Our prospective, analytical, cross-sectional cohort study was conducted in the Obstetrics and Gynecology Department of the Health Center of Commune IV of the District of Bamako between January 1, 2020 and September 30, 2020, a period of nine (09) months. The study population included all pregnant women who had completed their pregnancy and postpartum follow-up at the gynecological-obstetric service of the Health Center of Reference of Commune IV of the District of Bamako.

The inclusion criteria concerned all women who had started their pregnancy follow-up from the first trimester and who had given birth in our department. The exclusion criteria concerned all women who had consulted for the first time after the first trimester of pregnancy, all women who had consulted in the first trimester but who had not accepted to participate in the study, all women who had been followed up in another department for their pregnancy and all women who had had an abortion for their current pregnancy.

The minimum sample size was calculated using the Schwartz formula below:

Ideal sample size: n = Z 2 P ( 1 − P ) / E 2

n = sample size;

Z = point of the normal distribution corresponding to the significance level of 1.96;

P = prevalence of anal pathology in pregnant women and newborns obtained in previous studies (10%);

A confidence interval of 95% will be used;

E = maximum probable error of 5%.

Therefore the minimum sample size was

n = ( 1 . 96 ) 2 × 0. 1 0 ( 1 − 0. 1 ) / ( 0.0 5 ) 2 = 138

In order to facilitate the study, we developed a survey form with the variables to be studied. Our data were collected on the survey forms from: Obstetrical records; Antenatal consultation books (CPN); Anesthesia registers; and Delivery registers.

The variables studied included socio-demographic variables (age, marital status, education level, dietary habits), medico-clinical variables (parity, body mass index (BMI), transit disorders, history of proctological disease, duration of expulsion, route of delivery, weight of the newborn, perineal tears, episiotomy, type of delivery and twin pregnancy).

The methodology used for this study will be the search for anal pathologies in pregnant women. Each of them benefited from an obstetrical and proctological examination in the 1^st, and 3^rd trimester of pregnancy and postpartum. The clinical proctological examination was performed on a patient examination table in the knee-pectoral or left lateral decubitus position. The first step of the examination was the observation of the anus (inspection) which was done by unfolding the radial folds allowing observing a fissure; a fistula; a swelling; a hemorrhoidal thrombosis; a condyloma. We asked the patients to push to reveal possible ano-perineal pathologies such as internal hemorrhoids that prolapsed; swelling or a rectal prolapse. The second part of the examination included palpation of the anal verge and an anorectum to look for an abnormality such as swelling; pain; or an anal fistula opening. This also allowed evaluating the tone of the anal sphincters. The third step was anoscopy to visualize internal hemorrhoids in the anal canal; an endo-canal fissure; an endo-canal cancer and the lower rectum. This third step was done for women who had a proctological pathology at the end of the clinical examination.

The data were entered in Excel and analyzed with the Epi info 7 Software. The statistical test used was Fisher’s exact test and the Mantel Haenszel test with a significance threshold set at 5%.

The average age of the women was 26 years with extremes of 14 and 39 years. The age range of 20 to 29 years was the most represented with 56.6% of the cases. Our patients were relatively younger. Our result was close to that of Poskus et al. [14] who found a mean age of 28.7 years with extremes of 18 and 45 years. On the other hand, Ferdinand K et al. [15] found a mean age of 31 years with extremes of 20 and 40 years. This can be explained by the young age at pregnancy of the African population in general and Mali in particular.

A univariate analysis was performed with a suspected risk factor for each type of anal pathology. We identified that chronic constipation (p = 0.003), newborn weight > 3500 g (p = 0.000), age 30 years (p = 0.048), body mass index at 25 kg/m² (p = 0.006), instrumental vacuum extraction (p = 0.001) and fetal expulsion time > 20 minutes (p = 0.000) were significantly associated with the occurrence of hemorrhoidal disease. For anal fissure, we identified that the weight of the newborn > 3500 g (p = 0.002) and a duration of fetal expulsion > 20 minutes (p = 0.000) were significantly associated with the occurrence of anal fissure.

Finally, we also identified that a weight of the newborn > 3500 g (p = 0.000), an age up to 30 years (p = 0.001), a duration of fetal expulsion > 20 minutes (p = 0.000) and the instrumental extraction by suction cup (p = 0.044) were significantly associated with the appearance of anal incontinence.

The mean duration of fetal expulsion was 12 minutes with extremes of 5 minutes and 40 minutes, standard deviation = 10.13. The average weight of the newborn was 3079 g with extremes of 2090 and 4102 g, standard deviation = 319.52.

Poskus T et al. [14] identified constipation, birth weight > 3800 g, prolonged expulsion time > 20 minutes and personal history of anal disease as risk factors for the development of anal disease in pregnant women. In the literature, the risk factors for the occurrence of hemorrhoidal disease, and anal fissure in pregnancy or postpartum, are traumatic delivery (birth weight greater than 3800 g and soft tissue tear) or duration of expulsion of more than 20 minutes, and history of anal pathology [11] [16] [17] . The main risk factors for postnatal anal incontinence are: advanced maternal age (to 30 years); high parity; maternal obesity; prolonged second stage of labor; median episiotomy; obstetric anal sphincter injury; forceps delivery [18] [19] .

1) Hemorrhoidal disease

· Functional signs

Anal pain was the main symptom found. Its frequency in our study was 50%. It was the most frequent symptom in the study by Poskus T et al. [14] who recorded 98.3% of patients with anal pain. The frequency of rectal bleeding in our study was 50%. It was of variable intensity, appearing during or after the stool [14] . Our result was lower than that reported by Ollende C et al. [20] in 2010 89.5% of functional signs (p = 0.000010). This could be explained by the fact that rectal discharge was mostly occult due to the use of traditional latrines in our

context. Pruritus and oozing were found in 20% of our patients. Our result is lower than that reported by Poskus T et al. [14] 74%. This difference could be explained by the size of the samples. They usually occurs secondary to hemorrhoidal procidence [20] .

· Physical signs

Proctological examination at the digital rectal exam allows the diagnosis of hemorrhoidal disease. Hypertonicity of the anal sphincter was an important sign of hemorrhoidal disease [11] [14] [20] . We observed a significant sphincter tone in 40% of the patients when touched. However, this hypertonicity could not be evaluated because we did not have a manometer

Anal fissure

· Clinical signs

Anal pain was more frequently found in our study (88.2%), as well as in those of Siproudhis et al. in France and Keita KI et al. in Mali [21] [22] , with 100% and 100% respectively. It was the most common clinical manifestation of anal fissure, regardless of its location. It was a pain like a tear or a sensation of broken glass in the anus, provoked and punctuated by defecation [23] . The three-stroke pain characterizes the anal fissure. It was a pain triggered by the passage of stool, calmed down for a while after the stool and then resumed for several hours (4 to 6 hours). Sometimes it was replaced by simple discomfort [15] [20] [21] [23] . Jaundice was frequently found in our study (35.3%) as well as in those of Siproudhis et al. [21] and Keita CO et al. [22] with a rate of 85% and 71.5% respectively. It was generally made of red blood, emitted from the anus but coming from the anal canal as evidenced by the traces of blood on the stool. Anal pruritus was found in more than half of our patients (52.9%). Siproudhis et al. [21] recorded it in 60% of cases.

2) Anal incontinence

In the female population, it has been shown that less than 20% of women affected by anal incontinence symptoms tell their doctor [24] (Table 9, Table 10).

Of the 9 cases of anal incontinence, 8 were gas and 1 was fluid. We did not note any cases of AI to solids. In the literature [22] [24] , it is most often gas leakage with a repercussion that can be very disabling in professional life, during leisure activities or intimate relations. In 1 to 2% of cases, it involves loss of liquid stools with an even greater impact on quality of life.

1) Hemorrhoidal disease

During our study, all patients with hemorrhoidal disease were put on a bowel regulator. We agreed with other authors, Abramowitz L et al., Holzheimer RG et al. [11] [25] , that transit regulation was the most important element in the treatment of hemorrhoidal disease. In our study, the rate of symptomatic improvement was 45% after the regularization of the transit and a cessation of rectal bleeding in 25%.

Holzheimer RG et al. [25] found an improvement of the symptomatology in 47% after the regularization of the transit and a stop of the rectal bleeding in 50%. In addition, other drugs were used in the department as adjunctive treatment, in particular those improving venous circulation (venotonics and phlebotonics) per os, topicals (ointments and suppositories) and analgesics. Dietary recommendations were given such as the avoidance of spices, continuous sitting (long car journeys) and dietary excesses, the recommendation in case of overweight a restrictive diet, of general hygiene. None of our patients had benefited from an instrumental treatment (injection of botulinum toxin) or surgical treatment (hemorrhoidectomy) during our study.

In the literature, instrumental treatments and surgery should be re-discussed at a distance from the delivery according to the usual indications [11] .

2) Anal fissure

During our study, all patients with anal fissure were put on bowel regulator. It was used in all 17 cases of anal fissure. Other drugs were used as treatment to lubricate the anal canal, heal the anal fissure and calm the pain (local topical suppository cream). In the literature, the treatment of anal fissure in pregnant women consists of a combination of regulation of intestinal transit (almost exclusively constipation to be treated with osmotic or oily laxatives or mucilage) and lubrication of the anal canal (local topical in the form of suppositories and ointments) [26] .

3) Anal incontinence

Of the 9 cases of anal incontinence during the entire study, 84.2% had been put on laxatives. Another important data was collected during this study, that of post-partum perineal rehabilitation. The first line treatment of incontinence combines specific perineal rehabilitation of the anus with dietary measures and drug prescriptions to regulate intestinal transit Damon H et al. [27] . During counseling during pregnancy, 30 women agreed to undergo perineal rehabilitation after delivery; and during the postpartum period, the majority of them mentioned the lack of time, hence the low rate of rehabilitation. It is therefore essential to inform future mothers from the time of pregnancy of the interest of post-partum rehabilitation, whatever the weight of the child and the mode of delivery.