Clinical Practice Guidelines Antenatal Care — Module II

7.2Resources

7.3References

Cherian S, Forbes D, Sanfilippo F et al (2008) The epidemiology of Helicobacter pylori infection in African refugee children resettled in Australia. Med J Aust 189(8): 438–41.

da Silva JB, Nakamura MU, Cordeiro JA et al (2009) Acupuncture for dyspepsia in pregnancy: a prospective, randomised, controlled study. Acupunct Med 27(2): 50–53.

Diav-Citrin O, Arnon J, Shechtman S et al (2005) The safety of proton pump inhibitors in pregnancy: a multicentre prospective controlled study. Aliment Pharmacol Ther 21(3): 269–75.

Dowswell T & Neilson JP (2008) Interventions for heartburn in pregnancy. Cochrane Database Syst Rev(4): CD007065.

Gill SK, O'Brien L, Einarson TR et al (2009a) The safety of proton pump inhibitors (PPIs) in pregnancy: a meta-analysis. Am J Gastroenterol 104(6): 1541–45.

Gill SK, O'Brien L, Koren G (2009b) The safety of histamine 2 (H2) blockers in pregnancy: a meta-analysis. Dig Dis Sci 54(9): 1835–38.

Majithia R & Johnson DA (2012) Are proton pump inhibitors safe during pregnancy and lactation? Evidence to date. Drugs 72(2): 171–79.

Matok I, Levy A, Wiznitzer A et al (2012) The safety of fetal exposure to proton-pump inhibitors during pregnancy. Dig Dis Sci 57(3): 699–705.

Pasternak B & Hviid A (2010) Use of proton-pump inhibitors in early pregnancy and the risk of birth defects. N Engl J Med 363(22): 2114–23.

Rey E, Rodriguez-Artalejo F, Herraiz MA et al (2007) Gastroesophageal reflux symptoms during and after pregnancy: a longitudinal study. Am J Gastroenterol 102(11): 2395–400.

Richter JE (2003) Gastroesophageal reflux disease during pregnancy. Gastroenterol Clin North Am 32(1): 235–61.

Richter JE (2005) Review article: the management of heartburn in pregnancy. Aliment Pharmacol Ther 22(9): 749–57.

Tiong AC, Patel MS, Gardiner J et al (2006) Health issues in newly arrived African refugees attending general practice clinics in Melbourne. Med J Aust 185(11-12): 602–6.

Tytgat GN, Heading RC, Muller-Lissner S et al (2003) Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting. Aliment Pharmacol Ther 18(3): 291–301.

7.4

7.5Haemorrhoids

Background

Haemorrhoids are enlarged, swollen veins around the anus that are characterised by anorectal bleeding, painful bowel movements, anal pain and anal itching. While the mechanism is not clear, this is thought to be a result of prolapse of the anal canal cushions, which play a role in maintaining continence. Constipation (see Section 7.9 of Module I) is the major precipitating factor for haemorrhoids. Pregnancy also facilitates development or exacerbation of haemorrhoids, due to increased pressure in rectal veins caused by restriction of venous return by a woman’s enlarged uterus (Avsar & Keskin 2010).

Incidence during pregnancy

Haemorrhoids that were present previously may become symptomatic for the first time in pregnancy. Haemorrhoidal symptoms are most common in the second and third trimesters of pregnancy and after birth (Avsar & Keskin 2010).

While estimates vary, it is thought that 25–35% of pregnant women are affected by haemorrhoids (Staroselsky et al 2008; Abramowitz & Batallan 2003). One observational study found that 8% of pregnant women (n=165) experienced thrombosed external haemorrhoids in the last 3 months of pregnancy (Abramowitz et al 2002).

Diagnosis

Pain with bowel movements, bleeding and itching are often the first signs and symptoms of haemorrhoids. Diagnosis is made by examining the anus and anal canal, usually by inspection. Digital rectal examination and endoscopy (sigmoidoscopy and colonoscopy) may also be used. It is important to rule out more serious causes of bleeding (Avsar & Keskin 2010).

Discussing haemorrhoids

Summary of the evidence

Treatment during pregnancy aims mainly to relieve symptoms and control pain (Avsar & Keskin 2010).

Most evidence for the effectiveness of haemorrhoid treatments comes from studies of non-pregnant patients. Given the overall lack of evidence, there is consensus in clinical reviews for conservative management in pregnancy including avoiding constipation, dietary modification, dietary fibre supplementation and stool softeners (Avsar & Keskin 2010; Dietrich et al 2008; Wald 2003).

Topical products with analgesics and anti-inflammatory effects provide short-term local relief of symptoms. There is no evidence on the effectiveness or safety of creams used in pregnancy; however, the small doses and limited systemic absorption mean that they are unlikely to harm the third trimester infant (Staroselsky et al 2008).

While surgical removal of haemorrhoids may be a consideration in extreme circumstances, surgery is rarely an appropriate intervention for pregnant women as haemorrhoidal symptoms often resolve spontaneously after the birth (Staroselsky et al 2008).

Consensus-based recommendation vii

Offer women who have haemorrhoids information about increasing dietary fibre and fluid intake. If clinical symptoms remain, advise women that they can consider using standard haemorrhoid creams.

Practice summary: haemorrhoids

When: A woman had haemorrhoids before pregnancy or has symptoms of haemorrhoids.

Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker; accredited dietitian.

Provide advice: Advise women that avoiding constipation (see Section 7.9 of Module I) is the best way to prevent and manage haemorrhoids during pregnancy and they should also try to avoid straining with bowel motions.

Discuss treatments: Advise women that haemorrhoid creams can be used to further ease their symptoms.

Take a holistic approach: Explore culturally appropriate, low cost ways for women to increase their fibre intake. Advise women who are increasing their fibre intake to make sure they drink adequate fluids.

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