Constipation in Pregnancy delivered in December 2021 at the Wanbury CME

1. Dyschezia in Pregnancy

2. Dyschezia is the most common
gastrointestinal dysfunctions in pregnancy
….......... 2nd only to nausea2
1. Ghosal UC. Tropical Gastroenterology. 2007; July. Vol (28). Issue 3: 91-5.
2. Fan W. Int J Clin Exp Med 2020;13(3):2022-2026
Dyschezia – Difficulty in evacuating the bowel 1

3. 1. Fan W. Int J Clin Exp Med 2020;13(3):2022-2026. 2. Turawa
EB. Cochrane Database of Systematic Reviews 2015, Issue 9.
Art. No.: CD011625.DOI: 10.1002/14651858.CD011625.pub2 as
accessed on 14/10/21 3. Cooklin AR et al. BIRTH 42:3
September 2015). 254-59
Burden

4. Majority of Pregnant women
ROME III Criteria1
Presence of at least 2 of the 6
symptoms during at least 25% of
defecations
• 1. Body C. Gastroenterol Clin N Am 45 (2016) 267–283

5. RISK FACTORS
IN PREGNANCY
• Age
• Increases with age. High risks above 35
years
• Pre-pregnancy BMI
• Prevalence rate increased with pre-
pregnancy
• BMI >24 (27%); 18.5 – 24 (6.6%); < 18.5
(4.16%)
• Sedentary lifestyle
• Spicy food intake
• Stress
• Depression
• Threatened Abortion during early pregnancy
• Subsequent pregnancies
Shi W, Xu X, Zhang Y, Guo S, Wang J,
Wang J (2015) Epidemiology and Risk Factors of
Functional Constipation in Pregnant Women. PLoS
ONE 10(7): e0133521. doi:10.1371/journal

6. Etiology of Dyschezia in Pregnancy
Bonapace ES and Fischer R. Constipation and
Diarrhea in Pregnancy.Gastroenterology clinics of North
America. 1998 March. Volume 27.Issue 1: 197 – 211.

7. Delayed
Transit time
- Allow greater time for
the absorption of fluids
and electrolytes
- Hormonal changes
in pregnancy can cause
changes in intestinal
motility
• Role of Progesterone in causing dyschezia
• Inhibit gut smooth muscle
• Decrease esophageal, gastric and colonic muscle
contractility
• Decrease gastric motility and prolong gastric
emptying
• Alteration of Ca+2 flux across cell membrane
• Alter mechanical activity of colonic smooth muscle
and slow colonic transit
• Longer colonic transit time in women compared to
men as studied using radiopaque markers
• Slowest transit time during luteal phase of menstrual
cycle and third trimester of pregnancy
• Delay in the transit occur primarily when
progesterone levels increased from less than 1
ng/ml to 80 ng/ml
• Inhibits hormone MOTILIN responsible for stimulating
the smooth muscles of LES, stomach, small and large
intestines
Bonapace ES and Fischer R. Constipation and
Diarrhea in Pregnancy.Gastroenterology clinics of North
America. 1998 March. Volume 27.Issue 1: 197 – 211.

8. Resistance to
intestinal transit
• Mechanical Obstruction on
rectosigmoid
• Gravid Uterus
• Large Hemorrhoids
• Intestinal Obstructions due to
adhesion from prior surgeries
• Intestinal volvulus (25% o fthe
cases of mechanical
obstruction)
Bonapace ES and Fischer R. Constipation and
Diarrhea in Pregnancy.Gastroenterology clinics of North
America. 1998 March. Volume 27.Issue 1: 197 – 211.

9. Miscellaneous
Factors
• Oral Iron preparations
• Volitional suppression due to
psychological and environmental
stress
• Acute intestinal psuedo –
obstruction
• Tocolytic therapy with Mg and
Nifedipine for preterm labour
Bonapace ES and Fischer R. Constipation and
Diarrhea in Pregnancy.Gastroenterology clinics of North
America. 1998 March. Volume 27.Issue 1: 197 – 211.

10. Clinical Profile –
symptoms
Dyschezia Symptoms and Diagnoses
(by the Rome II Criteria)
Reported in Each Trimester and at 3 Months
Postpartum
(Obstet Gynecol 2007;110:1351–7)
• Majority of pregnant women –
• `Presence of abdominal pain and
bloating – Irritable bowel
syndrome
• First trimester – 19%
• Second trimester – 13%
• Third trimester – 13%
• 3 month of postpartum – 5%
• Straining or use of digital manipulation
and/or perineal pressure to facilitate
defecation – pelvic floor dysfunction

11. Clinical Evaluation
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12. Impact in pregnant women
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Shi W, Xu X, Zhang Y, Guo S, Wang J, Wang J (2015) Epidemiology and Risk Factors of Functional Constipation in Pregnant Women.
PLoS ONE 10(7): e0133521. doi:10.1371/journal. pone.0133521

13. Management
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Can Fam Phy. Aug 2012. Vol. 58. No. 8: 836 - 38

15. LAXATIVES
Bulk – forming laxative
• Psyllium
• Dietary Fibers
• Bran
• Carboxymethylcellulose
Osmotic Agents
• Milk of Magnesia
• Lactulose
• Sorbitol
• Polyethylene Glycol
Prokinetic Agents
• Cisapride
• Tegaserod
Lubricants
• Mineral Oil
Stimulant
• Senna
• Bisacodyl
Stool Softeners
• Sodium Docusate
Chloride Channel
Activator
• Lubiprostone

16. BULK – FORMING AGENTS
• Retain fluid in the stool and increase stool weight and
consistency
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Canadian Fam Phy. Aug 2012. Vol. 58 (*): 836 - 38

17. Stool Softeners
• Surface active agents lower surface tension, which leads to
water and fats penetrating the stool
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Canadian Fam Phy. Aug 2012. Vol. 58 (*): 836 - 38

18. Lubricant Laxatives
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Canadian Fam Phy. Aug 2012. Vol. 58 (*): 836 - 38

19. Osmotic Laxatives
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Canadian Fam Phy. Aug 2012. Vol. 58 (*): 836 - 38

20. Stimulant Laxatives
• Stimulant laxatives stimulate the myenteric plexus and the
Auerbach plexus, which increase intestinal secretions and
motility
• They also decrease the absorption of water from the lumen of
the bowel
• They have poor bioavailability
• Senna does not appear to be associated with increased risk of
malformations
• Unpleasant side effects such as abdominal cramps ARE LESS
Canadian Fam Phy. Aug 2012. Vol. 58 (*): 836 - 38

21. Lubiprostone
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Wilson N et al. Ther Adv Chronic Dis. 2015 Mar; 6(2): 40–5.

22. Prokinetic Drugs
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Cullen G and O’Donoghue D. Constipation and Pregnancy. Best Practice & Research Clinical Gastroenterology
2007 .Vol. 21, No. 5, pp. 807–818,

23. Summary of Laxatives
Laxatives Usual Daily
Dose
Pregnancy
Category
Comments
Bulk forming
Psyllium
6.4 – 10 g B Preferred in long term management. To be taken with large amount
of water (at least 8 oz). Abdominal bloating and flatulence
Lactulose 15 – 30 ml B May cause gas, abdominal bloating, long term use may be
associated with electrolyte imbalance. Cannot be preferred in
gestational diabetes patients
PEG 15 – 30 ml B Minimum systemic absorption. Same as above
Magnesium oxide 30 – 45 ml B Hypermagnesemia
Senna 7.5 – 30 mg C Faster onset of action . Senna was found to be effective in a short-
term treatment in pregnancy without any increased risk of
malformations
Bisacodyl 10 – 15 mg
orally or 10
mg per
rectum
C Abdominal cramps
Prather CM. Pregnancy related constipation. Curr Gastro Reports. 2004. 6:402 - 404

24. Senna in Pregnancy
• Animal studies
• No fetal risk
• No uterine stimulant activity
• Human studies
• 937 pregnant women treated with Senna preparations
• Treatment period range ( 2 weeks – 9 month)
• Good laxative efficacy with few side effects
• No uterine stimulant effect seen even in pregnancies with tendencies to
premature labor or bleeding during late pregnancy
• Prophylactic use to avoid undue straining
Pharmacology 1992;44:20–22

25. Senna Safety in Pregnancy: Risk of Congenital Anomalies
• Nandor Acs et al.
• Population based case control
Surveillance System of
Congenital Anomalies
(HCCSCA)
• 22843 cases of Congenital
Anomalies studied (1980 – 1996)
Among laxative drugs,
senna has no teratogenic
potential; thus, if severe,
requires laxative drug
treatment in pregnant
women, senna is not
contraindicated.

26. Safety of Laxatives – clinical studies
Senna has poor systemic bioavailability and local action with no increased risk
for malformations
836 Canadian Family Physician • Le Médecin de famille canadien | Vol 58: august • aoûT 2012

27. Cochrane Reviews 2015
• Rungsiprakarn P et al
• Senna is not associated with teratogenic effects and is
considered to be safe in pregnancy
• Compared with bulk-forming laxatives, Senna preparations led
to an improvement
Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD011448. DOI: 10.1002/14651858.CD011448.pub2.

28. Senna use in Puerperium
• Shelton MG et al
• Double blind
randomized placebo
controlled trial
• 471 mothers treated
with Senna
preparations 7 mg two
tablets in the morning
or placebo for
maximum of 4 days
Shelton MG. S. Afr, med J., 57, 78 (1980)
Early postpartum bowel
actions
• Success rates of 93% white mothers
treated with Senna at day 1
• Success rates of 96% Colored
mothers treated with Senna at day 1
Assisted Vaginal Delivery
• 91% of women with assisted vaginal
deliveries treated with Senna had
bowel movements within 48 hours
Episiotomy and Perineal
tears
• 91% of women with assisted vaginal
deliveries treated with Senna had
bowel movements within 48 hours
No incidence of loose stools
in infants born to colored
mothers

29. Summary
• Dyschezia is the most common complaint in pregnancy and
postpartum women
• Education, lifestyle and dietary changes are initial steps in the
management
• In case of no relief, laxatives are prescribed
• Bulk forming are preferred for long term relief but it is slow acting
and associated with abdominal discomfort, bloating and flatulence
• Stimulant laxatives such as Senna are useful for short term relief
with no increased risk of congenital malformations

30. Thank You