Constipation is a common condition, affecting 15-30% of the population and is more prevalent in women than in men [4]. Up to 40% of pregnant women complain of constipation symptoms [3]. Pregnant women often suffer from constipation due to various reasons such as: increased progesterone levels decreasing smooth muscle activity of the colon, the uterus pressing on the rectum, iron supplementation, decreased motilin levels (a peptide hormone secreted by the intestines to increase intestinal motility), increased absorption of sodium and water in the colon, reduced mobility.
Diagnostic criteria for functional constipation (ROME IV):
Having two or more criteria (criteria present in the last 3 months and symptoms occurring at least 6 months prior)
Straining during more than 1/4 of defecations.
Hard stools or lumpy stools (Bristol scale 1-2) in more than 1/4 of defecations.
Sensation of incomplete evacuation in more than 1/4 of defecations.
Sensation of anorectal obstruction/blockage in more than 1/4 of defecations.
Manual maneuvers to facilitate more than 1/4 of defecations.
Less than 3 spontaneous bowel movements per week.
Rarely passing loose stools without the use of laxatives.
Does not meet the criteria for irritable bowel syndrome.
Classification:
Slow transit constipation: characterized by reduced colonic motility and poor response to fiber supplementation.
Normal transit constipation: patients experience a sensation of incomplete evacuation, bloating, and discomfort in the abdomen.
Pelvic floor dysfunction: patients often strain, have a sensation of incomplete evacuation, and can be determined by measuring rectal pressure.
Before diagnosing any of the forms of constipation above, secondary factors causing constipation need to be ruled out such as:
Structural causes: obstructive masses, anal stenosis, rectal prolapse, rectal intussusception.
Medications: opioids, Tramadol, NSAIDs, acid blockers, calcium channel blockers, anticholinergics (antihistamines, tricyclic antidepressants, antipsychotics), iron.
Metabolic or endocrine: diabetes mellitus, hypothyroidism, hyperthyroidism, hypercalcemia, hypokalemia, hypomagnesemia, pregnancy, adrenal insufficiency, porphyria.
Neurologic or neuromuscular disorders: multiple sclerosis, Parkinson’s disease, scleroderma, myotonic dystrophy, dermatomyositis, amyloidosis, spinal cord injury, autonomic neuropathy.
Treatment
Non-pharmacological measures
Exercise, low-fat diet, increased fiber intake, drinking plenty of water; not worrying about changes in bowel habits or inability to have a bowel movement daily; paying attention to bowel signals and allocating appropriate time for defecation.
Fiber
– Fiber is beneficial for patients with mild to moderate constipation. However, it will not be beneficial when supplementing fiber in patients with slow transit constipation, pelvic floor dysfunction, or severe constipation. In these patients, fiber increases stool volume and exacerbates bloating symptoms.
– In cases of mild to moderate normal transit constipation, supplementing 20-25 g/day of fiber helps increase bowel movement frequency and soften stools. Patients should gradually increase fiber intake over a few weeks along with adequate water intake until reaching the goal to avoid bloating and worsening constipation.
– Priority should be given to using fiber-rich foods if tolerated: cereals, fruits, vegetables.
– Some fiber supplements: Psyllium, methylcellulose, polycarbophil, wheat dextrin, guar gum, inulin or chewable polydextrose.
Medication therapy
If a high-fiber diet and fiber supplements are ineffective, some medications can be used:
– Lactulose, macrogol can be used during pregnancy.
– If unsuccessful, bisacodyl can be used for a short period. Some rectal medications may be used: glycerol, sodium picosulfate, sodium sulfate, mannitol, and sorbitol.
– Limit the use of docusate, magnesium sulfate.
– Avoid using anthraquinones, paraffin, and mineral oil.
