How is constipation during pregnancy managed?

Management of Constipation During Pregnancy

Constipation during pregnancy should be treated with a stepwise approach starting with dietary modifications, followed by bulk-forming agents and osmotic laxatives if needed, while avoiding stimulant laxatives due to limited safety data. 1

Prevalence and Causes

• Constipation affects 20-40% of pregnant women, with symptoms typically worsening in the third trimester 1
• Primary causes include:
  • Increased progesterone levels slowing gastrointestinal motility 1
  • Mechanical compression of the rectum by the gravid uterus 1
  • Hormonal, medication-related, anatomic, dietary, and metabolic changes 1

First-Line Management: Lifestyle and Dietary Modifications

• Increase dietary fiber intake to approximately 30 g/day through:
  • Fruits, vegetables, whole grains, and legumes 1
  • This helps promote regular bowel movements and prevent constipation 1
• Ensure adequate fluid intake, particularly water, to soften stools 1
• Allow sufficient time for bowel movements and avoid straining 1
• Use relaxation techniques during defecation 1

Second-Line Management: Bulk-Forming Agents

• Bulk-forming agents like psyllium husk (Metamucil) or methylcellulose are safe during pregnancy due to minimal systemic absorption 1
• Psyllium generally produces bowel movements within 12-72 hours 2
• Soluble fiber (psyllium) improves stool viscosity and transit time in addition to increasing bulk 1
• These agents are preferred over insoluble fiber which is exclusively bulk-forming 1

Third-Line Management: Osmotic Laxatives

• Polyethylene glycol (PEG) and lactulose are safe osmotic laxatives during pregnancy 1
• PEG generally produces bowel movements within 1-3 days 3
• PEG may have a faster therapeutic effect than lactulose, showing significant improvement by the second week of treatment 4
• Caution: Excessive use of osmotic laxatives like lactulose can cause maternal bloating 1

Treatments to Avoid or Use with Caution

• Stimulant laxatives should be avoided during pregnancy due to conflicting safety data 1
• Short-term use of osmotic laxatives is recommended to avoid dehydration or electrolyte imbalances 5

Management of Associated Conditions

• Hemorrhoids occur in approximately 80% of pregnant women, more commonly during the third trimester 1
• For hemorrhoid treatment, hydrocortisone foam has been shown to be safe in the third trimester 1
• A prospective study of 204 patients showed no adverse events with hydrocortisone foam treatment compared to placebo 1

Evaluation of Constipation in Pregnancy

• Detailed history should focus on:
  • Frequency and consistency of bowel movements 1
  • Presence of pain or bleeding during defecation 1
  • Severity of symptoms 1
• Most cases of new-onset constipation during pregnancy do not require extensive evaluation 6
• Women with pre-existing constipation that worsens during pregnancy should be fully evaluated after delivery 7

Treatment Algorithm

1. Start with dietary modifications (increased fiber and fluids) 1
2. If ineffective after 1 week, add bulk-forming agents like psyllium 1, 2
3. If still inadequate relief after 1-2 weeks, add an osmotic laxative like polyethylene glycol 1, 3, 4
4. For associated hemorrhoids, consider hydrocortisone foam treatment 1
5. Avoid stimulant laxatives throughout pregnancy 1

Remember that constipation during pregnancy is usually temporary and resolves after delivery, but proper management can significantly improve quality of life during this period 7.