Postpartum Haemorrhoids

Postpartum haemorrhoids are swollen vascular cushions in the anal canal that become painful, bleed or prolapse in the weeks after birth. They are common after birth and result from raised pelvic pressure in late pregnancy, straining at the second stage of labour, constipation and hormonal effects on veins. They matter because they cause pain, bleeding and distress, and thrombosis causes severe pain.

• Risk factors: constipation, long second stage, large baby, first birth, haemorrhoids in pregnancy, obesity, perineal tears, low fibre diet.
• Most settle in 2 to 6 weeks without surgery.
• Grade 1 to 4 describes degree of prolapse.

Women have rectal bleeding (bright red on the paper or stool), a lump at the anus, itching, soiling and pain on defaecation. A thrombosed external haemorrhoid is a tense, tender, bluish lump at the anal margin.

• Painless bright red bleeding with defaecation.
• Tender blue lump at the anus in thrombosis.
• Differential diagnosis: anal fissure, perianal haematoma, perianal abscess, rectal prolapse, anal skin tags, perineal tear, rectal polyp or cancer, anal warts.
• Complications: thrombosis, strangulation, anaemia from chronic bleeding, pruritus ani, skin tags, recurrence.

The approach is inspection and anorectal examination.

• Inspect the anal margin with the woman lying on her side; digital rectal examination; anoscopy (proctoscopy) to view internal haemorrhoids; grade 1 (bleed, no prolapse), 2 (prolapse and reduce on their own), 3 (need manual reduction), 4 (cannot be reduced).
• Haemoglobin if bleeding is heavy or prolonged.
• Examination for fissure, abscess and sphincter injury.
• Colonoscopy if bleeding persists beyond 6 weeks, there is change in bowel habit or age above 45 years.

The principle is stool softening, local treatment and rest, with a minor procedure for thrombosis or persistent disease.

• Supportive: fibre 25 to 30 g daily; fluids 2 to 3 litres; avoid straining and sitting on the toilet more than 5 minutes; sitz baths with warm water for 10 minutes 3 times daily; ice packs for 15 minutes; gentle replacement of prolapsed haemorrhoids with lubricant; cleaning with water and soft tissue; loose cotton underwear.
• Pharmacological: lactulose 15 mL oral 12-hourly; ispaghula husk 3.5 g oral 12-hourly with water; lignocaine 2 percent ointment applied to the anal area 8-hourly for up to 7 days; hydrocortisone 1 percent cream applied 12-hourly for up to 7 days; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); diclofenac 50 mg oral 8-hourly for 3 days with food if no contraindication; micronised purified flavonoid fraction (diosmin 450 mg with hesperidin 50 mg) 3 tablets oral 12-hourly for 4 days then 2 tablets 12-hourly for 3 days where available; ferrous sulphate 200 mg oral 8-hourly for 3 months if anaemic.
• Procedures: incision and evacuation of clot under lignocaine 1 percent 5 mL for a thrombosed external haemorrhoid within 72 hours of onset; rubber band ligation after 6 weeks for persistent grade 2 or 3 haemorrhoids; haemorrhoidectomy for grade 4 or failed treatment.
• Special groups: women with a third or fourth degree tear keep stool soft with lactulose 15 mL oral 12-hourly and avoid enemas and rectal suppositories until the repair has healed.
• Red flags: heavy bleeding, severe pain with a tense blue lump, fever, strangulated prolapse, change in bowel habit, weight loss, persistent bleeding beyond 6 weeks.
• Follow-up: review at 1 week and 6 weeks; haemoglobin at 4 weeks if bleeding was heavy; repeat examination and colonoscopy if bleeding persists.