Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study

Authors


Abstract

Objective

To identify the incidence and risk factors of haemorrhoids and fissures during pregnancy and after childbirth.

Design

Prospective observational cohort study.

Setting

University hospital and outpatient clinics in Lithuania.

Population

A total of 280 pregnant women followed up until 1 month after delivery.

Methods

Women were examined four times through pregnancy and after delivery; those that developed peri-anal diseases were compared with those that did not.

Main outcome measures

Incidence, time and risk factors of haemorrhoids and fissures.

Results

In all, 123 (43.9%) women developed peri-anal disease: 1.6% in the first trimester, 61% during the third trimester, 34.1% after delivery and 3.3% 1 month after delivery; 114 (40.7%) women were diagnosed with haemorrhoids, seven (2.5%) with haemorrhoids and anal fissure and two (0.71%) with anal fissure. Ninety-nine (80.5%) women had vaginal delivery and 24 (19.5%) women had undergone caesarean section. Multivariate analysis identified personal history of peri-anal diseases (odds ratio [OR] 11.93; 95% confidence interval [95% CI] 2.18–65.30), constipation (OR 18.98; 95% CI 7.13–50.54), straining during delivery for more than 20 minutes (OR 29.75; 95% CI 4.00–221.23) and birthweight of newborn >3800 g (OR 17.99; 95% CI 3.29–98.49) as significant predictors of haemorrhoids and anal fissures during pregnancy and perinatal period.

Conclusions

Haemorrhoids and fissures are common during the last trimester of pregnancy and 1 month after delivery, with constipation, personal history of haemorrhoids or fissures, birthweight of newborn >3800 g, straining during delivery for more than 20 minutes being independently associated risk factors.

Introduction

About one-third of women after childbirth complain of peri-anal symptoms. This is well documented by multiple population questionnaire-based studies.[1-5] Self-diagnosis of peri-anal diseases is highly inaccurate,[6] and true diagnosis of the nature of peri-anal discomfort in women in the last trimester of pregnancy or in the puerperal period has been evaluated in a few studies.[7-10] The most recent study by Abramowitz et al.[7] identified constipation and late delivery (after 39.7 weeks of pregnancy) as independent risk factors for haemorrhoids and anal fissures during the third trimester of pregnancy and puerperium. We were unable to find any prospective studies that have investigated incidence and the risk factors of peri-anal diseases from the first trimester of pregnancy to 1 month after delivery.

The aim of our study was to identify the incidence of haemorrhoids, fissures and other peri-anal diseases of pregnancy and puerperium and to identify the risk factors for peri-anal diseases.

Methods

This was a prospective observational cohort study. The Regional Bioethics Committee approved the study.

Pregnant women who were over 18 years of age and who consented to the study by signing the informed consent form were included in the study. During the first visit, the gynaecologist (DB) interviewed all women. Each woman completed a detailed questionnaire, including demographic (maternal age, nationality, family status), social (education, family income, place of residence, conditions of the life), anthropometric (body mass index, diet, bowel habit, family history, personal history of peri-anal diseases, previous pregnancy) factors and delivery-related questions.

All women were examined four times: in the first and third trimesters, on the first or second day after delivery, and 1 month after delivery.

The same gynaecologist (DB) interviewed and examined the women at all four scheduled visits. The flow diagram of the study is presented in Figure 1.

Figure 1.

Flow diagram of the study.

On the first or second day after delivery the following data were recorded: obstetric data—method of birth, length of labour, perineal trauma during labour (i.e. tear or episiotomy) and anthropometric information of the newborn. If any peri-anal symptoms—pain, rectal bleeding, peri-anal tissue enlargement or protrusion—or any peri-anal discomfort occurred during the study period, a colorectal surgeon (TP or NES) investigated the woman immediately (inspection of peri-anal region and anoscopy) and made a diagnosis. Women were examined in a left lateral decubitus position, looking for external or thrombosed haemorrhoids. Women complaining of any kind of protrusion were examined on the commode and asked to strain, if convenient, to demonstrate any protrusion. Digital rectal examination was performed and after that, rigid anoscopy with a lighted direct-view endoscope was performed with the woman relaxed and later with the woman straining.

The characteristics of the women were described by counts and percentages for categorical variables and median and ranges for continuous variables.

The women were divided into two groups: women in one group had developed peri-anal disease, the other group had not. Categorical data between the groups was compared by a chi-square or Fisher's exact test as appropriate. Continuous characteristics were compared by Student's t-test or the Mann–Whitney U-test as appropriate. All differences for which the probability value was less than 0.05 were considered to be significant in univariate analysis. All significant univariate risk factors were included in a multiple logistic regression model to identify independent risk factors. Calculations were performed using statistical software package SPSS, version 17 (IBM corporation, Armonk, NY, USA).

Results

Out of 440 consecutive pregnant women invited to enter the study from January 2010 to January 2011, 20 women declined to participate in subsequent study visits and were excluded and 280 women who agreed to participate in the study during their pregnancy up until 1 month after delivery were included. Women's mean age was 28.7 years (18–45 years). Mean body mass index was 23.1 kg/m2 (15.4–43.8 kg/m2).

Of the 280 women, 124 (44.3%) were pregnant for the first time, 156 (55.7%) had a repeated pregnancy. Of them 151 (53.9%) were multipara: 128 (84.8%) had a previous normal delivery and 23 (15.2%) had previous caesarean section.

In all, 188 women (67.1%) were married, 27 (9.6%) were single, 37 (13.2%) were divorced and 28 (10%) were in partnership.

Fifty-six (20%) of the 280 women had a previous history of peri-anal diseases before the current pregnancy.

Constipation was defined according to Rome III criteria: defecation occurring less than three times per week, requiring prolonged or excessive straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual manoeuvring required to defecate. According to these criteria, women must have experienced at least two of the above symptoms over the preceding 3 months. We excluded symptoms of peri-anal pain on defecation from the definition, as this could be a symptom of peri-anal disease and not of constipation. Constipation was present in 128 (45.7%) women.

Of the 280 women, 206 (73.6%) had a vaginal delivery, 31 (11.1%) had an elective caesarean section, 37 (13.2%) had an emergency caesarean section, two (0.7%) had a vacuum extraction and four (1.4%) had forceps extraction. The mean duration of straining in women having a vaginal delivery was 13.4 (3–50) minutes. Forty-four women (21.4%) suffered perineal tears and 97 (47.1%) underwent episiotomy.

The median weight of the newborn was 3545 g (2100–5340 g), 143 were boys (51.1%). Median height of the newborn was 53 cm (42–60 cm); median head circumference was 35 cm (31–52 cm), median chest circumference was 34 cm (27–39 cm).

In all, 123 women (43.9%) developed peri-anal symptoms during the study. The symptoms were usually multiple and included peri-anal discomfort, itching, burning, mucous discharge, painful protrusion at the anus, bleeding and peri-anal pain. The frequencies of peri-anal symptoms are presented in Table 1. The time of diagnosis of peri-anal disease is presented in Table 2. It is of note that 61% of women developed peri-anal diseases during the third trimester of pregnancy and 37.4% during or immediately after delivery.

Table 1. Frequency of peri-anal symptoms
SymptomFrequency, n (% from 123 symptomatic women)
Peri-anal pain 121 (98.4)
Sharp pain6 (4.9)
Dull pain75 (61.9)
Dull pain with increase on defecation71 (58.7)
Pain only on defecation12 (9.9)
Peri-anal discomfort 110 (89.4)
Itching 99 (80.5)
Painful protrusion at the anus 54 (43.9)
Burning 98 (79.7)
Mucous discharge 91 (74.0)
Bleeding 77 (62.6)
Table 2. Time of the occurrence of peri-anal diseases
Time n %
First trimester21.6
Second trimester00
Third trimester7561
First to second day after delivery4234.1
First month after pregnancy43.3

Out of 123 women, 114 (92.7%) were diagnosed with haemorrhoids and seven (5.7%) with haemorrhoids and anal fissure. Out of the 121 women diagnosed with haemorrhoids, 64 (52.9%) were diagnosed with thrombosed haemorrhoids. Two women (1.6%) were diagnosed with an anal fissure. As the number of women with anal fissures was very small, they were added to the women with haemorrhoids and created the group (123 women) with peri-anal diseases. A total of 157 women (56.1%) did not develop any peri-anal symptoms during the study time and they were the healthy group.

Univariate analysis was performed with suspected risk factors for the peri-anal diseases (Table 3). We identified that a body mass index ≥25 kg/m2, positive family or personal history of peri-anal diseases, constipation during pregnancy, multiparity, birthweight of newborn >3800 g, straining during delivery for >20 minutes and perineal lacerations were significantly associated with peri-anal diseases of pregnancy.

Table 3. Univariate analysis of risk factors for peri-anal diseases of pregnancy
FactorPeri-anal diseases group, n (%)Healthy group, n (%)OR (95% CI)P value
Age ≥30 years52 (42.3)51 (32.5)1.52 (0.93–2.48)0.92
BMI ≥25 kg/m256 (45.6)21 (13.4)4.19 (2.29–7.67)<0.001
Positive family history of peri-anal diseases97 (78.7)82 (52.2)3.41 (2.00–5.82)<0.001
Birthweight of newborn40 (32.5)2 (1.3)37.35 (8.81–158.42)<0.001
Constipation in pregnancy107 (87)21 (13.4)40.38 (20.29–80.35)<0.001
Vaginal delivery99 (80.5)113 (72.0)1.61 (0.91–2.83)0.10
Caesarean section24 (19.5)44 (28)  
Multiparas82 (66.7)74 (47.1)2.25 (1.39–3.66)0.001
Personal history of peri-anal diseases54 (43.9)2 (1.3)60.65 (14.38–255.88)<0.001
Episiotomy42 (42.4)55 (48.7)0.96 (0.59–1.58)0.877
Perineal lacerations27 (27.3)17 (15)2.32 (1.20–4.48)0.013
Straining during delivery for >20 minutes21 (17.1)2 (1.3)0.67 (0.02–0.29)<0.001

All significant univariate risk factors were included in a multiple logistic regression model to identify independent risk factors (Table 4). Personal history of peri-anal diseases, constipation during pregnancy, straining during delivery for >20 minutes and birthweight of newborn >3800 g are significant and independent predictors of peri-anal diseases of pregnancy and the perinatal period.

Table 4. Results of multivariate logistic regression analysis of potential risk factors
VariableOR (95% CI)P value
Age ≥30 years1.285 (0.465–3.557)0.63
BMI ≥25 kg/m21.435 (0.513–4.016)0.49
Positive family history of peri-anal diseases1.377 (0.509–3.728)0.53
Birthweight of newborn >3800 g17.989 (3.286–98.486)0.001
Constipation during pregnancy18.975 (7.125–50.535)<0.001
Multiparity1.272 (0.440–3.674)0.68
Personal history of peri-anal diseases11.928 (2.179–65.295)0.04
Episiotomy0.869 (0.274–2.759)0.81
Perineal lacerations1.511 (0.429–5.326)0.52
Straining during delivery (for >20 minutes)29.746 (4.000–221.231)0.001

Discussion

Main findings

The study identified an incidence of peri-anal diseases of pregnancy and puerperium of 43.9%, with the most common problem being haemorrhoids (92.7%). Sixty-one percent of women developed peri-anal diseases during the third trimester of pregnancy and 37.4% after delivery. Multivariate analysis found that constipation in pregnancy, previous history of peri-anal diseases, birthweight newborn >3800 g, prolonged straining during second stage of labour (>20 minutes) are independently associated with peri-anal diseases of pregnancy and puerperium.

Strengths and limitations

This is a prospective cohort study, where the women were included and followed by one gynaecologist (DB) and peri-anal symptoms were evaluated by two surgeons with special interest in colorectal surgery (TP and NES). Also, only 20 women (7.14%) did not complete the study and the rest were followed for the duration of their pregnancy. This allows for minimal variation in data registration and diagnosis of peri-anal diseases.

The main weak point of the study is that we did not perform anoscopy throughout the study population, however, to avoid unnecessary awkward interventions in otherwise healthy pregnant women we proceeded with anoscopy and a consultation with a colorectal surgeon only in those women who developed peri-anal symptoms.

Interpretation

Although the incidence of peri-anal discomfort in women during pregnancy and the puerperal period has been described in several studies,[1-5, 7-20] most of them are based on postal questionnaires or telephone interviews,[1-5, 12, 14-20] where the symptoms of peri-anal pain and bleeding are attributed to haemorrhoids. It has been shown that self-diagnosis of peri-anal diseases is highly inaccurate.[6] Also, women in some of these studies were interviewed a few months to a few years after childbirth.[2, 14-20] Some of the studies specifically excluded symptoms, which occurred during pregnancy.[16] The present study gives accurate estimation on incidence and type of peri-anal diseases, as physical examination and anoscopy were used to diagnose the conditions.

Other studies have included physical examination, anoscopy or colonoscopy.[7-11, 13] However, they mostly looked only at specific times in pregnancy—last trimester and after delivery,[7] immediately postpartum,[8, 11, 13] or 6 weeks after delivery.[9, 10] The present study gives accurate estimation on time of occurrence of peri-anal diseases, as the women were diagnosed at the point when they complained of peri-anal symptoms during the pregnancy or after delivery. This could explain the difference in findings: Abramowitz et al.[7] found 9.1% incidence of peri-anal disease in the third trimester and 35.2% incidence within 1 month of delivery. Our study, in contrast, shows that 61% of peri-anal symptoms and diseases occur in the third trimester of pregnancy, and 37.4% at the time of delivery. Only 1.6% of women developed peri-anal diseases during the first trimester and 3.3% 1 month after delivery. Our finding is important because prophylactic measures, if any, should be undertaken within or before the third trimester, and not around delivery.

Abramowitz et al.[7] identified dyschezia and late birth as significant independent prognostic factors for peri-anal disease. Interestingly, a study from India, where population consumption of fibre is very high and constipation is not common, showed incidence of haemorrhoids to be only 1.8%.[19] Our study also identified constipation as the single independent preventable risk factor for peri-anal disease, with highly significant odds ratio of 18.975 (95% CI 7.125–50.535). Constipation was documented early, during the first interview, and so was likely to have caused peri-anal diseases later, during the third trimester. This is also a factor that could be influenced by prophylactic measures. Hence studies into how to avoid constipation in pregnant women and hence avoid peri-anal diseases, should be performed.

Peri-anal diseases have been linked to difficult labour.[2, 4, 13] This corresponds well with the occurrence of diseases at the time of delivery. Our study also proved that a birthweight of >3800 g and prolonged straining during the second stage of labour of >20 minutes are independently associated with peri-anal diseases of pregnancy and puerperium. Hence women with a personal history of peri-anal diseases should avoid difficult labour if they want to reduce their risk of haemorrhoids and fissures.

Conclusions

Haemorrhoids and anal fissures are common during the last trimester of pregnancy and at the time of delivery. Constipation, personal history of peri-anal diseases, the birthweight of the newborn being >3800 g and prolonged straining during second stage of labour for >20 minutes are independently associated risk factors. Further studies must be performed to evaluate measures to prevent constipation and reduce the incidence of haemorrhoids and fissures during pregnancy.

Disclosure of interests

None of the authors have any conflicts of interest to disclose.

Contribution of authorship

All authors are responsible for the study concept and design and the analysis of the data. TP drafted the article and all authors contributed to reviewing the draft and approving the final version to be published. All authors (except GD, ABd and AJf) contributed to data acquisition and all authors accept responsibility for the paper as published.

Details of ethics approval

Vilnius Regional Bioethics Committee approved the study on 10 July 2009, approval number: 158200-7-059-13.

Funding

The study did not receive funding.

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