Constipacy in pregnancy.pptx

Constipacy in pregnancya review from RCOG April 2015

Presenter

Dr. Roza Maulindra

Moderator

Dr. Hj. Putri Mirani, SpOG(K)

Fetomaternal Division

To understand the prevalence and pathophysiology of this condition in pregnancy.

To understand the management of constipation in pregnancy

Learning Objectives

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

Ethical Issue

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

Introduction

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 chronic constipation (Table 1).

The Rome III Criteria

Pathophysiology

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

Clinical Evaluation

Treatment

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

1. Bulk-forming agents

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, Norgine Ltd., Middlesex, UK) are inert polymers of ethylene glycol, which sequester fluid in the bowel.

2. Osmotic 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 from the gastrointestinal tract.

No evidance fetal anomalies

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

3. Stimulant laxative

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 a guanylate cyclase-C receptor agonismanagement of moderate to severe irritable bowel syndrome with constipation (IBS-C).

the concentration of extracellular cyclic guanosine monophosphate (c-GMP) reduce visceral 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

4. New agents

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.

5. Suppositories and enemas

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.

How to stop laxatives

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

Conclusion

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