Keywords
puerperium - constipation - haemorrhoids - anal fissures
Introduction
Puerperium is an extremely important period for a woman. Extensive physiological,
biochemical, and dietary changes occur during pregnancy and puerperium. The body secretes
a large amount of progesterone which causes decreased muscle tone and lower motility
of the gastrointestinal tract. About one-third of women after childbirth complain
of perianal symptoms. Patients in puerperium show a significant increase in the incidence
of perianal symptoms compared with the normal population. Perianal problems, including
constipation, hemorrhoids, and fissure, are among the most common digestive complications
among women in puerperium. Due to the recurring physical and psychological problems
they cause for the patient, these disorders can cause a significant reduction in the
quality of life of those afflicted with them.
Considering the results of the previous studies, the great prevalence of perianal
problems during puerperium, and the paucity of similar research of this kind conducted
in India, we set out with an aim to assess the various perianal problems seen in women
during their puerperal period, their prevalence, and the risk factors which cause
it.
Methodology
This is a prospective observational cohort study conducted over a span of 2.5 years
in which 902 puerperal women who have delivered in our institute and were admitted
in our PNC ward were enrolled. Informed consent form and patient information sheet
regarding the study were provided to every patient. Institutional Ethical committee
approval was obtained before the start of the study. Patients who developed perianal
complaints anytime during their puerperium were considered as a positive case. A detailed
history using a self-structured questionnaire and a thorough clinical examination,
per-rectal examination and proctoscopic examination was done in all the patients enrolled.
Patients were followed up telephonically about regression of the problems post management.
All the data was filled in a Microsoft Excel (Microsoft Corporation, Redmond, WA,
USA) spreadsheet; the Student t test was used to find the significance of study parameters
on continuous scale between two groups on metric parameters. The chi-squared/fisher
exact test were used to find the significance of study parameters on a categorical
scale between two or more groups. Data was analyzed using IBM SPSS Statistics for
Windows software trial version 22 (IBM Corp., Armonk, NY, USA).
Results
The present study included a total of 902 study subjects who were in the puerperal
period. The highest number of patients presented with constipation (24.2%) as their
main symptom followed by bleeding from the rectum (11.6%) as seen in [Table 1].
Table 1
DISTRIBUTION OF PERIANAL SYMPTOMS
|
Sr. No
|
Symptoms
|
Frequency (n)
|
Percentage (%)
|
|
1
|
Constipation
|
218
|
24.2
|
|
2
|
Bleeding from rectum
|
105
|
11.6
|
|
3
|
Pain in perianal region
|
30
|
3.3
|
|
4
|
Perianal itching
|
12
|
1.3
|
|
5
|
Perianal discomfort
|
51
|
5.7
|
|
6
|
Painful protrusion at the anus
|
21
|
2.3
|
|
7
|
Perianal burning
|
23
|
2.5
|
|
8
|
Mucus discharge
|
14
|
1.6
|
|
9
|
None
|
428
|
47.5
|
The total prevalence of all the perianal problems in puerperium was 327 (36.3%). According
to [Table 2], The perianal problems encountered were fissure (20.5%) followed by hemorrhoids
(12.2%). Other perianal problems encountered were perianal episiotomy infections and
perineal tears.
Table 2
PREVALENCE OF PERIANAL PROBLEMS IN PUERPERIUM IN THE STUDY POPULATION
|
Sr. No
|
Perianal problem
|
Frequency (n)
|
Percentage (%)
|
|
1
|
Hemorrhoids
|
110
|
12.2
|
|
2
|
Fissure
|
185
|
20.5
|
|
3
|
Perianal episiotomy infections
|
25
|
2.8
|
|
4
|
Perineal tear
|
7
|
0.8
|
|
5
|
None
|
575
|
63.7
|
|
Total
|
Prevalence of perianal problems in puerperium
|
327
|
36.3%
|
On comparative analysis of suspected risk factors of perianal diseases in puerperium,
it was seen that positive family history, macrosomia, past history of perianal diseases,
second stage of labor > 50 minutes showed a higher prevalence in the perianal disease
group as compared to the healthy group, in which positive family history of perianal
diseases (p = 0.015) and past history of perianal diseases (p = 0.016) were the risk factors that were statistically significant, as seen in [Table 3].
Table 3
RISK FACTORS FOR PERIANAL DISEASES OF PUERPERIUM
|
Sr. No
|
Risk Factor
|
Perianal diseases group, n (%)
|
Healthy group, n (%)
|
Odds ratio (95%CI)
|
p-value
|
|
1
|
Age > 30 years old
|
25 (46.3%)
|
29 (53.7%)
|
0.768
|
0.347
|
|
2
|
Positive family history
|
60 (64.5%)
|
33 (35.5%)
|
1.735
|
0.015
|
|
3
|
Macrosomia
|
72 (52.6%)
|
65 (47.4%)
|
1.000
|
1
|
|
4
|
Vaginal delivery
|
357 (51.3%)
|
339 (48.7%)
|
1.282
|
0.128
|
|
5
|
Cesarean section
|
74 (61.2%)
|
47 (38.8%)
|
1.282
|
0.128
|
|
6
|
Past history of perianal diseases
|
147 (59.0%)
|
102 (41.0%)
|
1.437
|
0.016
|
|
7
|
Second stage of labor > 50mins
|
176 (56.1%)
|
138 (43.9%)
|
1.241
|
0.124
|
Abbreviation: CI, confidence interval.
Constipation
The highest prevalence of constipation among current delivery type was seen in those
with forceps delivery followed by those with vacuum delivery, but this was not statistically
significant. There was no statistically significant correlation between occurrence
of constipation and age, parity, past history of perianal disease, family history
of perianal disease, prolongation of second stage of labor, neonatal macrosomia, and
consumption of iron tablets.
Hemorrhoids
As seen in [Table 4], A statistically significant relationship was observed between prevalence of hemorrhoid
and parity (p = 0.01) and past history of any anorectal disorders (p = 0.00). Patients with constipation in pregnancy have a higher chance of presenting
with hemorrhoids in pregnancy. This was statistically significant (p = 0.01).
Table 4
RELATIONSHIP BETWEEN SIGNIFICANT RISK FACTORS AND HEMORRHOIDS IN PUERPERIUM
|
Sr. No
|
Parity
|
Hemorrhoids
|
p-value
|
|
|
Positive
|
Negative
|
0.01
|
|
1
|
Primipara
|
37
(9.11%)
|
369
(90.89%)
|
|
2
|
Multipara
|
73
(14.72%)
|
423
(85.28%)
|
|
Sr. No
|
Past history
|
Hemorrhoids
|
p-value
|
|
|
Positive
|
Negative
|
0.00
|
|
1
|
Present
|
52
(20.88%)
|
197
(79.12%)
|
|
2
|
Absent
|
58
(8.88%)
|
595
(91.12%)
|
|
Sr. No
|
History of constipation in pregnancy
|
Hemorrhoids
|
p-value
|
|
|
Positive
|
Negative
|
0.01
|
|
1
|
Present
|
16
(7.33%)
|
202
(92.66%)
|
|
2
|
Absent
|
94
(13.74%)
|
590
(86.25%)
|
|
Total
|
|
110
|
792
|
The highest level of hemorrhoid in puerperium was reported among people with previous
vacuum delivery (37.5%) and with current vacuum delivery (22.22%). There was no significant
statistical relationship between prevalence of hemorrhoid and type of previous and
current mode of delivery and family history of any anorectal disorders, prolonged
length of second stage of labor, or macrosomic babies on presence of hemorrhoids in
puerperium according to the present study.
Fissure
There was a statistically significant relationship between presence of fissure and
past history of any perianal disease (p = 0.00), length of second phase of labor (p = 0.00),
and macrosomic babies (p = 0.02), as studied in [Table 5]. The highest level of fissure in puerperium was reported among people with previous
forceps delivery and among people with current vaginal delivery. No significant statistical
relationship was observed between parity, type of previous childbirth, type of current
childbirth, and family history of perianal disease on the presence of fissures in
puerperium.
Table 5
RELATIONSHIP BETWEEN SIGNIFICANT RISK FACTORS WITH PRESENCE OF FISSURE
|
Sr. No
|
Past history of perianal disease
|
Fissure
|
p-value
|
|
|
Positive
|
Negative
|
0.00
|
|
1
|
Present
|
79
(31.73%)
|
170
(68.27%)
|
|
2
|
Absent
|
106
(16.23%)
|
547
(83.77%)
|
|
Sr. No
|
Length of 2nd stage of labour
|
Fissure
|
p-value
|
|
|
Positive
|
Negative
|
0.00
|
|
1
|
< 50 mins
|
95
(16.16%)
|
493
(83.84%)
|
|
2
|
> 50 mins
|
90
(28.66%)
|
224
(71.34%)
|
|
Sr. No
|
Neonatal weight
|
Fissure
|
p-value
|
|
|
Positive
|
Negative
|
0.02
|
|
1
|
Macrosomia
|
38
27.74%
|
99
72.26%
|
|
2
|
Nonmacrosomia
|
147
19.22%
|
618
80.78%
|
|
Total
|
|
185
|
717
|
Discussion
Constipation
Prevalence of Constipation in Puerperium
In the present study, 218 patients (24.2%) presented with constipation as their main
symptom. This was very similar to the study done by Bradley et al. in which the incidence
of constipation was 24% in 3 months postpartum.[1] Another study conducted by Derbyshire et al. showed that the prevalence of both
straining and incomplete evacuation were high in all trimesters.[2] This could be attributed to a higher fiber intake in the Indian population compared
with the western world. There were studies that showed high prevalence of constipation
in pregnancy and puerperium, ranging from 45% to 55% like those by Goshal et al.[3] and Beksac et al.[4] This can be attributed to the lower fiber consumption in western countries. On the
other hand, lower prevalence, ranging between 4.5% and 13%, were shown in a few studies,
such as those by Shi et al.[5] and Van Brummen et al..[6]
Hemorrhoids
Prevalence of Hemorrhoids in Puerperium
In the present study, the prevalence of hemorrhoids in puerperal subjects was 12.2%.
Most of the studies done all over the world by Simmons et al.,[7] Beksac et al.,[4] Ghasemzade et al.,[8] and Abramowitz et al.,[9] have documented the prevalence of hemorrhoids in puerperium as ranging between 12.2
to 40%. A higher prevalence of hemorrhoids in puerperium is seen when compared with
other gestational periods and when compared with the general population. This was
reinforced by Koning et al.,[10] Johanson et al.,[11] Kukla et al.,[12] and Pradel et al.[13] Most of these studies were an overestimate, because many studies had an anal examination
done during pregnancy, but half of the patients reported proctologic disease in the
past, and many were lost to follow-up. Around 90% of thrombosed external hemorrhoids
during puerperium were observed during the 1st day after delivery as studied by Abramowitz et al[14] and Rouillon et al.[15] Few studies have reported a lower prevalence of hemorrhoids in puerperium ranging
between 5.3 and 9.3%, as seen by MacArthur et al.[16] and Ledward.[17] In these two studies, the low prevalence could be attributed to the way information
was obtained, by use of a postal questionnaire within 6 weeks postpartum. Contrary
to all other studies, Poskus et al.[18] identified the highest prevalence of hemorrhoids in puerperium to be around 92.7%
of all the other perianal diseases seen in puerperium. This was because postal questionnaires
or telephone interviews were used and various symptoms like perianal pain and bleeding
were attributed to hemorrhoids without a clinical examination.
Significant Risk Factors of Hemorrhoids in Puerperium
Relationship Between Parity and Hemorrhoids in Puerperium
With increasing parity, there is an increase in the prevalence of hemorrhoids. This
was also studied by Ghasemzade et al.[8] and Gojnic et al.[19] Patients with parity above two have a greater chance of hemorrhoids in puerperium.
This was attributed to the repeated change in the environment and emotional stress
on repeated pregnancies causing constipation and further hemorrhoids in subsequent
pregnancies. A study done by Beksac et al.[4] talks about the presence of pregnancy-related vascular growth factors, which increased
in every pregnancy, which could be one of the causes of hemorrhoids in puerperium.
Surprisingly, in a few studies, Parity has no effect in the prevalence of hemorrhoids in puerperal women as seen by MacArthur et al.[16] and Unadkat et al.,[20] the reasoning for which was not given, although it is seen in these studies that
as parity increases, the risk of new symptoms decreases.
Relationship Between Past History of Perianal Diseases and Hemorrhoids in Puerperium
A history of past perianal problems was considered to have a higher prevalence of
hemorrhoids in pregnancy and puerperium, which was also seen in studies done by Ghasemzade
et al.,[8] Medich et al.,[21] and Unadkat et al.[20] This could be attributed to the increase in hemorrhoidal symptoms as pregnancy progresses
since circulating blood volume reportedly increases by 25 to 40%. This leads to increased
vascular engorgement and dilatation, with venous stasis increased by the enlarging
gravid uterus or increased pelvic floor laxity.
Relationship Between Constipation and Hemorrhoids in Puerperium
The prevalence of hemorrhoids in patients with a history of constipation was higher
as compared with those who did not have constipation. This was reinforced by a study
done by Shi et al.[5] The study done by Poskus et al.,[18] Abramowitz et al.,[14] Calhoun.,[22] and Beksac et al.[4], identified terminal constipation (dyschezia) as the single independent preventable
risk factor for hemorrhoids in pregnancy and puerperium, with highly significant odds
ratio in logistic regression analysis. The reason for these as deciphered on reviewing
literature were many, including straining during defecation, impairment of defecation
habits during pregnancy, decrease in physical activity, compression of the lower bowel
by the uterus and psychosocial stress may also lead to constipation and hence hemorrhoids.
Increase in intra-abdominal pressure leading to vascular engorgement can also be attributed
to the presence of constipation in pregnancy.
Fissure
Prevalence of Fissure in Puerperium
The prevalence of fissures is 20.5% (185 patients) according to the present study.
The prevalence of anal fissure in puerperium, according to the literature, ranged
from 9 to 15.2%. Very few people have studied fissure in ano in puerperium including
Abramowitz et al,[14] Martin,[23] and Corby et al.[24] The rest of the studies have studied various anorectal disorders as a whole or have
focused on symptomatic constipation. The higher frequency observed by Abramowitz et
al[14] could be attributed to a longer period of follow-up. The high prevalence rate seen
in our study compared with other studies could be due to the higher level of constipation
which posed as an independent risk factor itself, and the ignorance regarding the
treatment advised to the uneducated population in the rural city.
Significant Risk Factors of Fissure in Puerperium
Relationship Between Past History of Perianal Disease with Presence of Fissure in
Puerperium
Patients with past history of any perianal problems had a higher chance of fissure
during puerperium. This was consistent with the study done by Ghasemzade et al.[8] This is probably due to the vicious cycle of pain, Sphincter contraction, and fissure
intensification in patients with past history of fissures with added hormonal and
mechanical factors of pregnancy.
Relationship Between Length of Second Stage of Labor with Presence of Fissure in Puerperium
Patients having a prolonged length of second stage of labor (> 50 minutes) have a
higher chance of fissure in puerperium as seen in the present study. Few studies,
including those by Ghasemzade et al.[8] and Abramowitz et al.[14] identified prolonged length of second stage of labor to be a significant independent
prognostic factor for fissure in pregnancy. The reason for this link is unclear. Some
studies mention that prolonged straining can cause increased venous stasis. These
delayed changes in the perineum and the increased duration of hormonal change may
predispose females to fissure.
Relationship Between the Weight of the Baby with the Presence of Fissure in Puerperium
Heavier babies (> 3,700 grams) were associated with anal fissure in puerperium as
studied by Ghasemzade et al.[8] and Abramowitz et al.[14], similar to the results seen in the present study. This can be attributed to decreased
blood flow in the anal mucosa due to heavier baby in pregnancy, causing higher chances
of fissure in puerperium. Along with this, heavier babies can cause increased perineal
tears causing higher chances of fissure.
Conclusion
Perianal problems in pregnancy and puerperium cause physical and psychological problems
in mothers resulting in a significant reduction in the quality of the life of those
afflicted. The elimination of these risk factors may lead to a higher quality of life
during pregnancy and puerperium. Positive family history and past history of perianal
diseases were the independently associated risk factors of perianal disease of puerperium.
Individually, multiparous patients and patients with a past history of perianal diseases
have higher prevalence of hemorrhoids in puerperium; whereas patients with a past
history of any perianal disease, prolonged length of second phase of labor, macrosomic
babies, and iron tablets consumption during pregnancy pose a risk factor for fissures
in puerperium.
