General obstetrics
DOI: 10.1111/1471-0528.12838 www.bjog.org
Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study T Poskus,a D Buzinskiene˙,b G Drasutiene,b NE Samalavicius,c A Barkus,d A Barisauskiene,b J Tutkuviene,d I Sakalauskaite,b J Drasutis,b A Jasulaitis,e A Jakaitienef a Centre of Abdominal Surgery, b Clinic of Obstetrics and Gynaecology, c Oncology Institute, d Department of Anatomy, Histology and Anthropology, e Department of Pathology, Pharmacology and Forensic Medicine, f Centre for Bioinformatics and Biostatistics, Department of Human and Medical Genetics, Vilnius University, Vilnius, Lithuania Correspondence: T Posˇkus, Centre of Abdominal surgery, Vilnius University, Santariskiu str. 2, LT-08661 Vilnius, Lithuania. Email [email protected]
Accepted 7 February 2014. Published Online 9 May 2014.
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. Keywords Anal fissure, haemorrhoids, pregnancy, prospective
study, risk. Linked article This article is commented on by Wall LL. p. 1672 in this issue. To view this mini commentary visit http://dx.doi.org/ 10.1111/1471-0528.12840.
Please cite this paper as: Poskus T, Buzinskien_e D, Drasutiene G, Samalavicius NE, Barkus A, Barisauskiene A, Tutkuviene J, Sakalauskaite I, Drasutis J, Jasulaitis A, Jakaitiene A. Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study. BJOG 2014;121:1666–1672.
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
1666
(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.
ª 2014 Royal College of Obstetricians and Gynaecologists
Haemorrhoids and anal fissures during pregnancy and after childbirth
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.
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.
Assessed for eligibility (n = 443)
Excluded (n = 163) ♦ Not meeting inclusion criteria (3800 g, straining during delivery for >20 minutes and perineal lacerations were significantly associated with peri-anal diseases of pregnancy. 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.
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
Table 3. Univariate analysis of risk factors for peri-anal diseases of pregnancy Factor
Peri-anal diseases group, n (%)
Age ≥30 years BMI ≥25 kg/m2 Positive family history of peri-anal diseases Birthweight of newborn Constipation in pregnancy Vaginal delivery Caesarean section Multiparas Personal history of peri-anal diseases Episiotomy Perineal lacerations Straining during delivery for >20 minutes
ª 2014 Royal College of Obstetricians and Gynaecologists
52 56 97 40 107 99 24 82 54 42 27 21
(42.3) (45.6) (78.7) (32.5) (87) (80.5) (19.5) (66.7) (43.9) (42.4) (27.3) (17.1)
Healthy group, n (%)
51 21 82 2 21 113 44 74 2 55 17 2
(32.5) (13.4) (52.2) (1.3) (13.4) (72.0) (28) (47.1) (1.3) (48.7) (15) (1.3)
OR (95% CI)
P value
1.52 4.19 3.41 37.35 40.38 1.61
(0.93–2.48) (2.29–7.67) (2.00–5.82) (8.81–158.42) (20.29–80.35) (0.91–2.83)
0.92
DOI: 10.1111/1471-0528.12838 www.bjog.org
Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study T Poskus,a D Buzinskiene˙,b G Drasutiene,b NE Samalavicius,c A Barkus,d A Barisauskiene,b J Tutkuviene,d I Sakalauskaite,b J Drasutis,b A Jasulaitis,e A Jakaitienef a Centre of Abdominal Surgery, b Clinic of Obstetrics and Gynaecology, c Oncology Institute, d Department of Anatomy, Histology and Anthropology, e Department of Pathology, Pharmacology and Forensic Medicine, f Centre for Bioinformatics and Biostatistics, Department of Human and Medical Genetics, Vilnius University, Vilnius, Lithuania Correspondence: T Posˇkus, Centre of Abdominal surgery, Vilnius University, Santariskiu str. 2, LT-08661 Vilnius, Lithuania. Email [email protected]
Accepted 7 February 2014. Published Online 9 May 2014.
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. Keywords Anal fissure, haemorrhoids, pregnancy, prospective
study, risk. Linked article This article is commented on by Wall LL. p. 1672 in this issue. To view this mini commentary visit http://dx.doi.org/ 10.1111/1471-0528.12840.
Please cite this paper as: Poskus T, Buzinskien_e D, Drasutiene G, Samalavicius NE, Barkus A, Barisauskiene A, Tutkuviene J, Sakalauskaite I, Drasutis J, Jasulaitis A, Jakaitiene A. Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study. BJOG 2014;121:1666–1672.
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
1666
(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.
ª 2014 Royal College of Obstetricians and Gynaecologists
Haemorrhoids and anal fissures during pregnancy and after childbirth
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.
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.
Assessed for eligibility (n = 443)
Excluded (n = 163) ♦ Not meeting inclusion criteria (3800 g, straining during delivery for >20 minutes and perineal lacerations were significantly associated with peri-anal diseases of pregnancy. 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.
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
Table 3. Univariate analysis of risk factors for peri-anal diseases of pregnancy Factor
Peri-anal diseases group, n (%)
Age ≥30 years BMI ≥25 kg/m2 Positive family history of peri-anal diseases Birthweight of newborn Constipation in pregnancy Vaginal delivery Caesarean section Multiparas Personal history of peri-anal diseases Episiotomy Perineal lacerations Straining during delivery for >20 minutes
ª 2014 Royal College of Obstetricians and Gynaecologists
52 56 97 40 107 99 24 82 54 42 27 21
(42.3) (45.6) (78.7) (32.5) (87) (80.5) (19.5) (66.7) (43.9) (42.4) (27.3) (17.1)
Healthy group, n (%)
51 21 82 2 21 113 44 74 2 55 17 2
(32.5) (13.4) (52.2) (1.3) (13.4) (72.0) (28) (47.1) (1.3) (48.7) (15) (1.3)
OR (95% CI)
P value
1.52 4.19 3.41 37.35 40.38 1.61
(0.93–2.48) (2.29–7.67) (2.00–5.82) (8.81–158.42) (20.29–80.35) (0.91–2.83)
0.92
