Rectal bleeding during pregnancy

Rectal bleeding during pregnancy

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  RECTAL BLEEDING ,DURING PREGNANCY Prof. M.C.Bansal MBBS. MS. FICOG. MICOG. Funder Principal 7 CONTROLLER., Jhalawar Medical college & Hospital Jhalawar. Ex Principal & controller., MGMC &H Sitapura, Jaipur.
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  Rectal Bleeding InPregnancy  Rectal bleeding usually occurs from disease involving anus , rectum and colon .  Bleeding from upper GIT can present a dark red blood loss per rectum because of a rapid transient time, but usually as Meleana .  Rectal bleeding may be chronic or acute and sudden in on set.  Patients with little and chronic blood loss present with chronic Iron deficiency anaemia and occult blood in stool.
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  Causes of rectalBleeding in Pregnancy  Anorectal Conditions Haemorrhoids. Anal Fissure. Solitary Rectal Ulcer Rectal Mucosal Prolapse Large Bowel Conditions Inflammatory bowel disease. Adenomatous Polyp. Carcinoma. Arteriovenous Malformations. Mecle’s Diverticulum.
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  Clinical Evaluation  Detailedhistory from patient can reveal the underlying cause of rectal bleeding .  Bright red blood separate from stool suggests an anorectal cause.  Diarrhoea with mucus mixed dark blood suggests colitis or carcinoma., where as faecal urgency ,acute bleeding and colic indicates colitis . History of altered bowel habits , alternate constipation and diarrhoea with abdominal discomfort may suggest malignancy.
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  Clinical Examination  Perre3ctal digital examination , proctoscopy , sigmoidoscopy can help in diagnosing anorectal cause.  Colonoscopy although difficult in active bleeding patient ,but it can help at least to identify the segment involved.  A women with active rectal bleeding and hemodynamic compromise , surgical and treatment in emergency is required.  Incases of melaena upper GIT is to be evaluated with the help of upper GI endoscopy.
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  Anorectal Disease 1.Haemorrhoids Very commonin pregnancy due to increased circulating blood volume , increased venous congestion owing to compression of superior rectal veins by enlarged gravid uterus as well as relaxing effect of progesterones on smooth muscles of vessels. Haemorrhoids may present as bleeding, prolapse, mucoid discharge, pruritus , constipation and rectal discomfort. Diagnosis is very simple on proctoscopy .
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  Haemorrhoids----  Treatment duringpregnancy is mainly to relieve rectal pain , pruritus and bleeding along with correction of anaemia.  Conservative management includes dietary advice, laxative , increased fluid intake, haematenics , local analgesic ointment’s use before and after defecation.  Definitive treatment can be done after delivery as majority of pregnant patient get relief and hemorrhoids resolve spontaneously after delivery .  When no relief rubber band ligation and even haemorrhoidectomy can be considered as a safe procedure in pregnancy.
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  Anorectal Disease----  2.Anal Fissure Anal fissure is painful condition. It is usually caused by passing hard stools damaging tear in anal mucosa. This leads to painful defecation with fresh blood in a line on hard stool. Anal fissure are common in pregnancy due to increased incidence of constipation . Progesterone's smooth muscle relaxation effect and iron therapy have constipating effect. Local analgesic gels ,laxatives , dilatation and stretching of anal sphincter will give relief .
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  Large Bowel Conditions 1.Inflammatory Bowel Disease- Most of pregnant women with pre existing inflammatory bowel disease have uneventful pregnancies and exacerbation can safely and easily controlled by drugs which they have been taking. It is rare that inflammatory bowel disease to present for the first time in pregnancy. Relapses of Crohn’s disease occur in 1st trimester . Medical treatment is sufficient. Surgery can safely be undertaken when presence of abscess causing peritonism develops. Many patient with H/O ulcerative colitis managed by ileal pouch anal anastomosis will become pregnant . Long term prognosis in these cases is good so far pregnancy and safe vaginal delivery is concerned .
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  Large Bowel Disease 2. Colorectal Carcinoma- It is rare in pregnancy . Cancer diagnosed in pregnancy are of rectal origin . presenting symptoms of rectal cancer such as rectal bleeding, nausea , vomiting and constipation are often attributed to common benign conditions reported in pregnancy. once suspected ., PR , flexible Sigmoidoscopy and colonoscopy directed biopsy will confirm it. Treatment of colorectal cancer (in pregnancy < 30 -32 weeks ) follows the same general guidelines as for non pregnant woman . If it is detected in late trimester than treatment may be delayed to achieve foetal maturity and planned LSCS.s