Review for 10.1186/s12876-024-03228-5 (2024)

Title: HAEMORRHOIDAL DISEASE IN PREGNANCY: RESULTS FROM A SELF-
ASSESSMENT QUESTIONNAIRE ADMINISTERED BY MEANS OF A SOCIAL
NETWORK
Version: 1 Date: 15 Oct 2023
Reviewer's report:
Thank you for this work and for the original idea of offering a questionnaire on social networks.
However, I have a few comments to make regarding this work.
Symptoms commonly associated with HD are bright red blood at defecation, anal pain, pruritus
ani, mucus discharge, constipation and prolapse.
I don’t think that constipation is one of the symptoms of HD.
Hemorrhoids can be classified into internal and external. These last are usually
lessuncomfortable.
I don’t think so. External thrombosis is usually painful and it is a usual cause of consultation
during pregnancy and after childbirth.
Please clearly specify the objectives of the study.
For the questionnaire, there are certain inconsistencies. On the one hand, there are repetitions
of questions where we lose a little. The first part concerns the period before pregnancy, and yet
the authors speak of a diagnosis made by a midwife. Some items are repeated several times with
some redundancies.
I did not understand the point of the question of the duration of treatment: 15/30 and 60 days.
Apart from medical treatment, there is instrumental treatment and surgical treatment. No patient
had such a procedure before pregnancy?
Thank you for defining physical activity.
Concerning the definition of constipation, there is indeed the frequency of stools, the consistency
of the stools, but the pushing effort during the bowel movement which has not been considered.
What is the definition of a diet rich in fruits and vegetables? It’s very arbitrary…
The Bristol score was used in the questionnaire but It is not clear if it was before the pregnancy,
during the pregnancy or at the time of answering the questionnaire.
It would have been good to address the use of forceps or spatulas during childbirth, the weight
of the baby and the occurrence of a perineal tear.
It is true that the questionnaire on social networks allows us to have a more homogeneous
pool of patients. We could also imagine that patients who had hemorrhoidal symptoms were
more inclined to respond. Moreover, the authors were disappointed with the number of patients
included.
The diagnosis of hemorrhoidal pathology was based only on symptoms (given that only half
of symptomatic patients consulted non-specialized doctors). So, this is a clear limitation of the
study. There may be a mix between fissure and hemorrhoids, knowing that these are the most
common pathologies during pregnancy.
Please review this part of the results, the percentages were sometimes calculated for the entire
symptomatic population and sometimes only for patients who consulted. We get a little lost.
Please standardize.
“Out of 68 symptomatic women, only 35 looked for medical consultation, asking mainly the
gynecologist (57%) and the midwife (25%). Six patients referred to the proctologist or to a
general practitioner (3 cases each, 9%). The remaining 48% of the women who were not seeking
for medical advice (33 patients), reported self-embarrassment as the reason for not doing a visit
in 53% of the cases (Figure 3).”
I don't know if figures 7, 8, 9, 10, 11 are necessary, especially since the differences were not
significant. Wouldn't it be better to simply make a summary table with the p. Moreover, it is
unusual to represent in absolute number and not in percentage.
Finally, I did not see in the questionnaire (appendix) that the authors asked the question about
the duration of time spent in the toilet. Where does this information come from?
Figure 4 represents patients in absolute numbers, please provide percentages.
Figure 6 is completely incomprehensible, please simplify.
The part of the results detailing the treatments taken by patients needs to be simplified and
clarified.
This sentence has no place in the results. It's an interpretation. To put in the discussion.
« In our sample of pregnant women, the analysis of those factors notoriously predisposing to the
development of hemorrhoids in the general population showed surprising results.”
In tables 1 and 2, I don't know what bowel function present or not present means. It means
disturbed or not. Was the Bristol score used?
We cannot use the word Cohort for a study based on retrospective.
« With this aim we ideated our questionnaire concerning symptoms of HD in pregnancy in a
cohort of women.”
The first part of the discussion explains the study design, which is not very usual. We usually
start by discussing our results and comparing them to data from the literature. This part could
be put at the end of the discussion: strengths and limitations of the study.
Data from the literature show that the frequency of hemorrhoidal disease is greater in the early
postnatal period (many incidents of thrombosis). How to explain this discrepancy with your
results. Below are some examples.
[Abramowitz L, Batallan A. Epidémiologie des lésions anales (fissure et thrombose
hémorroïdaire externe) pendant la grossesse et le post-partum [Epidemiology of anal lesions
(fissure and thrombosed external hemorroid) during pregnancy and post-partum] [Poskus T,
Buzinskien# 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 Dec;121(13):1666-71.]
I do not see the point in offering surgery in pregnant patients apart from a few exceptional cases
of hyperlagic polythromboses who have failed medical treatment.
I find that the conclusion is a little vague and does not summarize the results of the study and
does not open up real perspectives.
Presentation issues:
- double spaces or lack of space between certain words
- Review a little English
- Abstract : The anal symptoms occurring (during) pregnancy and post-partum
Only a previous history of haemorrhoidal  disease (was) correlated to
-Background : However, data on the true prevalence are limited and variably reported (poskus).
What is the meaning of poskus ?
- Pushing th(e) abdomen (questionnaire) : il manque le e
- OTC products : please define
In table 1 : please correct Emorrhoidal disease
Many other presentation errors that I did not notice