = 64), abs. (%)	Group 3 (n = 36), abs. (%)	p
Heredity
Varicose and/or hemorrhoidal disease in first-degree relatives		78 (68.4)	46 (71.9)	28 (77.8)	p1 = 0.631 p2 = 0.283 p3 = 0.519
Diet
The amount of vegetables and fruits in the diet (according to the subjective assessment of patients)	Up to 10% of the daily diet	56 (49.1)	38 (59.4)	8 (22.2)	p1 = 0.189 p2 = 0.005 p3 < 0.001
	From 10% to 40% of the daily diet	38 (33.3)	16 (25)	26 (72.2)	p1 = 0.246 p2 < 0.001 p3 < 0.001
	More than 40% of the daily diet	20 (17.5)	10 (15.6)	2 (5.6)	p1 = 0.743 p2 = 0.077 p3 = 0.137

 

The issues of intimacy and delicacy of the problem were considered and are reflected in Table 8. As the study shows, only no more than 1/3 of the patients had previously been examined by a proctologist in each group. Due to the intimacy of the problem, according to our data, patients more often turn to female proctologists for this problem than to male ones (statistically confirmed by mathematical processing of the results). But it is worth noting that patients in all groups have a sober assessment of the problem of the possible occurrence of hemorrhoids and in most cases would agree to surgical intervention to eliminate the disease.

 

Table 6. Characteristics of the act of defecation

Parameter		Group 1 (n = 114), abs. (%)	Group 2 (n = 64), abs. (%)	Group 3 (n = 36), abs. (%)	p
Frequency of defecation	1-2 times a day	92 (80.7)	60 (93.9)	28 (77.8)	p1 = 0.019 p2 = 0.703 p3 = 0.019
	Once every 3 days	16 (14)	0 (0)	4 (11.1)	p1 = 0.002 p2 = 0.653 p3 = 0.007
	Less than once every 3 days	6 (5.3)	4 (6.35)	4 (11.1)	p1 = 0.784 p2 = 0.221 p3 = 0.390
Defecation at the same time		36 (31.6)	32 (50)	22 (61.1)	p1 = 0.016 p2 = 0.002 p3 = 0.285
The patient takes a phone/book to the toilet		40 (35.1)	12 (18.8)	18 (50)	p1 = 0.022 p2 = 0.110 p3 = 0.002
The patient spends more than 5 minutes on the toilet		60 (52.6)	26 (40.6)	16 (44.4)	p1 = 0.124 p2 = 0.392 p3 = 0.711
Patients use after defecation	Toilet paper	46 (40.4)	32 (50)	14 (38.9)	p1 = 0.214 p2 = 0.876 p3 = 0.285
	Wet wipes	32 (28.1)	14 (21.9)	6 (16.7)	p1 = 0.365 p2 = 0.171 p3 = 0.532
	Intimate washing	36 (31.8)	30 (28.1)	16 (44.4)	p1 = 0.043 p2 = 0.158 p3 = 0.815

 

Fig. 2. Characteristics of hemorrhoid symptoms among women in labor, % of the number in the group

 

Fig. 3. Distribution of hemorrhoid symptoms among women in labor, %

 

Women in labor were also asked whether their doctor at the antenatal clinic had asked them about their diet, bowel habits, and any anal discomfort (Fig. 4). According to respondents, antenatal clinics provide extremely poor information on this topic and do not delve into such an intimate issue.

 

Table 7. Proctological complaints before the current pregnancy

Parameter		Group 1 (n = 114), abs. (%)	Group 2 (n = 64, abs. (%)	Group 3 (n = 36), abs. (%)	p
These complaints were a concern before pregnancy	Yes	8 (7)	6 (9.4)	4 (11.1)	p1 = 0.576 p2 = 0.430 p3 = 0.782
	No	66 (57,9)	38 (59.4)	26 (72.2)	p1 = 0.848 p2 = 0.124 p3 = 0.199
	Difficult to answer	40 (35.1)	20 (31.3)	6 (16.7)	p1 = 0.604 p2 = 0.037 p3 = 0.111

 

 Table 8. Consultation with doctors regarding possible proctological complaints

Parameter		Group 1 (n = 114), abs. (%)	Group 2 (n = 64), abs. (%)	Group 3 (n = 36), abs. (%)	p
The obstetrician-gynecologist/therapist asked questions about the nature of the diet, the nature of the stool, the presence of discomfort in the anus at the antenatal clinic		42 (36.8)	14 (21.9)	8 (22.2)	p1 = 0.040 p2 = 0.105 p3 = 0.968
Actions of an obstetrician-gynecologist/therapist in a women's clinic upon detection of the above complaints	The obstetrician-gynecologist/therapist did not provide recommendations regarding the existing complaints	110 (96.5)	62 (96.9)	30 (83.3)	p1 = 0.892 p2 = 0.006 p3 = 0.017
	The obstetrician-gynecologist/therapist recommended visiting a proctologist	2 (1.8)	0 (0)	4 (11.1)	p1 = 0.287 p2 = 0.013 p3 = 0.007
	The obstetrician-gynecologist/therapist independently prescribed treatment for hemorrhoids	2 (1,8)	2 (3.1)	2 (5.6)	p1 = 0.554 p2 = 0.218 p3 = 0.552
	The obstetrician/gynecologist/therapist recommended waiting until the childbirth	0 (0)	0 (0)	0 (0)	p1 = 1.000 p2 = 1.000 p3 = 1.000

Parameter	Group 1 (n = 114), abs. (%)	Group 2 (n = 64), abs. (%)	Group 3 (n = 36), abs. (%)	p
The patient had previously been examined by a proctologist	10 (8.8)	8 (12.5)	8 (22.2)	p1 = 0.429 p2 = 0.031 p3 = 0.204
It is important for the patient that the proctologist is a woman	32 (28)	8 (12.5)	18 (50)	p1 = 0.017 p2 = 0.015 p3 < 0.001
If the need was justified by a proctologist, the patient would agree to surgical treatment for hemorrhoids during pregnancy	76 (66.6)	42 (65.6)	18 (50)	p1 = 0.888 p2 = 0.072 p3 = 0.126

 

Fig. 4. Consultation with doctors

 

Conclusions

It was found in the conducted study that hemorrhoid symptoms were statistically more common in women in Group III, who, in turn, received progesterone hormonal therapy statistically longer – more than two trimesters. The most significant risk factors for hemorrhoid development in pregnant and postpartum women were: vaginal delivery; three or more pregnancies; long-term use of progestogens; a tendency toward constipation; and a family history of hemorrhoids and varicose veins. The problem of interdisciplinary monitoring of proctological complaints in pregnant and postpartum women by obstetricians and gynecologists remains relevant, since most doctors, unfortunately, do not provide recommendations regarding the existing symptoms in patients. The interdisciplinary problem of monitoring proctological complaints in pregnant women by obstetricians and gynecologists is also significant: in all three groups, a significant majority of doctors did not give recommendations regarding the existing rectal clinic in women.

About the authors

А. V. Romanovskaya

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0000-0003-4736-2749

DSc (Medicine), Professor, Head of the Department of Obstetrics and Gynecology of the Faculty of Medicine, the Director of the Clinic of Obstetrics and Gynecology, Chief External Gynecology Consultant to the Ministry of Health of the Saratov Region

Russian Federation, Saratov

A. V. Parshin

Saratov State Medical University named after V.I. Razumovsky

Author for correspondence.
Email: maksim.polidanoff@yandex.ru
ORCID iD: 0000-0001-8793-4786

PhD (Medicine), Associate Professor, Associate Professor of the Department of Obstetrics and Gynecology of the Faculty of Medicine

Russian Federation, Saratov

I. А. Arzhaeva

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru

PhD (Medicine), Associate Professor, Associate Professor of the Department of Obstetrics and Gynecology of the Faculty of Medicine

Russian Federation, Saratov

K. M. Karagyozyan

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru

Assistant of the Department of Obstetrics and Gynecology of the Faculty of Medicine

Russian Federation, Saratov

References

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