Williams Obstetrics and Gynecology is considered ‘The Bible’ of Obstetrics. It contains 1435 pages. I’ve read it twice. Yet only 2 paragraphs are devoted to constipation, one of the most common and annoying symptoms of pregnancy. A prime example of how physicians and patients are often concerned about very different things in pregnancy. Although in our defense, we do focus most of our learning on the life threatening/saving issues. Though constipation is not often a life threatening issue, over the years, I have heard from many women just how much added discomfort it can add to their pregnancy.
Constipation has been jokingly defined as having a bowel movement less often than your grandmother. Perhaps a better definition would be hard, painful and less frequent stools. Symptoms may include pain with bowel movements, rectal bleeding, hemorrhoids, bloating and cramping. The cramping can be quite intense. Due to the close proximity between the uterus and descending colon, it is often difficult to determine which organ is causing the cramping pain. This can be upsetting to women, especially those with a history of miscarriage, who have to fight fear with each twinge and cramp.
The amount of the hormone progesterone is much higher during pregnancy and causes one’s stool to move through the colon at a slower rate. The more time the stool is in the colon, the greater the volume of fluid that can be removed from it, leading to firmer stool. The enlarging uterus physically pushes on the bowel which can further impede its exit. First trimester nausea can lead to dehydration which causes the body to pull even more fluid from the stool. Also, commonly used medications in pregnancy such as zofran and iron supplements can also cause worsening constipation.
The key to treating constipation is prevention. In all pregnancies we recommend eating lots of fruits and vegetables (5-7 servings/day) as well as drinking 8-10 glasses of water per day. Try to get 25 grams of fiber per day. Often times prenatal vitamins will contain a small amount of stool softener, which can be helpful. Fiber supplements can also be beneficial, but in some women they can cause excessive bloating. Exercise like walking and yoga have also been shown to reduce constipation.
Joseph Schaffer, MD, chief of gynecology at the University of Texas Southwestern Medical Center in Dallas, presented an article in 2006 looking at a homemade fiber preparation that was found to be more effective than over the counter fiber supplements for treating constipation. I have had several patients find it beneficial:
Constipation Bowel Recipe
1 cup unprocessed wheat bran or miller’s bran
1 cup applesauce
1/4 cup prune juice
Take 2 tablespoons twice a day
If these measures are not working, the the next step is to take a daily stool softener such as docusate sodium (colace) . Colace works by keeping moisture in the stool. It does not stimulate the bowel like a laxative and is not absorbed, therefore it is safe for continuous usage.
If constipation is still an issue, then discuss it with your provider. A common next step would be to add Milk of Magnesia to the regimen. Using the pill form of milk of Mag is often more palatable than the liquid version. Miralax is also safe to use in pregnancy. If MOM doesn’t work, then taking magnesium citrate or using an enema will often result in relief.
Reasons to be concerned about constipation include: if it’ s associated with vomiting, abdominal pain, rectal bleeding or fever.
Again, the key is to NOT WAIT UNTIL IT IS SEVERE AND PAINFUL. Keep hydrated and eat lots of fiber. Stay on a stool softener if you are having issues, then add milk of magnesia as needed for breakthrough problems.