What is the emergency department management for an 11-week pregnant patient presenting with constipation and abdominal cramping?

Emergency Department Management of Constipation in an 11-Week Pregnant Patient with Abdominal Cramping

For an 11-week pregnant patient with constipation for 5 days and abdominal cramping, initial management should focus on lactulose as the safest osmotic laxative, followed by polyethylene glycol if needed, along with dietary modifications and adequate hydration. 1, 2

Initial Assessment

• Evaluate frequency and consistency of bowel movements, and assess for pain, bleeding, or hemorrhoids during defecation 1
• Rule out more serious causes of abdominal pain in pregnancy, including:
  • Ectopic pregnancy
  • Threatened abortion
  • Appendicitis
  • Intestinal obstruction 3
• Check vital signs including temperature to rule out infection 1
• Perform abdominal examination to assess for tenderness, distension, and abnormal peristalsis 3

First-Line Management

• Immediate dietary modifications:

  • Increase dietary fiber intake to approximately 30 g/day through fruits, vegetables, and whole grains 1
  • Ensure adequate hydration (at least 2-3 liters of water daily) 1
  • Aim for 3-4 servings of fruits and 3-4 servings of vegetables daily 1

• Pharmacological management:

  • Lactulose 15g daily - the only osmotic agent specifically studied in pregnancy with established safety profile 2, 1
  • If immediate relief is needed, consider glycerin suppository which works locally with minimal systemic absorption 1

Second-Line Management

• If no improvement within 24 hours, consider:

  • Polyethylene glycol (PEG) 17g daily - safe in pregnancy with minimal systemic absorption 2, 1, 4
  • Psyllium husk (bulk-forming agent) - can be added if dietary modifications are insufficient 1, 5

• Caution: Monitor for warning signs that require stopping treatment:

  • Rectal bleeding
  • Worsening abdominal pain
  • Nausea or vomiting
  • Diarrhea 4, 5

Third-Line Management

• For refractory cases after 48 hours:
  • Magnesium hydroxide 400-500 mg daily - use with caution in pregnancy 2, 1
  • Short-term use of stimulant laxatives may be considered:
    • Bisacodyl 5-10 mg daily for short-term use only 2, 1
    • Senna 8.6-17.2 mg daily for short-term use only 2, 6

Special Considerations

• Stimulant laxatives should be used cautiously and only for short-term relief when other methods fail, as they may cause abdominal discomfort and diarrhea 2, 7
• Compared to bulk-forming laxatives, stimulant laxatives appear more effective for constipation relief but have higher rates of abdominal discomfort (RR 2.33) and diarrhea (RR 4.50) 7
• If hemorrhoids are present due to constipation, consider topical hydrocortisone for symptomatic relief 1

Admission Criteria

• Consider admission if:
  • Severe abdominal pain becomes continuous rather than intermittent 3
  • Signs of dehydration are present 6
  • Symptoms of intestinal obstruction develop (tachycardia, pyrexia, positive Blumberg sign) 3
• If hospitalization is required, implement anticoagulant thromboprophylaxis during the hospital stay 1

Discharge Instructions and Follow-up

• Continue dietary modifications with high fiber intake and adequate hydration 1
• Adjust treatment based on response, with the goal of achieving soft, formed stools every 1-2 days 1
• Return to the emergency department if experiencing:
  • Rectal bleeding
  • Severe or worsening abdominal pain
  • Failure to have bowel movement despite treatment 5
  • Any vaginal bleeding or increased cramping 1