• Home
  • Pregnancy &           
Breastfeeding
  • Bookshop
  • Contact us
  • Donate now
  • Frequently Asked Questions
  • Please read

Our Helplines

1-877-439-2744 Motherisk Helpline
1-800-436-8477 Morning Sickness
1-877-327-4636 Alcohol and Substance
1-866-937-7678 Exercise in Pregnancy
1-888-246-5840 HIV and HIV Treatment
416-813-6780 Motherisk Helpline

Treating constipation during pregnancy

Magan Trottier, MSc, Aida Erebara, MD and Pina Bozzo

August 2012

ABSTRACT

QUESTION

Many of my patients experience constipation during pregnancy, even after increasing dietary fibre and fluids. Are there any safe treatments I can recommend to them?

ANSWER

Although the recommended first-line therapy for constipation includes increasing fibre, fluids, and exercise, these are sometimes ineffective. Therefore, laxatives such as bulk-forming agents, lubricant laxatives, stool softeners, osmotic laxatives, and stimulant laxatives might be considered. Although few of the various types of laxatives have been assessed for safety in pregnancy, they have minimal systemic absorption. Therefore, they are not expected to be associated with an increased risk of congenital anomalies. However, it is recommended that osmotic and stimulant laxatives be used only in the short term or occasionally to avoid dehydration or electrolyte imbalances in pregnant women.

QUESTION

Beaucoup de mes patientes enceintes souffrent de constipation, même si elles consomment plus de fibres alimentaires et de liquides. Existe-t-il des traitements sécuritaires que je pourrais leur recommander?

RÉPONSE

Bien que le traitement de première intention recommandé pour la constipation préconise l'ajout de fibres, de liquides et d'activité physique, ces moyens demeurent parfois inefficaces. Par conséquent, on peut envisager des laxatifs comme les laxatifs de lest, les lubrifiants, les émollients, les laxatifs osmotiques et les laxatifs stimulants. L'innocuité durant la grossesse de bon nombre de ces types de produits n'a pas été étudiée, mais leur absorption systémique est minime. On ne s'attend donc pas à ce qu'ils soient associés à un risque accru d'anomalies congénitales. Cependant, il est recommandé de n'utiliser les laxatifs osmotiques ou stimulants qu'à court terme ou qu'à l'occasion pour éviter la déshydratation ou les déséquilibres des électrolytes chez les femmes enceintes.


Treating constipation during pregnancy

Many of my patients experience constipation during pregnancy, even after increasing dietary fibre and fluids. Are there any safe treatments I can recommend to them?

Although the recommended first-line therapy for constipation includes increasing fibre, fluids, and exercise, these are sometimes ineffective. Therefore, laxatives such as bulk-forming agents, lubricant laxatives, stool softeners, osmotic laxatives, and stimulant laxatives might be considered. Although few of the various types of laxatives have been assessed for safety in pregnancy, they have minimal systemic absorption. Therefore, they are not expected to be associated with an increased risk of congenital anomalies. However, it is recommended that osmotic and stimulant laxatives be used only in the short term or occasionally to avoid dehydration or electrolyte imbalances in pregnant women.

It has been estimated that approximately 11% to 38% of pregnant women experience constipation, 1 which is generally described as infrequent bowel movements or difficult evacuation. 2 Pregnancy predisposes women to developing constipation owing to physiologic and anatomic changes in the gastrointestinal tract. For instance, rising progesterone levels during pregnancy and reduced motilin hormone levels lead to increases in bowel transit time. 2,3 Also, there is increased water absorption from the intestines, which causes stool to dry out. Decreased maternal activity and increased vitamin supplementation (eg, iron and calcium) can further contribute to constipation. 3 Later in pregnancy, an enlarging uterus might slow onward movement of feces. 4 Constipation can result in serious complications such as fecal impaction, but such complications are rare. It is important to note that constipation negatively affects patients' daily lives and is second only to nausea as the most common gastrointestinal complaint in pregnancy. 2,4

Treatment

Many patients find relief from constipation with an increase in dietary fibre and fluids, as well as daily exercise. Probiotics that alter the colonic flora might also improve bowel function. 3 If these are ineffective, laxatives are the second line of therapy (Table 1). 2,5,6 In general, there are insufficient data on the use of laxatives in pregnancy; however, limited studies have been performed for specific laxatives, and the safety of others can be inferred from information about their systemic absorption (Table 2). 7-16

Table 1

Types of laxatives

Treatment Mechanism of Action Examples
Bulk-forming agents Luminal water binding increases stool's bulk, making it easier to pass 5 Psyllium, bran
Stool softeners Stimulates net secretion of water, sodium, chloride, and potassium and inhibits net absorption of glucose and bicarbonate in the jejunum 6 Docusate sodium or calcium
Lubricant laxatives Decreases surface tension of bowel's liquid contents so that more liquid remains in the stool, thereby facilitating evacuation and decreasing straining 2 Mineral oil
Osmotic laxatives Increases osmolar tension, resulting in increased water collection, distention, peristalsis, and evacuation 2 Salts (eg, sodium chloride, potassium chloride), magnesium sulfate or citrate, lactulose, sorbitol, polyethylene glycol
Stimulant laxatives Acts locally to stimulate colonic motility and decrease water absorption from large intestine 5 Bisacodyl, senna
  • Data from West et al, 2 Tack et al, 5 and Moriarty et al. 6

Table 2

Studies examining safety in pregnancy and systemic absorption of commonly used laxatives

Drug Type of Study Details Outcomes
Psyllium Surveillance 100 > N < 199 during first trimester No increased risk of malformations 7
Docusate sodium Prospective N = 116 anytime during pregnancy No increased risk of malformations 8
Surveillance N = 473 during first trimester No increased risk of malformations (1/473 = 0.2%) 7
Surveillance N = 319 during first trimester No increased risk of malformations (3/319 = 0.9%) 9
Surveillance N = 232 during first trimester No increased risk of malformations (9/232 = 3.9%) 10
Lactulose Pharmacokinetics N = 6 adults given lactulose Systemic bioavailability < 3% 11
Polyethylene glycol Pharmacokinetics N = 11 adults given polyethylene glycol Not absorbed 12
Bisacodyl Pharmacokinetics N = 12 adults given oral and rectal bisacodyl Minimal absorption 13
Pharmacokinetics N = 16 adults given bisacodyl suppository Systemic bioavailability < 5% 14
Senna Case-control N = 506 cases (260 during first trimester) No increased risk of malformations (OR 0.8; 95% CI 0.4-1.4) or adverse pregnancy outcomes 15
Pharmacokinetics N = 937 control (500 during first trimester); N = 10 adults given senna Systemic bioavailability < 5% 16
  • OR—odds ratio.
  • Data from Jick et al, 7 Heinonen et al, 8 Aselton et al, 9 Briggs et al, 10 Carulli et al, 11 Wilkinson, 12 Roth and Beschke, 13 Flig et al, 14 Acs et al, 15 and Krumbiegel and Schulz. 16

Bulk-forming agents

Bulk-forming agents are not absorbed 4 or associated with increased risk of malformations 7; therefore, they are considered safe for long-term use during pregnancy. However, they are not always effective and might be associated with unpleasant side effects such as gas, bloating, and cramping. 4

Stool softeners

Docusate sodium has not been associated with adverse effects in pregnancy in a number of studies, and it is thus also considered safe to use. 7-10 There is one case report of maternal chronic use of docusate sodium throughout pregnancy, which was associated with symptomatic hypomagnesemia in the neonate. 17

Lubricant laxatives

Mineral oil is poorly absorbed from the gastrointestinal tract 18 and does not appear to be associated with adverse effects. 19 There is controversy about whether prolonged use reduces the absorption of fat-soluble vitamins, although this appears to be a theoretical rather than actual risk. 20

Osmotic laxatives

Lactulose and polyethylene glycol are poorly absorbed systemically. 11,12 Their use has not been associated with adverse effects; however, individuals might experience side effects such as flatulence and bloating. 3 Theoretically, prolonged use of osmotic laxatives might lead to electrolyte imbalances. 3

Stimulant laxatives

Absorption of bisacodyl is minimal as it has poor bioavailability. 13,14 Senna does not appear to be associated with increased risk of malformations 15 and is not readily absorbed systemically. 16 However, women might experience unpleasant side effects such as abdominal cramps with the use of stimulant laxatives. 2 Similar to osmotic laxatives, prolonged use might theoretically lead to electrolyte imbalances. 3

Conclusion

The first line of therapy for constipation includes increasing dietary fibre and water intake and moderate amounts of daily exercise. 3 If these are ineffective, laxatives are the second line of therapy. Because most laxatives are not absorbed systemically, short-term use has not been, and is not expected to be, associated with an increased risk of malformations. However, as with the general population, it is recommended that osmotic and stimulant laxatives be used only in the short term or occasionally to avoid dehydration or electrolyte imbalances and the theoretical risk of "athartic colon." 21

Motherisk questions are prepared by the Motherisk Team at The Hospital for Sick Children in Toronto, ON. Ms. Trottier and Dr. Erebara are counselors and Ms. Bozzo is Assistant Director of the Motherisk Program.

Do you have questions about the effects of drugs, chemicals, radiation, or infections in women who are pregnant or breastfeeding? We invite you to submit them to the Motherisk Program by fax at 416 813-7562; they will be addressed in future Motherisk Updates.

Published Motherisk Updates are available on the Canadian Family Physician website (www.cfp.ca) and also on the Motherisk website.

View abstract »»

Competing interests
None declared

Copyright © the College of Family Physicians of Canada
Can Fam Physician
Vol. 58, No. 8, August 2012 836-838
Copyright © 2012 by The College of Family Physicians of Canada

References

  1. Jewell DJ, Young G, Interventions for treating constipation in pregnancy. Cochrane Database Syst Rev 2001;(2):CD001142.
  2. West L, Warren J, Cutts T. Diagnosis and management of irritable bowel syndrome, constipation, and diarrhea in pregnancy. Gastroenterol Clin North Am 1992;21(4):793-802. Medline
  3. Longo SA, Moore RC, Canzoneri BJ, Robichaux A. Gastrointestinal conditions during pregnancy. Clin Colon Rectal Surg 2010;23(2):80-9. Medline
  4. Cullen G, O'Donoghue D. Constipation and pregnancy. Best Pract Res Clin Gastroenterol 2007;21(5):807-18. Medline
  5. Tack J, Müller-Lissner S, Stanghellini V, Boeckxstaens G, Kamm MA, Simren M, et al. Diagnosis and treatment of chronic constipation—a European perspective. Neurogastroenterol Motil 2011;23(8):697-710. Epub 2011 May 24. CrossRef | Medline
  6. Moriarty KJ, Kelly MJ, Beetham R, Clark ML. Studies on the mechanism of action of dioctyl sodium sulphosuccinate in the human jejunum. Gut 1985;26(10):1008-13. Abstract/FREE Full Text
  7. Jick H, Holmes LB, Hunter JR, Madsen S, Stergachis A. First-trimester drug use and congenital disorders. JAMA 1981;246(4):343-6. CrossRef | Medline
  8. Heinonen OP, Slone D, Shapiro S Birth defects and drugs in pregnancy: maternal drug exposure and congenital malformations. Littleton, MA: Publishing Sciences Group; 1977. p. 442.
  9. Aselton P, Jick H, Milunsky A, Hunter JR, Stergachis A. First-trimester drug use and congenital disorders. Obstet Gynecol 1985;65(4):451-5. Medline
  10. Briggs GG, Freeman RK,n Yaffe SJ. Drugs in pregnancy and lactation. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. p. 439.
  11. Carulli N, Salvioli GF, Manenti F. Absorption of lactulose in man. Digestion 1972;6(3):139-45. Medline
  12. Wilkinson R. Polyethylene glycol 4000 as a continuously administered nonabsorbable faecal marker for metabolic balance studies in human subjects. Gut 1971;12(8):654-60. Abstract/FREE Full Text
  13. Roth W, Beschke K. Pharmacokinetics and laxative effect of bisacodyl following administration of various dosage forms [article in German]. Arzneimittelforschung 1988;38(4):570-4. Medline
  14. Flig E, Hermann TW, Zabel M. Is bisacodyl absorbed at all from suppositories in man? Int J Pharm 2000;196(1):11-20. CrossRef | Medline
  15. Acs N, Bánhidy F, Puhó EH, Czeizel AE. Senna treatment in pregnant women and congenital abnormalities in their offspring—a population-based case-control study. Reprod Toxicol 2009;28(1):100-4. Epub 2009 Feb 24. Medline
  16. Krumbiegel G, Schulz HU. Rhein and aloe-emodin kinetics from senna laxatives in man. Pharmacology 1993;47(Suppl 1):120-4. Medline
  17. Schindler AM. Isolated neonatal hypomagnesaemia associated with maternal overuse of stool softener. Lancet 1984;2(8406):822. Medline
  18. Hazardous Substances Data Bank [website]. Mineral oil. CASRN: 8012-95-1. Bethedsa, MD: U.S. National Library of Medicine; 2005. Available from: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?HSDB. Accessed 2012 Jun 26.
  19. Sharif F, Crushell E, O'Driscoll K, Bourke B. Liquid paraffin: a reappraisal of its role in the treatment of constipation. Arch Dis Child 2001;85(2):121-4. FREE Full Text
  20. Gal-Ezer S, Shaoul R. The safety of mineral oil in the treatment of constipation—a lesson from prolonged overdose. Clin Pediatr (Phila) 2006;45(9):856-8. Abstract/FREE Full Text
  21. Joo JS, Ehrenpreis ED, Gonzalez L, Kaye M, Breno B, Wexner SD, et al. Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited. J Clin Gastroenterol 1998;26(4):283-6. CrossRef | Medline
Valid XHTML 1.0 Transitional [Valid RSS]

* - "MOTHERISK - Treating the mother - Protecting the unborn" is an official mark of The Hospital for Sick Children. All rights reserved.

The information on this website is not intended as a substitute for the advice and care of your doctor or other health-care provider. Always consult your doctor if you have any questions about exposures during pregnancy and before you take any medications.

Copyright © 1999-2013 The Hospital for Sick Children (SickKids). All rights reserved.

The Hospital for Sick Children (SickKids) is a health-care, teaching and research centre dedicated exclusively to children; affiliated with the University of Toronto. For general inquires please call: 416-813-1500.

  |  Contact SickKids  |  Terms of Use