Pregnancy and childbirth is a special physiological process, during which a series of physiological changes will occur, such as increased abdominal pressure, postpartum perineum and abdominal wall relaxation, human hormonal changes, etc., can increase the incidence of anal disease or aggravate the condition of existing anal diseases. The most important thing is that you will be able to get the most out of your own personal computer. Moreover, hemorrhoids can coexist with other anal diseases, and in the lower part of the rectum, which is about 4-5 cm long and 9 cm square, there are about 13 categories and more than 50 anal diseases concentrated, and most of their symptoms are bleeding, swelling or pain, or accompanied by constipation, incontinence, dampness, itching, etc. It is very easy to misdiagnose. However, for pregnant patients, the two most common are hemorrhoids and anal fissures, especially hemorrhoids. I. Pathogenesis of hemorrhoids 1. New concept of mechanical etiology of hemorrhoids: According to the concept of mechanical etiology of hemorrhoids, hemorrhoids are the result of degeneration of the supporting tissue of the anal cushion (Treitz muscle), which leads to the downward migration of the anal cushion. This is the well-known theory of the inferior displacement of the anal cushion, which consists of the venous sinus, connective tissue and Treitz muscle. The Treitz muscle is the anchor of the anal cushion and serves to retract the cushion upward after defecation. Under normal circumstances, the anal cushion is loosely attached to the muscle wall, but when the Treitz muscle is hypertrophied or broken, the anal cushion can become retracted and move down or prolapse, which produces the symptoms of hemorrhoid disease. However, the more forceful it is, the more serious the congestion and prolapse, and the more difficult it is to defecate. Initially, the hypertrophic anal cushion can be asymptomatic, and as the destruction of the supporting tissue intensifies, the hemorrhoid can develop from intermittent prolapse to persistent prolapse, and as the mucous membrane on the surface of the hemorrhoid is susceptible to repeated friction from feces and stool and breaks down, ulceration, bleeding or pain occurs, which becomes a symptomatic hemorrhoid. This is the mechanical etiology of hemorrhoids explaining the mechanism of hemorrhoid occurrence. 2. New concept of circulatory etiology of hemorrhoids: The anatomical basis of the circulatory etiology of hemorrhoids is the unique vascular pattern within the anal cushion. That is the arteriovenous anastomosis. Under normal conditions, the arteriovenous anastomosis is like a blood bank, and the volume of blood supply to the anal cushion changes by regulating the opening and closing of the anastomotic vessels, thus affecting the size of the anal cushion. In general, the concentration of systemic vasoconstrictor substances varies very little, and the contraction and diastole of microcirculatory vascular smooth muscle is mainly regulated by the feedback of substances produced by local tissues. Likewise, the microcirculation within the anal cushion is similar. Stimulation of the anal cushion by certain factors, such as increased intra-abdominal pressure, mechanical obstruction of the rectal jugular, pregnancy or certain biochemical changes in body fluids, alcohol consumption or spicy food, may lead to regulatory disorders, stimulating sympathetic excitation, causing spasm of the anastomotic duct, tissue ischemia and hypoxia, followed by stimulation of the anal cushion tissue by hypoxia, release of histamine and production of local histamine utility, spasm of the precapillary sphincter, and sudden arteriovenous anastomotic duct The pre-capillary sphincter spasms and the arteriovenous anastomoses suddenly open, resulting in a sudden increase in blood flow to the hemorrhoidal plexus and expansion and congestion. As the capillaries are closed, arterial blood flows directly into the veins via the arteriovenous anastomoses, resulting in hypoxia of the anal cushion tissue, which in turn stimulates local histamine secretion and aggravates anastomotic dilation, leading to venous blood flow stagnation, tissue edema, and thrombosis. Hypoxia of the anal cushion tissue causes local necrosis, erosion and bleeding, degeneration of the Treitz muscle, prolapse of the hemorrhoid, and increased tension of the internal dilator muscle, causing an increase in the pressure in the anal canal, so that symptomatic hemorrhoid disease occurs. Therefore, the circulatory etiology of hemorrhoids suggests that impaired regulation of the arteriovenous anastomosis occurs as a cause of hemorrhoid development. 3, hemorrhoids and pelvic floor dynamics relationship: about the impact of pelvic floor dynamics disorders on hemorrhoid disease, some experts proposed two concepts of myogenic high anal pressure and hemorrhoidogenic high anal pressure. Various causes of pelvic floor muscle overload lead to pelvic floor descent, corresponding elongation of muscle fibers and their connected nerves, smaller diameter of nerve fibers, slower excitation conduction, possible degeneration and rupture of the denervated Treitz muscle, and downward migration of the anal cushion into hemorrhoids. The formation of hemorrhoids in turn stimulates the anal wall, and through the hemorrhoid-sphincter reflex, causes the sphincter to contract and increase anal pressure, increasing the patient’s resistance to defecation, and when the stool passes through the high-pressure anal canal, it not only affects the blood flow back to the anal cushion, causing severe congestion, but also stretches or tears the supporting tissue of the anal cushion, which loses support and moves downward, thus causing the anal cushion to develop from intermittent prolapse to persistent prolapse into hemorrhoids. The development of continuous prolapse into hemorrhoids. This vicious cycle makes the condition deteriorate. This is how experts and scholars discuss the relationship between pelvic floor dynamics and hemorrhoid disease. The pathological reasons for the prevalence of hemorrhoids during pregnancy and childbirth are “blood nourishes the twins and heat knots the large intestine”, according to Chinese medicine. Modern medicine has a more satisfactory explanation of the mechanism of hemorrhoids during pregnancy and childbirth, according to the pathogenesis of hemorrhoids mentioned above. First of all, the pressure of the enlarged uterus during pregnancy can impede the reflux of the hemorrhoidal venous plexus, then the hemodynamic regulation of the anal cushion becomes impaired, which is an important factor leading to the occurrence of hemorrhoids. In addition, uterine compression and increased abdominal pressure can also cause the pelvic floor to drop and nerve strain leading to abnormal sphincter function, which is also an important factor in the development of hemorrhoids. Hormonal effects such as progesterone and relaxing peptides relax the pelvic floor and the supporting tissues of the anal canal, which can aggravate the downward migration of the anal cushion. In addition, the peripheral blood circulation in women starts to increase from the 6th week of pregnancy, reaching a peak at 32-34 weeks, with the increase averaging around 1400 ml. It has been reported in the literature that the arterial blood flow in the pelvis increases by 25% during pregnancy. This is accompanied by an increase in the volume of blood in the pelvic veins and a consequent increase in venous pressure. Due to the increase in pelvic blood volume, hemorrhoidal venous reflux is obstructed, which also leads to impaired hemodynamic regulation of the anal cushion and abnormal arteriovenous anastomosis, resulting in the formation of hemorrhoids. This is the first time that a person has a hemorrhoid, and the symptoms are aggravated. The hemorrhoids can be a very important part of the pregnancy, so as the pregnancy months increase, many people will suffer from hemorrhoids, the original mild may also aggravate. The danger of maternal hemorrhoid disease Pregnant women who have hemorrhoids, because of the fear of affecting the fetus, most do not want to use drugs or surgery, suffering from pain, which can seriously affect the quality of life. The fact that the blood in the stool will increase the psychological burden of pregnant women, repeated bleeding will cause anemia, and some pregnant women are afraid to eat because they are worried about the pain in the anus aggravated by defecation. This also greatly affects the development of the fetus. The hemorrhoids can come out when the abdominal pressure increases slightly during walking or coughing, which affects the normal activities of the pregnant woman and increases the symptoms such as bleeding, pain, and difficulty in defecating. And there will be more than 35% of deliveries complicated by hemorrhoids. 1, clinical symptoms Hemorrhoids often have symptoms such as blood in the stool, prolapse, pain, etc. Hemorrhoids during pregnancy and childbirth also have the same. However, hemorrhoids in women in the puerperium are still different from the general situation. With the arrival and end of labor, hemorrhoid symptoms will reach their peak. At this time, the condition is mostly characterized by prolapsed edema with prolapse of the mucous membrane. 2.Treatment staging Embryonic development is divided into three stages. These are the embryonic egg stage (fertilization – end of week 1), the embryonic stage (weeks 2-8) and the fetal stage (week 9 – birth). The time scale on the table is only an approximate customary statement. In general, patients with hemorrhoids in the third month of pregnancy should be treated as conservatively as possible, because progesterone in the blood is low during this period, and various stimuli in the perineum can reflexively cause uterine and vaginal contractions, resulting in miscarriage. In addition, in the first two stages of embryo, various drugs can easily affect the fetus and cause malformations, so this period is absolutely dangerous. Therefore, treatment of all types of hemorrhoids should be postponed until after 3 months as much as possible. During the 4th-7th months of pregnancy, the placenta can produce enough progesterone, and the pregnancy enters a relatively safe period, so the general injury to the perineum is less stimulating to the uterus and vagina. The procedure should be contraindicated for complicated and more invasive procedures, as well as for those with a history of habitual abortion and premature delivery to prevent miscarriage. During the 8th-10th months of pregnancy, inflammatory external hemorrhoids, internal hemorrhoids prolapse and bleeding can easily occur due to the increase in fetal size and hormonal changes in the body. It can be treated with safe medication, without sclerotherapy as much as possible, and it is best to delay surgery until the time of delivery or after the baby is weaned if possible. During the puerperium, which is 4 weeks after delivery, with the arrival and end of labor, the edematous hemorrhoids can often become smaller and shrink on their own due to the lowering of intra-abdominal pressure and the lifting of venous reflux obstruction after delivery, and surgical treatment is no longer needed. However, for patients with thrombosis, and painful anal fissures, active treatment should be taken without affecting lactation. 3.Treatment First of all, attention should be paid to basic treatment. Maintain a healthy psychological state, go to the hospital for regular review during pregnancy, have an anal examination before pregnancy, drink more water, change the diet structure to include more dietary fiber, develop good bowel habits, keep bowel movements smooth, prevent and control diarrhea, perform some light activities appropriately, and avoid prolonged standing and sitting. Warm water sitz bath, keep the perineum clean, etc. All of these measures are necessary for the treatment of all types of hemorrhoids. Some studies have shown that implementing health education, lifestyle changes and frequent anal lifting exercises for hemorrhoid patients can help reduce the pain of hemorrhoid recurrence and improve the quality of life. 4.Selecting the time of surgery The hemorrhoids that must be treated surgically during pregnancy are usually severe or acute hemorrhoids for which conservative treatment has failed, such as acute strangulated hemorrhoids, embedded hemorrhoids, acute prolapsed hemorrhoids, acute extensive thrombosed internal hemorrhoids and thrombosed external hemorrhoids. In principle, the time of surgery is 20-32 weeks of gestation; after 36 weeks, surgery is not recommended because the anus and perineum are fragile, congested and edematous, and it is difficult to heal the wound after surgery. Some people think that within one month after delivery, the postoperative wound is not easy to heal, so surgery is also not recommended. However, some experts advocate that surgery can be performed immediately after delivery. Personally, I think that surgery after childbirth should also be cautious, for hemorrhoids with severe edema of external hemorrhoids, it is better to first conservative treatment. 5. Precautions Surgery during pregnancy should be done with great caution: consent must be obtained from the patient, family, and obstetrics and gynecology before surgery, local anesthesia or sacral anesthesia should be used, and a less invasive and less painful procedure should be performed under strict fetal heartbeat detection depending on the condition. The main objective is to eliminate the symptoms. In case of abdominal pain, vaginal bleeding or intensified uterine contractions during and after the operation, obstetrics and gynecology should be consulted and dealt with immediately. In women with preanal external hemorrhoids or right preanal internal hemorrhoids combined with anal fissures, the local wound healing is slow in all postoperative cases due to different degrees of damage to the perineal muscle in the anterior part of the anus, and even after healing, anal discomfort can still occur for a period of time. Especially when the internal sphincter is chosen for the treatment of anal fissure, if the incision is borrowed here, it is easy to cause abnormal anal function. In pregnancy hemorrhoids with other anal diseases or with urinary tract infections and inflammation of genital organs, surgical treatment should not be taken easily to avoid aggravating the symptoms of the original disease and prolonging anal wound healing after surgery.