Hemorrhoidectomy During Pregnancy: Risk or Relief? Richard G. SaleebyJr., M.D., Lester Rosen, M.D., John J. Stasik, M.D., Robert D. Riether, M.D., James Sheets, M.D., Indru T. Khubchandani, M.D. From the Division of Colon and Rectal Surgery, The Allentown Hospital--Lehigh Valley Hospital Center, Allentown, Pennsylvania Saleeby RG Jr, Rosen L, Stasik JJ, Riether RD, Sheets J, Khubchandani IT. Hemorrhoidectomy during pregnancy: risk or relief? Dis Colon Rectum 1991;34:260261.
ative care, a n d to c o n s i d e r the hypothesis that h e m o r r h o i d e c t o m y during p r e g n a n c y is safe.
Acute hemorrhoidal crisis can occur in the pregnant female. When medical therapy fails to relieve pain, operative intervention may be necessary. The surgeon, however, may be reluctant to operate due to potential complications to the mother and fetus. From July 1983 to July 1989, hemorrhoidectomy was performed in 25 of 12,455 pregnant women (0.2 percent) who delivered in our institution. Twenty-two women were in their third trimester, 80 percent were multiparous, and each had a remote history of hemorrhoidal symptoms, including intermittent pain, bleeding, and protrusion. Closed hemorrhoidectomy was performed under local anesthesia. The surgery was directed at removing only symptomatic disease, which included three quadrants in 14 patients, two quadrants in seven patients, and one quadrant in four patients. All patients experienced relief of intractable pain the day after surgery, except one patient who required a hemostatic packing during the immediate postoperative period. There were no other maternal or fetal complications. Subsequent follow-up for anorectal disease ranged from 6 months to 6 years. Six (24 percent) patients required additional hemorrhoid treatment. Hemorrhoidectomy in selected pregnant patients is safe in our experience. [Key words: Prepuerperal hemorrhoidectomy; Hemorrhoidectomy in pregnancy; Hemorrhoidal crisis in pregnancy]
From July 1983 to July 1989, 12,455 p r e g n a n t w o m e n d e l i v e r e d to t e r m at T h e Allentown Hosp i t a l - L e h i g h Valley Hospital Center. Twenty-five w o m e n (0.2 p e r c e n t ) u n d e r w e n t operative h e m o r r h o i d e c t o m y for acute h e m o r r h o i d a l crisis. Office and hospital records w e r e reviewed. T h e patients r a n g e d in age f r o m 21-34 years. T w e n t y - t w o w o m e n w e r e in their third trimester, two in their s e c o n d trimester, and o n e was in her first trimester. Eighty p e r c e n t w e r e m u l t i p a r o u s and 88 p e r c e n t had a previous history of h e m o r rhoidal disease. All patients p r e s e n t e d with intractable pain, 88 p e r c e n t c o m p l a i n e d of protrusion, and 80 p e r c e n t c o m p l a i n e d of b l e e d i n g . At examination, 88 p e r c e n t w e r e f o u n d to have t h r o m b o s e d or g a n g r e n o u s h e m o r r h o i d s . All patients w e r e h o s p i t a l i z e d for surgery. W o m e n in the third trimester w e r e p l a c e d in the left Sims position; the jackknife p r o n e position was u s e d for those in the first and s e c o n d trimester. Local anesthesia with e p i n e p h r i n e and hyaluronidase was u s e d in all patients with IV sedation ( D e m e r o l or p e n t o b a r b i t o l ) , w h e n n e e d e d . Maternal m o n i t o r i n g i n c l u d e d b l o o d p r e s s u r e and oxyg e n saturation. Fetal m o n i t o r i n g was p e r f o r m e d for gestational age of 20 w e e k s or greater. Closed h e m o r r h o i d e c t o m y with 5-0 polyglycolic acid suture was p e r f o r m e d in all patients. 2 O n l y symptomatic quadrants w e r e excised. T h r e e quadrants w e r e excised in 14 w o m e n , two quadrants in s e v e n w o m e n , and o n e quadrant in four w o m e n . Postoperative b o w e l m o v e m e n t s w e r e e n c o u r a g e d with softeners and psyllium.
PATIENTS AND METHODS
e m o r r h o i d a l s y m p t o m s are c o m m o n in the s e c o n d and third trimesters of p r e g n a n c y . 1 Acute h e m o r r h o i d a l crisis can o c c u r with irreducible prolapse, t h r o m b o s i s and p r o t r a c t e d pain. W h e n h e m o r r h o i d a l s y m p t o m s are refractory to m e d i c a l t r e a t m e n t and intractable pain b e c o m e s the p r e d o m i n a n t feature, s u r g e o n s m a y b e reluctant to o p e r a t e d u e to potential complications. We r e v i e w e d our e x p e r i e n c e in an a t t e m p t to define risks involved, to establish the p r i n c i p l e s of oper-
H
Address correspondence to Dr. Rosen: Little Lehigh Medical Center, 1275 S. Cedar Crest Blvd., Allentown, Pennsylvania 18103. 0012-3706/91/3403-0260/$3.00 Diseases of the Colon & Rectum Copyright 9 1991 by The American Society of Colon & Rectal Surgeons
RESULTS All patients r e m a i n e d in the hospital overnight and had relief of pain within 24 hours, e x c e p t o n e 260
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patient who had persistent rectal bleeding 6 hours postoperatively and required a hemostatic pack placed in the anal canal at bedside. There were no surgical-related fetal complications. All wounds healed within 6 weeks, and the subsequent pattern of delivery was not affected. Long term follow-up ranged from 6 months to 6 years (mean 30 months). Six w o m e n required additional symptomatic hemorrhoidal treatment. Two patients had satisfactory results with rubberband ligation in the office, and four required subsequent surgical hemorrhoidectomy. No patient who originally had three quadrant hemorrhoidectomy required additional treatment.
261
Our patients who had persistent or recurrent intractable pain underwent surgical hemorrhoidectomy. Complications included one postoperative bleed treated by packing. Six of 11 women (54 percent) who had less than a three quadrant hemorrhoidectomy required additional treatment, but we feel that excising only the symptomatic quadrants is indicated as mother and child safety is our primary goal. With attention to operative and perioperative details and the excision of symptomatic quadrants only, there is minimal risk to the mother and fetus. Operative hemorrhoidectomy in selected pregnant patients was safe in our experience. Comparative studies are warranted.
DISCUSSION During pregnancy, hormonal changes can cause increased vascularity and hyperemia in the skin and muscles of the perineum as well as softening of the abundant connective tissue. 3 Hemorrhoid surgery during pregnancy has been considered risky secondary to the anticipation of postoperative bleeding, complications of episiotomy, premature labor, and poor wound healing. For these reasons, all pregnant women presenting with acute hemorrhoidal symptoms usually have initial conservative treatment.
REFERENCES 1. Creasy RK, Resnik R. Maternal fetal medicine. Philadelphia: WB Saunders, 1984:686. 2. Pritchard JA, MacDonald PC, Gant NF. Williams obstetrics. Norwalk, CT: Appleton-Century-Crofts, 1985:262. 3. Khubchandani IT, Trimpi HD, Sheets JA. Closed hemorrhoidectomy with local anesthesia. Surg Gynecol Obstet 1972:135:955-7.
ative care, a n d to c o n s i d e r the hypothesis that h e m o r r h o i d e c t o m y during p r e g n a n c y is safe.
Acute hemorrhoidal crisis can occur in the pregnant female. When medical therapy fails to relieve pain, operative intervention may be necessary. The surgeon, however, may be reluctant to operate due to potential complications to the mother and fetus. From July 1983 to July 1989, hemorrhoidectomy was performed in 25 of 12,455 pregnant women (0.2 percent) who delivered in our institution. Twenty-two women were in their third trimester, 80 percent were multiparous, and each had a remote history of hemorrhoidal symptoms, including intermittent pain, bleeding, and protrusion. Closed hemorrhoidectomy was performed under local anesthesia. The surgery was directed at removing only symptomatic disease, which included three quadrants in 14 patients, two quadrants in seven patients, and one quadrant in four patients. All patients experienced relief of intractable pain the day after surgery, except one patient who required a hemostatic packing during the immediate postoperative period. There were no other maternal or fetal complications. Subsequent follow-up for anorectal disease ranged from 6 months to 6 years. Six (24 percent) patients required additional hemorrhoid treatment. Hemorrhoidectomy in selected pregnant patients is safe in our experience. [Key words: Prepuerperal hemorrhoidectomy; Hemorrhoidectomy in pregnancy; Hemorrhoidal crisis in pregnancy]
From July 1983 to July 1989, 12,455 p r e g n a n t w o m e n d e l i v e r e d to t e r m at T h e Allentown Hosp i t a l - L e h i g h Valley Hospital Center. Twenty-five w o m e n (0.2 p e r c e n t ) u n d e r w e n t operative h e m o r r h o i d e c t o m y for acute h e m o r r h o i d a l crisis. Office and hospital records w e r e reviewed. T h e patients r a n g e d in age f r o m 21-34 years. T w e n t y - t w o w o m e n w e r e in their third trimester, two in their s e c o n d trimester, and o n e was in her first trimester. Eighty p e r c e n t w e r e m u l t i p a r o u s and 88 p e r c e n t had a previous history of h e m o r rhoidal disease. All patients p r e s e n t e d with intractable pain, 88 p e r c e n t c o m p l a i n e d of protrusion, and 80 p e r c e n t c o m p l a i n e d of b l e e d i n g . At examination, 88 p e r c e n t w e r e f o u n d to have t h r o m b o s e d or g a n g r e n o u s h e m o r r h o i d s . All patients w e r e h o s p i t a l i z e d for surgery. W o m e n in the third trimester w e r e p l a c e d in the left Sims position; the jackknife p r o n e position was u s e d for those in the first and s e c o n d trimester. Local anesthesia with e p i n e p h r i n e and hyaluronidase was u s e d in all patients with IV sedation ( D e m e r o l or p e n t o b a r b i t o l ) , w h e n n e e d e d . Maternal m o n i t o r i n g i n c l u d e d b l o o d p r e s s u r e and oxyg e n saturation. Fetal m o n i t o r i n g was p e r f o r m e d for gestational age of 20 w e e k s or greater. Closed h e m o r r h o i d e c t o m y with 5-0 polyglycolic acid suture was p e r f o r m e d in all patients. 2 O n l y symptomatic quadrants w e r e excised. T h r e e quadrants w e r e excised in 14 w o m e n , two quadrants in s e v e n w o m e n , and o n e quadrant in four w o m e n . Postoperative b o w e l m o v e m e n t s w e r e e n c o u r a g e d with softeners and psyllium.
PATIENTS AND METHODS
e m o r r h o i d a l s y m p t o m s are c o m m o n in the s e c o n d and third trimesters of p r e g n a n c y . 1 Acute h e m o r r h o i d a l crisis can o c c u r with irreducible prolapse, t h r o m b o s i s and p r o t r a c t e d pain. W h e n h e m o r r h o i d a l s y m p t o m s are refractory to m e d i c a l t r e a t m e n t and intractable pain b e c o m e s the p r e d o m i n a n t feature, s u r g e o n s m a y b e reluctant to o p e r a t e d u e to potential complications. We r e v i e w e d our e x p e r i e n c e in an a t t e m p t to define risks involved, to establish the p r i n c i p l e s of oper-
H
Address correspondence to Dr. Rosen: Little Lehigh Medical Center, 1275 S. Cedar Crest Blvd., Allentown, Pennsylvania 18103. 0012-3706/91/3403-0260/$3.00 Diseases of the Colon & Rectum Copyright 9 1991 by The American Society of Colon & Rectal Surgeons
RESULTS All patients r e m a i n e d in the hospital overnight and had relief of pain within 24 hours, e x c e p t o n e 260
Vol. 34, No. 3
HEMORRHOIDECTOMY DURING PREGNANCY
patient who had persistent rectal bleeding 6 hours postoperatively and required a hemostatic pack placed in the anal canal at bedside. There were no surgical-related fetal complications. All wounds healed within 6 weeks, and the subsequent pattern of delivery was not affected. Long term follow-up ranged from 6 months to 6 years (mean 30 months). Six w o m e n required additional symptomatic hemorrhoidal treatment. Two patients had satisfactory results with rubberband ligation in the office, and four required subsequent surgical hemorrhoidectomy. No patient who originally had three quadrant hemorrhoidectomy required additional treatment.
261
Our patients who had persistent or recurrent intractable pain underwent surgical hemorrhoidectomy. Complications included one postoperative bleed treated by packing. Six of 11 women (54 percent) who had less than a three quadrant hemorrhoidectomy required additional treatment, but we feel that excising only the symptomatic quadrants is indicated as mother and child safety is our primary goal. With attention to operative and perioperative details and the excision of symptomatic quadrants only, there is minimal risk to the mother and fetus. Operative hemorrhoidectomy in selected pregnant patients was safe in our experience. Comparative studies are warranted.
DISCUSSION During pregnancy, hormonal changes can cause increased vascularity and hyperemia in the skin and muscles of the perineum as well as softening of the abundant connective tissue. 3 Hemorrhoid surgery during pregnancy has been considered risky secondary to the anticipation of postoperative bleeding, complications of episiotomy, premature labor, and poor wound healing. For these reasons, all pregnant women presenting with acute hemorrhoidal symptoms usually have initial conservative treatment.
REFERENCES 1. Creasy RK, Resnik R. Maternal fetal medicine. Philadelphia: WB Saunders, 1984:686. 2. Pritchard JA, MacDonald PC, Gant NF. Williams obstetrics. Norwalk, CT: Appleton-Century-Crofts, 1985:262. 3. Khubchandani IT, Trimpi HD, Sheets JA. Closed hemorrhoidectomy with local anesthesia. Surg Gynecol Obstet 1972:135:955-7.
