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Fetomaternal

Division

Constipacy in pregnancy
a review from RCOG April
2015
Presenter
Dr. Roza Maulindra
Moderator
Dr. Hj. Putri Mirani, SpOG(K)

Learning Objectives

To

understand

the

prevalence

and

pathophysiology of this condition in pregnancy.

To understand the management of constipation


in pregnancy

Ethical Issue

The studies on safety of laxatives in pregnancy


have small sample sizes although they have not
shown any effect on congenital malformations.

When to involve a gastroenterologist or a


colorectal surgeon in the care of a woman with
constipation in pregnancy

Introduction

Functional (primary) constipation is defined as


infrequent bowel motion and/or difficulty in passing
stool, which is not attributable to an underlying
pathology

Secondary

constipation

results

from

either

pharmacotherapy or a medical condition

Pregnancy, immobility and change in diet can also


worsen constipation

The prevalence of constipation is estimated to


affect 1138% of pregnancies

Information

on

bowel

dysfunction

during

pregnancy is limited

The Rome III criteria are the most commonly


used

classification for

(Table 1).

chronic

constipation

The Rome III Criteria

Pathophysiology

Clinical Evaluation
Evaluate from its symptoms:

Evacuating infrequently

Dry hard stools with pain and strain

Excessive

straining

pudendal

nerve

weakening

pelvic floor

Incomplete evacuation digital manipulation

Record: history of laxative with dosage, comorbodities;


hypothyroidism, DM, bowel syndrome; haemorrhoids,
IBS

Treatment

1. Bulk-forming agents
Relive constipation by bulking facal mass
thereby stimulating peristalsis
Not absorb in GI tract
No adverse effect to fetus
Slowly act
Not effective in acute
Contraindicated to faecal impaction
Eq: Wheat bran, isphagula husk,
methylcellulose, sterculia

2. Osmotic laxative

comprises lactulose, sorbitol, polyethylene glycol


(PEG), magnesium sulphate or citrate, and salts
(sodium chloride, potassium chloride).

osmolar tension ammount of water in colon


peristalsis and evacuation

Lactulose and PEG poorly absorbed

PEG is a choise for chronic constipation in


pregnancy

2. Osmotic laxative

Side

effect:

flatulence

and

abdominal

bloating, electrolyte immbalance

No adverse effect to fetus

Macrogols

(like

Movicol,

Middlesex,

UK)

are

inert

Norgine

Ltd.,

polymers

of

ethylene glycol, which sequester fluid in the


bowel.

3. Stimulant laxative

Stimulant laxatives such as bisacodyl and senna


act regionally within the large intestine by
reducing water absorption and causing colonic
hyper-motility

> effective than bulking

Senna

is

partially

absorbed

gastrointestinal tract.

No evidance fetal anomalies

from

the

3. Stimulant laxative

Docusate sodium acts both as a stimulant

and as a softening agent


A case of neonatal hypomagnesaemia
after maternal overuse of docusate
sodium has been reported
excreted in breast milk

4. New agents

Prucalopride stimulates the serotonin 5-HT4


receptor

altering

colonic

motility

propulsive force for defaecation


2010 the NICE approved prucalopride of
chronic constipation in women if treatment
with two different types of laxatives at
maximum dose for a minimum period of 6
months had failed and were being considered
for invasive treatment
Limited data

4. New agents

linaclotide and lubiprostone are pregnancy category C drugs

Linaclotide

is

guanylate

cyclase-C

receptor

agonismanagement of moderate to severe irritable bowel


syndrome with constipation (IBS-C).

the

concentration

monophosphate

of

(c-GMP)

extracellular

reduce

cyclic
visceral

guanosine
pain

by

decreasing pain fibre activity

concentration of intracellular c- GMP increasing secretion


of electrolytes (chloride and bicarbonate) into the intestinal
lumen increased intestinal fluid to ease and accelerate
passage of stool

4. New agents

Lubiprostone is a locally acting CIC-2 chloride-channel


activator, which augments intestinal fluid secretion and
increases motility

Chronic idiopathic constipation if treatment with two


different types of laxative at maximum dose for a
minimum period of 6 months have failed and invasive
treatment is being considered

Experimentation, maternal toxicity and over-dosage


(higher than recommended human maximum dose)
have detected adverse fetal effects

5. Suppositories and
enemas

faecal loading or impaction may benefit


from use of glycerine suppositories in
addition to the use of oral laxatives as
necess

No study exist regarding teratogenicityry.

How to stop laxatives

regular bowel movements occur without


difficulty,

laxatives

can

be

withdrawn

gradually

a combination of laxatives is used, one


laxative should be stopped at a time,
reducing stimulant laxatives first.

Conclusion

physical examination play a key role in diagnosing and


managing

women

with

constipation

in

pregnancy

effectively

The following circumstances warrant a prompt referral to


a gastroenterologist:

A change in bowel habit for longer than 6 weeks.

Rectal bleeding.

Known history of gastrointestinal disorders such as


inflammatory bowel disease.

A family history of colorectal cancer

THANK YOU

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