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WOMEN AND NEWBORN HEALTH SERVICE King Edward Memorial Hospital CLINICAL GUIDELINES OBSTETRICS AND MIDWIFERY ANTENATAL CARE MINOR SYMPTOMS OR DISORDERS IN PREGNANCY CONSTIPATION : MANAGEMENT OF PURPOSE The management of constipation in pregnancy. PROCEDURE BACKGROUND Approximately 11% to 38% of women experience constipation during pregnancy, which is usually worse in the second trimester.1,5,6 The cause of constipation usually multifactorial. In pregnancy it can be caused by the elevated progesterone levels causing smooth muscle relaxation, reduced motility and increased water absorbtion.1,5,6 Straining to defecate can lead to damage of the pudendal nerve, impairing the supportive functioning of the pelvic floor muscles. This can be a contributing factor in development of utero-vaginal prolapse.1 CLINICAL HISTORY There is a wide variation in what each patient consider ‘normal’ bowel function.3 Perform a medical history – diagnosis of constipation is made when there is an infrequent defecation (usually < 3 times/week) with stools that are hard and difficult to pass (need to strain or feeling of incomplete defecation). 1,2,3,4,5 Note any medical history that could lead to bowel symptoms, including use of laxatives, dietary habits, water consumption, physical activity, and use of medications such as iron supplements1,7 Management Options: See below Page 1 of 6 B 1.1.10.1 STEP 1 Identify and, if possible, avoid causative drugs. 3 A change in dosage regimen or formulation may alleviate constipation (e.g. CR Iron is claimed to have fewer GI adverse effects).3 Examples of causative drugs: opioids, drug with anticholinergic effects, antacids containing aluminium or calcium, iron supplements, calcium supplements, verapamil.3,4 STEP 2 Identify and manage possible underlying causes 3 E.g. chronic use of laxatives, dietary habits, lack of physical activity, dehydration, depression, neurological disorders (Parkinson’s disease, stroke), metabolic disturbances (diabetes mellitus, hypercalcaemia, hypothyroidism), malignancy, pelvic floor dysfunction, faecal impaction or obstruction, anal fissure.1,3, STEP 3 Encourage mobility and adequate fluid intake (at least 2 litres per day).3,4,5,6 Encourage adequate fibre intake (e.g. whole grains, rice, bran, beans, lentils, nuts, dried fruit, fresh fruit and vegetables.8 Introduce these foods gradually if the woman is not used to these foods as bloating and flatulence may occur otherwise.9 Encourage responding to the urge to defecate immediately. 3,4,5,6 STEP 4 If the above strategies are insufficient, the addition of pharmacological treatment should be used for a short period of time where possible, until the patient has returned to regular and full bowel evacuation.3 Refer to Step-wise Choice of Pharmacological Treatment. B 1.1.10.1 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 2 of 6 Step-wise Choice of Pharmacological Treatment FIRST Option: Bulk-forming laxatives3,10 Do not use for acute relief of constipation as they can take several days to work fully 3 Do not use for opioid-induced constipation. 3 Onset of action: 48-72 hours 3 Ensure adequate fluid intake 3,4,5,6 Introduce to diet slowly to prevent abdominal discomfort 4 Should not be taken immediately before going to bed3 Active Ingredient Psyllium (preferred agent) Available Products at KEMH 10 Ispaghula (preferred agent)10 Frangula bark, sterculia Note: Frangula bark is a stimulant laxative. May be used at recommended doses3,10 Wheat dextrin Note: no reference available regarding safety in pregnancy Metamucil® capsules Metamucil® oral powder Fybogel® oral granules Normacol Plus® oral granules Benefiber® oral powder SECOND Option: Osmotic Laxatives3 Not all Saline laxatives are safe in pregnancy, for example those containing magnesium salts.4 Ensure adequate fluid and fibre intake. 3,4,5,6 Active Ingredient Lactulose (preferred agent) 3, 10 Sorbitol Macrogol laxatives Note: - limited data available in pregnancy, should only be considered on doctors advice, occasional doses appears safe) Available Products at KEMH Actilax® oral liquid Sorbilax® oral liquid Movicol® oral powder Onset of Action 24-72 hours3 24-72 hours3 1-4 days3 3,4 Saline laxatives Note: B 1.1.10.1 Microlax® Rectal Enema 2-30 minutes3 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 3 of 6 - Microlax® brand is safe to use in pregnancy.3 - May cause electrolyte disturbances.3,6 Glycerol Petrus® Rectal Note: useful if stool is present in lower Suppository rectum3 5-30 minutes3 Third Option: Stool Softeners3 Ensure adequate fluid and fibre intake 3,4,5,6 There is limited evidence of efficacy when used as monotherapy1,3 Active Ingredient Docusate Liquid Paraffin Note: - Do not give dose immediately before lying down to avoid aspiration3 - Avoid chronic use as maternal absorption of food, fat-soluble vitamins, and some oral medicines may be impaired10 Poloxamer Available Products Onset of at KEMH Action Coloxyl® tablets 24-72 hours3 Agarol® Vanilla oral 24-72 hours3 liquid Parachoc® oral liquid Coloxyl® oral liquid drops 24-72 hours3 LAST Option: Stimulant Laxatives3 B 1.1.10.1 Stimulant laxatives are usually reserved for severe constipation or if unresponsive to other laxatives mentioned in previous sections. 3 Stimulant laxatives are used if colon motility is poor (e.g. from opioids). 3 Stimulant laxatives are category A in pregnancy and do not cause congenital abnormalities, however should be avoided except for occasional doses. 3,5,10 Stimulant laxatives should not be given to women with a history of preterm labour without medical consultation. Stimulant laxatives are contraindicated where there is an intestinal obstruction, acute abdominal conditions, and inflammatory bowel conditions. 3 Ensure adequate fluid and fibre intake 3,4,5,6 Castor oil should be avoided as it may induce premature labour. Stimulant laxatives are usually given at night.3 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 4 of 6 Active Ingredient Senna Note: High doses or prolonged use may cause inadvertent uterine stimulation especially in cases of threatened premature labour10 Senna combined with Docusate Note: High doses or prolonged use may cause inadvertent uterine stimulation especially in cases of threatened premature labour10 Bisacodyl Bisacodyl Sodium picosulfate Note: use only when no other alternatives are available10 Available Products at KEMH Onset of Action Senokot® oral tablets 6-12 hours3 Coloxyl with Senna® oral tablets 6-12 hours3 Bisalax® oral tablets Dulcolax® rectal suppositories Unavailable 6-12 hours3 5-60 minutes3 6-12 hours3 ADDITIONAL INFORMATION While a stepwise approach as outlined above is preferred, treatment approach should be individualised to each woman. Acute constipation usually benefits from aperients with a quick onset of action such as suppositories or osmotic laxatives, whilst for chronic constipation; a bulk forming laxative may be useful. B 1.1.10.1 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 5 of 6 REFERENCES ( STANDARDS) 1. Cullen G, O'Donoghue D. Constipation and pregnancy. Best Practice & Research Clinical Gastroenterology. 2007;21(5):807-18. 2. Murray I, Hassall J. Change and adaptation in pregnancy. In: Fraser DM, Cooper MA, editors. Myles Textbook for Midwives. Nottingham: Churchill Livingstone; 2009. p. 189-225. 3. Australian Medicines Handbook. 12.4 Laxatives. Adelaide: Australian Medicines handbook Pty Ltd; 2014 4. Therapeutic Guidelines Limited. eTG Complete (online). c2014. Available from: http://www.tg.org.au Vazquez JC. Constipation, haemorrhoids and heartburn in pregnancy. Clinical Evidence. Published online 2010, August. 5. Vazquez JC. Constipation, haemorrhoids and heartburn in pregnancy. Clinical Evidence. Published online 2010, August. 6. Derbyshire E, et al. Diet, physical inactivity and the prevalence of constipation throughout and after pregnancy. Maternal & child nutrition. 2006;2(3):127-134. 7. Murray I, Hassall J. Change and adaptation in pregnancy. In: Fraser DM, Cooper MA, editors. Myles Textbook for Midwives. Nottingham: Churchill Livingstone; 2009. p. 189-225. 8. Grigg C. Working with with women in pregnancy. In: Pairman S, Pincombe J, Thorogood C, Tracy S, editors. Midwifery preparation for Practice. Sydney: Churchill Livingstone; 2010. p. 431-68. 9. Ford F. Constipation in pregnancy. The Practising Midwife. 2008;11(10):28-31. 10. The Royal Women’s Hospital. Pregnancy and Breastfeeding Medicines Guide. C2010. Melbourne. National Standards – 1 Clinical Practice; 4 Medication Safety Legislation - Nil Related Policies – Minor Symptoms and Disorders of Pregnancy Other related documents – Nil RESPONSIBILITY Policy Sponsor Initial Endorsement Last Reviewed Last Amended Review date Chief Pharmacist KEMH July 2014 October 2015 July 2017 Do not keep printed versions of guidelines as currency of information cannot be guaranteed. Access the current version from the WNHS website B 1.1.10.1 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 6 of 6