Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium

Abstract

Haemorrhoids (piles) are swollen veins at or near the anus, normally asymptomatic. They do not constitute a disease, unless they become symptomatic. Pregnancy and the puerperium predispose to symptomatic haemorrhoids, being the most common ano-rectal disease at these stages. Symptoms are usually mild and transient and include intermittent bleeding from the anus and pain. Depending on the degree of pain, quality of life could be affected, varying from mild discomfort to real difficulty in dealing with the activities of everyday life. Treatment during pregnancy is mainly directed to the relief of symptoms, especially pain control. The so-called conservative management includes dietary modifications, stimulants or depressants of the bowel transit, local treatment, and phlebotonics (drugs that cause decreased capillary fragility, improving the microcirculation in venous insufficiency). For many women, symptoms will resolve spontaneously soon after birth, and so any corrective treatment is usually deferred to some time after birth. Thus, the objective of this review is to evaluate the efficacy of conservative management of piles during pregnancy and the puerperium. To determine the possible benefits, risks and side-effects of the conservative management of symptomatic haemorrhoids during pregnancy and the puerperium. We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 June 2004). Randomised-controlled trials comparing any of the conservative treatments for symptomatic haemorrhoids during pregnancy and the puerperium (such as dietary modifications, stimulant/depressant of the bowel transit, local treatments, drugs that improve the microcirculation in venous insufficiency) with a placebo or no treatment. Two review authors independently performed a methodological assessment for deciding which studies to include/exclude from the review and extracted data. From 10 potentially eligible studies, two were included in this review (150 women). Both compared oral rutosides against placebo. Rutosides seem to be effective in reducing the signs identified by the healthcare provider, and symptoms and signs reported by women, of haemorrhoidal disease. For the outcome no response to treatment: relative risk 0.07, 95% confidence interval 0.03 to 0.20. Regarding perinatal outcomes, one fetal death and one congenital malformation (possible not related to exposure) were reported in the control and treatment group respectively. Although the treatment with oral hydroxyethylrutosides looks promising for symptom relief in first and second degree haemorrhoids, its use cannot be recommended until new evidence reassures women and their clinicians about their safety. The most commonly used approaches, such as dietary modifications and local treatments, were not properly evaluated during pregnancy and the puerperium.