Both pregnancy and delivery increase the risk of rectal symptoms in women. There are several factors responsible for this increased risk, such as elevated intra-abdominal pressure during labour and the associated venous blood stasis in the perianal region, microtrauma to the rectal mucosa during labour and, most of all, increased constipation during pregnancy. Constipation in pregnancy occurs due to hormones, frequent intake of iron preparations, limited physical exercise and weight gain. The two latter are particularly pronounced in the third trimester, when the uterus reaches its maximum size, compressing the intestines, which consequently leads to the lowering of pelvic floor muscles. The above mentioned factors may promote haemorrhoidal disease, perianal venous thrombosis and, consequently, hypertrophy of marginal anodermal folds (which are often identified as haemorrhoids by patients) and postpartum fissure. There are many reports confirming the increased incidence of rectal conditions in pregnant women. Abramowitz and Batallan (1) found that anal fissure or perianal venous thrombosis, which according to the authors are most likely to result from increased constipation during pregnancy, occur in up to 1/3 of pregnant women, and that perianal venous thrombosis is often seen in cases of difficult labour. Rectal conditions such as abscess and fistula occur at a rate similar to that in the general population.

The paper discusses the method of rectal examination in a pregnant patient as well as treatment approaches for the most common rectal conditions in pregnant and postpartum patients. Symptoms of gas and stool incontinence associated with complicated childbirth should be discussed separately.

In general, the method of collecting medical history and performing physical examination in a pregnant patient is the same as in other patients. Each patient should be ensured intimacy during medical history collection and physical examination, which is a typical feature of proctological examination. In addition to routine questions about symptoms, particular attention should be paid to obstetric history, including previous natural childbirths, birth weight, perineal trauma or instrumental delivery, and the obtained data should be related to the symptoms reported with particular emphasis on gas and stool incontinence. Increased itching and burning sensation around the anus are not necessarily symptoms of haemorrhoidal disease, but may result from reduced sphincter tone. There are cases, when a decision to terminate pregnancy by Caesarean section needs to be made to avoid putting the patient at a risk of increased incontinence after another delivery. An important element of the interview is its active form. Young patients are not always ready to openly talk about intimate symptoms such as stool incontinence in a clinical setting. Also, patients may fail to report venereal diseases or HIV infection if not asked. However, this information may help diagnose the aetiology of rectal symptoms.

Both physical examination and surgical procedures should be performed in a pregnant patient lying on her left side. Proctological examination involves visual inspection of the perianal region, palpation and anoscopy. Each of these elements should be appropriately documented, with particular emphasis on passive and active tone of the anal sphincter prior to childbirth. Thorough obstetric and proctological history along with the evaluation of muscle tone helps make decisions on the method for pregnancy termination. A detailed description of the prenatal examination may be also an important element of doctor’s legal protection against the consequences associated with potential postpartum complications. Anoscopy and rectoscopy are invasive procedures and should be performed during pregnancy only in justified cases, when there is a need for diagnosis (e.g. a bowel tumour) or treatment (e.g. massive haemorrhoid bleeding) (2).

It is estimated that haemorrhoidal disease occurs in 1 in 5 pregnant women (1). Constipation, which affects 11 to 38% of pregnant women, is one of the primary risk factors for haemorrhoidal symptoms (3-5). It was found that large-sized uterine compression on the intestines is not as important as previously thought as there are no significant differences in the incidence of constipations between the first and the third trimester. Most patients with haemorrhoidal disease receive conservative treatment after delivery. Pregnancy is a relative contraindication to surgical treatment of haemorrhoids. Patients with massive haemorrhoid bleeding, secondary anaemia or acute haemorrhoidal thrombosis are an exception. Therapeutic recommendations include anti-constipation diet (high-fibre diet with high intake of water) and pharmacotherapy that is not toxic for the child. Since most women breastfeed after childbirth, pharmacotherapy is used carefully, considering the fact that each agent, including those in the form of suppositories, may enter bloodstream and, consequently, breast milk. Diosmin derivatives or Butcher’s broom (Ruscus aculeatus), which are present in breast milk in trace amounts, may be used in the acute phase of haemorrhoidal disease. It should be emphasised that papers on pharmacotherapy in pregnant women are sparse. A large retrospective study in 2,092 pregnant patients assessing the safety of Butcher’s Broom preparations was conducted in France; however the study is considered “old” as it was conducted in 1985 (6). Currently, no such studies are conducted in pregnant patients for ethical reasons. In cases of mild haemorrhoidal disease, the treatment is limited to diet and lubrication of the anal canal with hyaluronic acid or herbal preparations. Invasive procedures also play a role in the treatment of haemorrhoidal disease in postpartum women. Barron’s rubber band ligation may be used in the case of mild, yet persistent haemorrhoid bleeding, while surgical approach should be used in rare cases of massive bleeding causing secondary anaemia. In her clinical practice, the author of this paper performed several surgical procedures in postpartum patients due to haemorrhoidal bleeding via classical Milligan Morgan haemorrhoidectomy with good clinical effect (the risk of hypoxia in the child outweighed the risk of surgery). Therefore, patients with advanced haemorrhoidal disease (grade IV, massive bleeding, extensive inflammation) should be referred to a proctological surgeon. Patients with mild haemorrhoidal disease may be successfully conservatively treated by their gynaecologist.