DOI: 10.1111/1471-0528.

12838 General obstetrics

www.bjog.org

Haemorrhoids and anal fissures during

pregnancy and after childbirth: a prospective
cohort study
T Poskus,a D Buzinskienė,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 Poškus, Centre of Abdominal surgery, Vilnius University, Santariskiu str. 2, LT-08661 Vilnius, Lithuania.
Email toshcus@yahoo.com

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.

(after 39.7 weeks of pregnancy) as independent 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
for haemorrhoids and anal fissures during the third trimes-
ter 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 tri-
mester 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 preg-
nancy and puerperium and to identify the risk factors for
peri-anal diseases.

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 Haemorrhoids and anal fissures during pregnancy and after childbirth

On the first or second day after delivery the following

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.
data were recorded: obstetric data—method of birth, length
of labour, perineal trauma during labour (i.e. tear or episi-
otomy) and anthropometric information of the newborn. If
any peri-anal symptoms—pain, rectal bleeding, peri-anal
tissue enlargement or protrusion—or any peri-anal discom-
fort occurred during the study period, a colorectal surgeon
(TP or NES) investigated the woman immediately (inspec-
tion of peri-anal region and anoscopy) and made a diagno-
sis. Women were examined in a left lateral decubitus
position, looking for external or thrombosed haemorrhoids.
Women complaining of any kind of protrusion were exam-
ined 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 (<18
years of age) (n = 3)
♦ Declined to participate (n = 140)
♦ Did not complete the follow-up
(n = 20)
Included in the study
(n = 280)

♦Detailed questionnaire
♦Physical examination
♦Perianal symptoms?

♦ Brief questionnaire
♦Physical examination
♦Perianal symptoms?

♦Brief questionnaire
♦Physical examination
♦Birth and newborn factors
♦Perianal symptoms?

♦Brief questionnaire
♦Physical examination
♦Perianal symptoms?

Colorectal surgical
consultation, anoscopy,
diagnosis

Figure 1. Flow diagram of the study.

ª 2014 Royal College of Obstetricians and Gynaecologists 1667

 Poskus et al.

The women were divided into two groups: women in The median weight of the newborn was 3545 g (2100–
one group had developed peri-anal disease, the other group 5340 g), 143 were boys (51.1%). Median height of the new-
had not. Categorical data between the groups was com- born was 53 cm (42–60 cm); median head circumference
pared by a chi-square or Fisher’s exact test as appropriate. was 35 cm (31–52 cm), median chest circumference was
Continuous characteristics were compared by Student’s 34 cm (27–39 cm).
t-test or the Mann–Whitney U-test as appropriate. All dif- In all, 123 women (43.9%) developed peri-anal symp-
ferences for which the probability value was less than 0.05 toms during the study. The symptoms were usually multi-
were considered to be significant in univariate analysis. All ple and included peri-anal discomfort, itching, burning,
significant univariate risk factors were included in a multi- mucous discharge, painful protrusion at the anus, bleeding
ple logistic regression model to identify independent risk and peri-anal pain. The frequencies of peri-anal symptoms
factors. Calculations were performed using statistical soft- are presented in Table 1. The time of diagnosis of peri-anal
ware package SPSS, version 17 (IBM corporation, Armonk, disease is presented in Table 2. It is of note that 61% of
NY, USA). women developed peri-anal diseases during the third tri-
mester of pregnancy and 37.4% during or immediately
after delivery.
Results
Out of 123 women, 114 (92.7%) were diagnosed with
Out of 440 consecutive pregnant women invited to enter haemorrhoids and seven (5.7%) with haemorrhoids and
the study from January 2010 to January 2011, 20 women anal fissure. Out of the 121 women diagnosed with haem-
declined to participate in subsequent study visits and were orrhoids, 64 (52.9%) were diagnosed with thrombosed
excluded and 280 women who agreed to participate in haemorrhoids. Two women (1.6%) were diagnosed with
the study during their pregnancy up until 1 month after an anal fissure. As the number of women with anal
delivery were included. Women’s mean age was 28.7 years fissures was very small, they were added to the women with
(18–45 years). Mean body mass index was 23.1 kg/m2 haemorrhoids and created the group (123 women) with
(15.4–43.8 kg/m2). peri-anal diseases. A total of 157 women (56.1%) did not
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 Table 1. Frequency of peri-anal symptoms
normal delivery and 23 (15.2%) had previous caesarean
section. Symptom Frequency, n (% from 123
symptomatic women)
In all, 188 women (67.1%) were married, 27 (9.6%) were
single, 37 (13.2%) were divorced and 28 (10%) were in
Peri-anal pain 121 (98.4)
partnership.
Sharp pain 6 (4.9)
Fifty-six (20%) of the 280 women had a previous history
Dull pain 75 (61.9)
of peri-anal diseases before the current pregnancy. Dull pain with increase on defecation 71 (58.7)
Constipation was defined according to Rome III criteria: Pain only on defecation 12 (9.9)
defecation occurring less than three times per week, requir- Peri-anal discomfort 110 (89.4)
ing prolonged or excessive straining, lumpy or hard stools, Itching 99 (80.5)
sensation of incomplete evacuation, sensation of anorectal Painful protrusion at the anus 54 (43.9)
Burning 98 (79.7)
obstruction, manual manoeuvring required to defecate.
Mucous discharge 91 (74.0)
According to these criteria, women must have experienced
Bleeding 77 (62.6)
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
Table 2. Time of the occurrence of peri-anal diseases
was present in 128 (45.7%) women.
Of the 280 women, 206 (73.6%) had a vaginal delivery, Time n %
31 (11.1%) had an elective caesarean section, 37 (13.2%)
had an emergency caesarean section, two (0.7%) had a vac- First trimester 2 1.6
uum extraction and four (1.4%) had forceps extraction. Second trimester 0 0
The mean duration of straining in women having a vaginal Third trimester 75 61
delivery was 13.4 (3–50) minutes. Forty-four women First to second day after delivery 42 34.1
First month after pregnancy 4 3.3
(21.4%) suffered perineal tears and 97 (47.1%) underwent
episiotomy.

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 Haemorrhoids and anal fissures during pregnancy and after childbirth

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 per-
sonal history of peri-anal diseases, constipation during
pregnancy, multiparity, birthweight of newborn >3800 g,
straining during delivery for >20 minutes and perineal lac-
erations 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 com-
mon problem being haemorrhoids (92.7%). Sixty-one per-
cent of women developed peri-anal diseases during the
third trimester of pregnancy and 37.4% after delivery. Mul-
tivariate analysis found that constipation in pregnancy, pre-
vious 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, how-
ever, to avoid unnecessary awkward interventions in other-
wise 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 esti-
mation 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, anos-
copy 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 Healthy group, n (%) OR (95% CI) P value

group, n (%)

Age ≥30 years 52 (42.3) 51 (32.5) 1.52 (0.93–2.48) 0.92

BMI ≥25 kg/m2 56 (45.6) 21 (13.4) 4.19 (2.29–7.67) <0.001
Positive family history of peri-anal diseases 97 (78.7) 82 (52.2) 3.41 (2.00–5.82) <0.001
Birthweight of newborn 40 (32.5) 2 (1.3) 37.35 (8.81–158.42) <0.001
Constipation in pregnancy 107 (87) 21 (13.4) 40.38 (20.29–80.35) <0.001
Vaginal delivery 99 (80.5) 113 (72.0) 1.61 (0.91–2.83) 0.10
Caesarean section 24 (19.5) 44 (28)
Multiparas 82 (66.7) 74 (47.1) 2.25 (1.39–3.66) 0.001
Personal history of peri-anal diseases 54 (43.9) 2 (1.3) 60.65 (14.38–255.88) <0.001
Episiotomy 42 (42.4) 55 (48.7) 0.96 (0.59–1.58) 0.877
Perineal lacerations 27 (27.3) 17 (15) 2.32 (1.20–4.48) 0.013
Straining during delivery for >20 minutes 21 (17.1) 2 (1.3) 0.67 (0.02–0.29) <0.001

ª 2014 Royal College of Obstetricians and Gynaecologists 1669

 Poskus et al.

peri-anal diseases should avoid difficult labour if they want

Table 4. Results of multivariate logistic regression analysis of
potential risk factors to reduce their risk of haemorrhoids and fissures.

Variable OR (95% CI) P value

Age ≥30 years
BMI ≥25 kg/m2
Positive family history
of peri-anal diseases
Birthweight of newborn
>3800 g
Constipation during pregnancy
Multiparity
Personal history of
peri-anal diseases
Episiotomy
Perineal lacerations
Straining during delivery
(for >20 minutes)
1.285 (0.465–3.557)
1.435 (0.513–4.016)
1.377 (0.509–3.728)
17.989 (3.286–98.486)
18.975 (7.125–50.535) <0.001
1.272 (0.440–3.674)
11.928 (2.179–65.295)
0.869 (0.274–2.759)
1.511 (0.429–5.326)
29.746 (4.000–221.231)
Conclusions
0.63 Haemorrhoids and anal fissures are common during the
0.49 last trimester of pregnancy and at the time of delivery.
0.53
Constipation, personal history of peri-anal diseases, the
0.001
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
0.68 must be performed to evaluate measures to prevent consti-
0.04 pation and reduce the incidence of haemorrhoids and
fissures during pregnancy.
0.81
0.52
0.001
Disclosure of interests
None of the authors have any conflicts of interest to
disclose.

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-a-
nal 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 trimes-
ter and 3.3% 1 month after delivery. Our finding is impor-
tant 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 dis-
ease. 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 indepen-
dently associated with peri-anal diseases of pregnancy and
puerperium. Hence women with a personal history of
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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