Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy

Management of Acute Hemorrhoidal Crisis: Evaluation, Treatment, and Special Considerations

Hemorrhoidal disease is one of most common pathologies seen by colorectal and general surgeons. Although hemorrhoids themselves are a normal anatomic occurrence, development of symptomatic disease, usually due to bleeding, prolapse, or thrombosis, can cause significant patient distress. Acute presentation related to significant thrombosis or bleeding is referred to as acute hemorrhoidal crisis. Management of this pathology varies from nonoperative intervention for symptom control to definitive incisional or excisional hemorrhoidectomy. Here we will explore the approach to evaluating and treating acute hemorrhoidal crises.

Regulation of PDGFRα+ cells and ICC in progesterone-mediated slow colon transit in pregnant mice

Background

Progesterone can inhibit intestinal smooth muscle contraction; however, the specific mechanism remains unclear. Besides smooth muscle cells, smooth muscle has two important mesenchymal cells, namely interstitial cells of Cajal (ICC) and PDGFRα+ cells, which induce the contraction and relaxation of smooth muscles. We aimed to explore the regulation of PDGFRα+ cells and ICC in progesterone-mediated colon slow transit in pregnant mice.

Methods

Colon transit experiments were performed in vivo and in vitro to observe slow colon transit. The expression of PDGFRα and c-KIT was detected by Western blot, RT-PCR, and immunofluorescence. An isometric tension experiment was performed to investigate smooth muscle contractions.

Results

The colon transit time in pregnant mice was longer than that in non-pregnant mice. Progesterone significantly blocks colonic smooth muscle contractions. However, when the relaxation and contraction of PDGFRα+ cells and ICC are blocked, progesterone cannot inhibit smooth muscle contraction. When the function of only PDGFRα+ cells are blocked, progesterone has a more obvious inhibitory effect on smooth muscle in the non-pregnant group than that in the pregnant group. However, when ICC alone was blocked, progesterone inhibited smooth muscle contractions more clearly in pregnant mice. The protein and mRNA expression of PDGFRα was higher and c-KIT was lower in pregnant mice. PDGFRα+ cells and ICC from smooth muscle all co-localize progesterone receptors.

Conclusions

Under the regulation of progesterone, the relaxation function of PDGFRα+ cells is enhanced and the contraction function of ICC is weakened, leading to the slow colon transit of pregnant mice.

Prevalence and course of pregnancy symptoms using self-reported pregnancy app symptom tracker data

During pregnancy, almost all women experience pregnancy-related symptoms. The relationship between symptoms and their association with pregnancy outcomes is not well understood. Many pregnancy apps allow pregnant women to track their symptoms. To date, the resulting data are primarily used from a commercial rather than a scientific perspective. In this work, we aim to examine symptom occurrence, course, and their correlation throughout pregnancy. Self-reported app data of a pregnancy symptom tracker is used. In this context, we present methods to handle noisy real-world app data from commercial applications to understand the trajectory of user and patient-reported data. We report real-world evidence from patient-reported outcomes that exceeds previous works: 1,549,186 tracked symptoms from 183,732 users of a smartphone pregnancy app symptom tracker are analyzed. The majority of users track symptoms on a single day. These data are generalizable to those users who use the tracker for at least 5 months. Week-by-week symptom report data are presented for each symptom. There are few or conflicting reports in the literature on the course of diarrhea, fatigue, headache, heartburn, and sleep problems. A peak in fatigue in the first trimester, a peak in headache reports around gestation week 15, and a steady increase in the reports of sleeping difficulty throughout pregnancy are found. Our work highlights the potential of secondary use of industry data. It reveals and clarifies several previously unknown or disputed symptom trajectories and relationships. Collaboration between academia and industry can help generate new scientific knowledge.

Prevalence and severity of bowel disorders in the third trimester of pregnancy

BACKGROUND

Bowel-related disorders are common conditions associated with pregnancy and are a cause of significant distress and healthcare burden. However, there is a lack of data in the literature about these disorders.

OBJECTIVE

This study aimed to investigate bowel dysfunctions during the third trimester of pregnancy in a large cohort of women using the validated bowel domain of the Italian version of the Pelvic Floor Questionnaire for Pregnant and Postpartum Women.

STUDY DESIGN

This was a secondary analysis of a multicenter cross-sectional study conducted in hospitals in Italy and Italian-speaking Switzerland. Women in the third trimester of pregnancy were asked to complete the Italian Pelvic Floor Questionnaire for Pregnant and Postpartum Women.

RESULTS

During the study period, 927 pregnant women in the third trimester of pregnancy responded to the questionnaire and were included in the analysis. Overall bowel dysfunctions were reported by 29.6% of patients. Constipation was reported by 66.6% of pregnant women, whereas symptoms of obstructed defecation were reported by 49.9% of patients. In contrast, urgency was reported by 41.1% of patients. Incontinence to flatus and incontinence to stool were reported by 45.1% and 2.8% of patients, respectively. Moreover, age >35 years, familiarity with pelvic floor disorders, nicotine abuse, and pelvic floor contraction inability were identified as independent risk factors for at least 1 bowel symptom.

CONCLUSION

Bowel symptoms are extremely common in the third trimester of pregnancy and can greatly affect a patient's quality of life; therefore, bowel symptoms deserve to be investigated and managed properly. The use of validated questionnaires represents a precious tool to investigate functional symptoms that could be very frequent and disabling in this particular period of life for women.

Review of the Safety Profiles of Laxatives in Pregnant Women

Chronic constipation is one of the most common complaints seen in the gastroenterology clinic and is particularly prevalent in women. Women who become pregnant may suffer from existing constipation or develop constipation de novo. A thorough understanding of the safety of laxative therapies during pregnancy and the postpartum period is essential to successfully treating these women. Current understanding of the safety of both over the counter and prescription laxatives has not been adequately evaluated. In this article we provide an updated and comprehensive review of the safety profiles of laxatives that are currently used for the treatment of chronic constipation to aid the clinician in risk-benefit discussions with women who are currently or planning to become pregnant.

Perianal Diseases in Pregnancy and After Childbirth: Frequency, Risk Factors, Impact on Women's Quality of Life and Treatment Methods

Hemorrhoids and anal fissures occur in about 40% of pregnant women and women during postpartum period. Usually they occur during the third trimester of pregnancy and 1–2 days after giving birth. Constipation during pregnancy, perianal diseases during previous pregnancy and childbirth, instrumental delivery, straining duration of more than 20 min, and weight of the newborn more than 3,800 g are associated with hemorrhoids. Perianal diseases reduce the quality of life of both pregnant and postpartum women. In the absence of acute conditions, surgical treatment of hemorrhoids is delayed after pregnancy, childbirth, and lactation. Thrombosed internal hemorrhoids and perianal thrombosis are to be treated conservatively in most instances by prescribing adequate pain relief, oral, and topical flavonoid preparations.

Bisacodyl: A review of pharmacology and clinical evidence to guide use in clinical practice in patients with constipation

BACKGROUND

Bisacodyl is a member of the diphenylmethane family and is considered to be a stimulant laxative. It has a dual prokinetic and secretory action and needs to be converted into the active metabolite bis-(p-hydroxyphenyl)-pyridyl-2-methane (BHPM) in the gut to achieve the desired laxative effect. Bisacodyl acts locally in the large bowel by directly enhancing the motility, reducing transit time, and increasing the water content of the stool. A recent network meta-analysis concluded that bisacodyl showed similar efficacy to prucalopride, lubiprostone, linaclotide, tegaserod, velusetrag, elobixibat, and sodium picosulfate for the primary endpoint of ≥3 complete spontaneous bowel movements (CSBM)/week and an increase of ≥1 CSBM/week over baseline. The meta-analysis also found that bisacodyl may be superior to the other laxatives for the secondary endpoint of change from baseline in the number of spontaneous bowel movements per week in patients with chronic constipation. This observation stimulated the authors to review the available literature on bisacodyl, which has been available on the market since the 1950 s.

PURPOSE

The aim of the current review was to provide an overview of the historic background, structure, function, and mechanism of action of bisacodyl. Additionally, we discuss the important features and studies for bisacodyl to understand its peculiar characteristics and guide its use in clinical practice, but also stimulate research on open questions.

Irritable Bowel Syndrome in Pregnancy

Irritable bowel syndrome (IBS) affects a significant percentage of the general population and is more common in women. A large proportion of women affected with IBS are of childbearing age; however, there is a paucity of studies and guidelines to specifically address the epidemiology, course, maternal/fetal prognosis, or management of IBS in pregnancy. This scarcity of literature on IBS and pregnancy poses significant challenges to healthcare providers in counseling and managing patients. In this comprehensive review, we summarize the current literature and knowledge gaps regarding the effects of pregnancy on IBS and vice versa, along with the efficacy and safety profiles of commonly used IBS diets and medications in pregnancy. The management of pregnant women with IBS should be multidisciplinary, with emphasis on education and judicious use of dietary modifications and pharmacologic options that are deemed relatively safe during pregnancy.

Effects of self-acupressure on pregnancy-related constipation: A single-blind randomized controlled study

OBJECTIVES

This study aimed to demonstrate that acupressure could be used to relieve the symptoms of constipation during pregnancy.

DESIGN

Single-blind randomized controlled trial SETTING: Private Medipol Nisa Hospital, Istanbul, Turkey INTERVENTION: This trial including 120 women aged ≥20 years was conducted from November 2019 to February 2020. The participating women who were in the 1st, 2nd or 3rd trimester of their pregnancy, had singleton pregnancy and had a complaint of constipation were randomized into the acupressure (n = 75) and control groups (n = 75). The women in the acupressure group applied 15 min of self-acupressure to the TH-6 acupuncture point twice a day for one week. The women in the control group received no intervention treatment.

MAIN OUTCOME MEASURES

Constipation levels of the participants in the two groups were assessed before and after the procedure using the Constipation Severity Instrument RESULTS: In the present study, after the application of self-acupressure, the severity of constipation decreased significantly in the acupressure group compared to the control group (before treatment: 41.36 ± 6.5 vs. 37.56 ± 6.17 respectively, after treatment: 26.08 ± 7.93 vs. 36.88 ± 5.93, respectively, p < 0.01) CONCLUSION: Although it is safe to use medical drugs in constipation associated with pregnancy, can't reduce it to the extent desired. This study's evidence indicates that self-administered acupressure can effectively alleviate the symptoms of constipation in clinical practice.

Gastrointestinal diseases during pregnancy: what does the gastroenterologist need to know?

Pregnancy is characterized by numerous physiological changes that may lead to a diversity of symptoms and frequently to gastrointestinal complaints, such as heartburn, nausea and vomiting, or constipation. Chronic gastrointestinal diseases require treatment maintenance during this period, raising the challenging question whether outcomes beneficial to the mother may be harmful for the fetus. In addition, certain diseases, such as acute fatty liver of pregnancy, only develop during pregnancy and may require urgent procedures, such as fetus delivery. Even though they are not present in our day-to-day practice, knowledge of pregnancy-related diseases is fundamental and collaboration between gastroenterologists and obstetricians is often necessary. Herein, we review pregnancy-related diseases and systematize the most appropriate treatment choices according to the recent literature and guidelines, so that the article can serve as a guide to the gastroenterologist regarding the medical approach to pregnancy-related gastrointestinal and liver diseases and their therapeutic management.

Hemorrhoids during pregnancy: Sitz bath vs. ano-rectal cream: A comparative prospective study of two conservative treatment protocols

BACKGROUND

Hemorrhoids are a very common ano-rectal condition affecting pregnant females worldwide and representing a major medical and socioeconomic problem. In this paper, we aim to compare the effectiveness of the Sitz bath method with an ano-rectal cream as part of a conservative management protocol to treat hemorrhoids among pregnant Saudi Arabian females.

METHODS

A prospective comparative study of the results of two conservative treatment protocols of 495 pregnant females diagnosed to have hemorrhoids during pregnancy between January 2010 and December 2014 was done. The first conservative protocol consisted of three times per day salty warm Sitz bath (using 20g of commercial salt) for 284 patients. The second protocol consisted of topical cream twice daily for 211 patients. Both protocols included the supportive treatments of 2g glycerin suppositories per rectum 20min before defecation as lubricant and Metamucil bulk-forming fiber (a mix of one dose (sachet) within 240ml (8 oz) of cold liquid) once daily after breakfast for constipation.

RESULTS

Complete healing was achieved in all patients 284 (100%) in the Sitz bath group, compared to 179 (84.8%) in the cream group. Sitz bath was found to represent a statistically significant difference in achieving complete healing for hemorrhoids in pregnant Saudi Arabian females compared to an ano-rectal cream (p-value<0.05).

CONCLUSION

A conservative treatment protocol for hemorrhoids during pregnancy, in which Sitz bath is an essential modality, showed very promising outcomes compared to an ano-rectal cream.

Colonic luminal microbiota and bacterial metabolite composition in pregnant Huanjiang mini-pigs: effects of food composition at different times of pregnancy

The gut harbours diverse and complex microbiota, which influence body health including nutrient metabolism, immune development, and protection from pathogens. Pregnancy is associated with immune and metabolic changes that might be related to microbiota compositional dynamics. We therefore investigated the colonic luminal bacteria community in Huanjiang mini-pigs fed diets with different nutrient levels from the first to third trimester of pregnancy. The concentrations of intestinal metabolites including short-chain fat acids, NH₃-N, indole, skatole, and bioamines were also determined. We found that the colonic bacteria species richness estimators (Chao1 and ACE) decreased with increased gestational age. The dominant phyla identified were Firmicutes and Bacteroidetes; the dominant genera were Lactobacillus, Treponema, Ruminococcus, Clostridium, and Prevotella. In addition, microbiota displayed spatial and temporal heterogeneity in composition, diversity, and species abundance in different colonic segments from the first to third trimester of pregnancy. Furthermore, the bacterial metabolites also changed according to the diet used and the pregnancy stage. These findings suggest that colonic bacteria richness decreased as gestational age increased, and that the higher nutrient level diet increased the production of metabolites related to nitrogen metabolism. However, although the higher nutrient diet was associated with pregnancy syndrome, causal links remain to be determined.

Metagenomic Analysis of Antibiotic-Induced Changes in Gut Microbiota in a Pregnant Rat Model

Food and Drug Administration (FDA, USA)-approved category B antibiotics are commonly prescribed to treat infections during pregnancy. The aim of this study was to investigate antibiotic-induced changes in gut microbiota (GM) that occur during pregnancy. The 16S rRNA amplicon deep-sequencing method was used to analyze the effect of category B antibiotics (azithromycin, amoxicillin and cefaclor) on GM during pregnancy using a rat model. The GM composition was substantially modulated by pregnancy and antibiotics administration. Firmicutes, Bacteroidetes, Proteobacteria, Chlamydiae, Actinobacteria, and Cyanobacteria were the dominant phyla. Antibiotic treatment during pregnancy increased the relative abundance of Proteobacteria and reduced Firmicutes. The genera Shigella, Streptococcus, Candidatus Arthromitus, and Helicobacter were significantly (p < 0.05) more abundant during pregnancy. Antibiotics significantly (p < 0.05) reduced the relative abundance of Lactobacillus but increased that of Enterobacter. There was a significant (p < 0.05) decrease in Lactobacillus sp., Lactobacillus gallinarum and Lactobacillus crispatus during pregnancy. Antibiotic treatment reduced bacterial diversity; the lowest number of operational taxonomic units (OTUs) were detected in the cefaclor-treated groups. Antibiotics significantly (p < 0.05) promoted weight gain during pregnancy, and increased relative abundance of Shigella sonnei, Enterococcus hormaechei, and Acinetobacter sp. GM perturbations were accompanied by increases in Proteobacteria abundance and weight gain in pregnancy following antibiotic treatment.

Interventions for preventing postpartum constipation

BACKGROUND

Postpartum constipation, with symptoms such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones and haematinics used in pregnancy can increase the risk of postpartum constipation. Eating a high-fibre diet and increasing fluid intake is usually encouraged, although laxatives are commonly used in relieving constipation. The effectiveness and safety of available interventions for preventing postpartum constipation needs to be ascertained.

OBJECTIVES

To evaluate the effectiveness and safety of interventions for preventing postpartum constipation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015), Stellenbosch University database, ProQuest Dissertation and Theses database, World Health Organization International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov (30 April 2015) and reference lists of included studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing any intervention for preventing postpartum constipation versus another intervention, placebo or no intervention. Interventions could include pharmacological (e.g. laxatives) and non-pharmacological interventions (e.g. acupuncture, educational and behavioural interventions).We included quasi-randomised trials. Cluster-RCTs were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the search to select potentially relevant studies, extracted data and assessed risk of bias. Results were pooled in a meta-analysis only where there was no substantial statistical heterogeneity.

MAIN RESULTS

We included five trials (1208 postpartum mothers); four compared a laxative with placebo and one compared a laxative alone versus the same laxative plus a bulking agent in women who underwent surgical repair of third degree perineal tears. Trials were poorly reported and risk of bias was unclear for most domains. Overall, there was a high risk of selection and attrition bias. Laxative versus placeboNone of the four trials included in this comparison assessed any of our pre-specified primary outcomes (pain or straining on defecation, incidence of postpartum constipation or changes in quality of life).All four trials reported time to first bowel movement (not pre-specified in our protocol). In one trial, more women in the laxative group had their first bowel movement less than 24 hours after delivery compared to women in the placebo group (risk ratio (RR) 2.90, 95% confidence interval (CI) 2.24 to 3.75, 471 women). Individual trials also reported inconsistent results for days one, two and three after delivery. Pooled results of two trials showed that fewer women in the laxative group were having their first bowel movement at day four compared with controls (average RR 0.36, 95% CI 0.21 to 0.61, 671 women).Regarding secondary outcomes, no trials reported on stool consistency using the Bristol stool form scale orrelief of abdominal pain/discomfort . One trial reported the number of women having loose or watery stools and there were more women who experienced this in the laxative group compared to the placebo group (RR 26.96, 95% CI 3.81 to 191.03, 106 women). One trial found no clear difference in the number of enemas between groups (RR 0.63, 95% CI 0.38 to 1.05, 244 women). One trial reported more women having more than two bowel movements per day in the laxative compared to the placebo group (RR 26.02, 95% CI 1.59 to 426.73, 106 women). Adverse effects were poorly reported; two trials reported the number of women having abdominal cramps, but their results could not be pooled in a meta-analysis due to substantial statistical heterogeneity. In one trial, more women in the laxative group had abdominal cramps compared to the placebo group (RR 4.23, 95% CI 1.75 to 10.19, 471 women), while the other trial showed no difference between groups (RR 0.25, 95% CI 0.03 to 2.20, 200 women). With regards to adverse effects of the intervention on the baby , one trial found no difference in the incidence of loose stools (RR 0.62, 95% CI 0.16 to 2.41, 281 women) or diarrhoea (RR 2.46, 95% CI 0.23 to 26.82, 281 women) between the two groups. Laxative versus laxative plus bulking agentOnly one trial was included in this comparison and reported on pain or straining on defecation in women who underwent surgical repair of third degree perineal tears; there was no reported difference between groups (median (range) data only). No difference was reported in the incidence of postpartum constipation (data not reported) and the outcome changes in quality of life was not mentioned.Time to first bowel movement was reported as a median (range) with no difference between the two groups. In terms of adverse effects , women in the laxative plus stool-bulking group were reported to be at a greater risk of faecal incontinence during the immediate postpartum period (median (range) data only). However the number of women having any episode of faecal incontinence during first 10 days postpartum was reported with no clear difference between the two groups (14/77 (18.2%) versus 23/70 (32.9%), RR 0.55, 95% CI 0.31 to 0.99, 147 women). The trial did not report on adverse effects of the intervention on the babies.The trial reported none of the following pre-specified secondary outcomes: stool consistency using Bristol stool form scale , use of alternative products , laxative agents , enemas , relief of abdominal pain/discomfort and stool frequency .

AUTHORS' CONCLUSIONS

We did not identify any trials assessing educational or behavioural interventions. We identified four trials that examined laxatives versus placebo and one that examined laxatives versus laxatives plus stool bulking agents. Results from trials were inconsistent and there is insufficient evidence to make general conclusions about the effectiveness and safety of laxatives.Further rigorous trials are needed to assess the effectiveness and safety of laxatives during the postpartum period for preventing constipation. Trials assessing educational and behavioural interventions and positions that enhance defecation are also needed. Future trials should report on the following important outcomes: pain or straining on defecation; incidence of postpartum constipation, quality of life, time to first bowel movement after delivery, and adverse effects caused by the intervention such as: nausea or vomiting, pain and flatus.

Interventions for treating constipation in pregnancy

BACKGROUND

Constipation is a common symptom experienced during pregnancy. It has a range of consequences from reduced quality of life and perception of physical health to haemorrhoids. An understanding of the effectiveness and safety of treatments for constipation in pregnancy is important for the clinician managing pregnant women.

OBJECTIVES

To assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

We considered all published, unpublished and ongoing randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs, evaluating interventions (pharmacological and non-pharmacological) for constipation in pregnancy. Cross-over studies were not eligible for inclusion in this review. Trials published in abstract form only (without full text publication) were not eligible for inclusion.We compared one intervention (pharmacological or non-pharmacological) against another intervention, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Four studies were included, but only two studies with a total of 180 women contributed data to this review. It was not clear whether they were RCTs or quasi-RCTs because the sequence generation was unclear. We classified the overall risk of bias of three studies as moderate and one study as high risk of bias. No meta-analyses were carried out due to insufficient data.There were no cluster-RCTs identified for inclusion. Comparisons were available for stimulant laxatives versus bulk-forming laxatives, and fibre supplementation versus no intervention. There were no data available for any other comparisons.During the review process we found that studies reported changes in symptoms in different ways. To capture all data available, we added a new primary outcome (improvement in constipation) - this new outcome was not prespecified in our published protocol. Stimulant laxatives versus bulk-forming laxativesNo data were identified for any of this review's prespecified primary outcomes: pain on defecation, frequency of stools and consistency of stools.Compared to bulk-forming laxatives, pregnant women who received stimulant laxatives had significantly more improvement in constipation (risk ratio (RR) 1.59, 95% confidence interval (CI) 1.21 to 2.09; 140 women, one study, moderate quality of evidence), but also significantly more abdominal discomfort (RR 2.33, 95% CI 1.15 to 4.73; 140 women, one study, low quality of evidence), and borderline difference in diarrhoea (RR 4.50, 95% CI 1.01 to 20.09; 140 women, one study, moderate quality of evidence). In addition, there was no significant difference in women's satisfaction (RR 1.06, 95% CI 0.77 to 1.46; 140 women, one study, moderate quality of evidence).No usable data were identified for any of this review's secondary outcomes: quality of life; dehydration; electrolyte imbalance; acute allergic reaction; or asthma. Fibre supplementation versus no interventionPregnant women who received fibre supplementation had significantly higher frequency of stools compared to no intervention (mean difference (MD) 2.24 times per week, 95% CI 0.96 to 3.52; 40 women, one study, moderate quality of evidence). Fibre supplementation was associated with improved stool consistency as defined by trialists (hard stool decreased by 11% to 14%, normal stool increased by 5% to 10%, and loose stool increased by 0% to 6%).No usable data were reported for either the primary outcomes of pain on defecation and improvement in constipation or any of this review's secondary outcomes as listed above. Quality Five outcomes were assessed with the GRADE software: improvement in constipation, frequency of stools, abdominal discomfort, diarrhoea and women's satisfaction. These were assessed to be of moderate quality except for abdominal discomfort which was assessed to be of low quality. The results should therefore be interpreted with caution. There were no data available for evaluation of pain on defecation or consistency of stools.

AUTHORS' CONCLUSIONS

There is insufficient evidence to comprehensively assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy, due to limited data (few studies with small sample size and no meta-analyses). Compared with bulk-forming laxatives, stimulant laxatives appear to be more effective in improvement of constipation (moderate quality evidence), but are accompanied by an increase in diarrhoea (moderate quality evidence) and abdominal discomfort (low quality evidence) and no difference in women's satisfaction (moderate quality evidence). Additionally, fibre supplementation may increase frequency of stools compared with no intervention (moderate quality evidence), although these results were of moderate risk of bias.There were no data for a comparison of other types of interventions, such as osmotic laxatives, stool softeners, lubricant laxatives and enemas and suppositories.More RCTs evaluating interventions for treating constipation in pregnancy are needed. These should cover different settings and evaluate the effectiveness of various interventions (including fibre, osmotic, and stimulant laxatives) on improvement in constipation, pain on defecation, frequency of stools and consistency of stools.

Gastrointestinal distress in pregnancy: prevalence, assessment, and treatment of 5 common minor discomforts

Gastrointestinal discomforts are a very common complaint in pregnancy. In fact, most pregnant women will experience at least one discomfort. This article focuses on 5 common conditions that occur in pregnancy: gastroesophageal reflux disease, diarrhea, constipation, hemorrhoids, and pica. While these conditions do occur in men and nonpregnant women, they occur more frequently in pregnancy because of the anatomic and physiologic changes associated with gestation. The type and severity of symptoms can vary from individual to individual, making treatment a challenge for healthcare providers, particularly when caring for pregnant women because the effects of medications and other treatments on the developing fetus are often not extensively studied. While these discomforts are rarely life-threatening, they can cause significant distress and impair quality of life. The goal of this article was to provide a summary of the anatomic and physiological changes during pregnancy that contribute to the increasing incidence of these discomforts and to provide information about each condition including prevalence, symptoms, and treatment modalities.

Management of gastrointestinal and liver diseases during pregnancy

In the majority of patients with chronic gastrointestinal and liver diseases, maintenance therapy is required during pregnancy to control the disease, and disease follow-up or disease control might necessitate endoscopy. Evidence on the safety of drugs and imaging techniques during pregnancy is scarce and sometimes difficult to interpret. In this review we summarise existing literature with the aim of optimising counselling of patients with common chronic gastrointestinal and liver diseases who want to conceive.

[Consensus statement haemorrhoidal disease]

Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.

Medical management of constipation

Constipation is a common clinical problem. Initial management of chronic constipation should include lifestyle maneuvers, and increased fiber and fluids. Polyethylene glycol, sodium picosulfate, bisacodyl, prucalopride, lubiprostone, and linaclotide were all more effective than placebo for treating chronic idiopathic constipation. Many commonly used agents lack quality evidence supporting their use.

Gastrointestinal Conditions during Pregnancy

Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.

Haemorrhoids during pregnancy

Haemorrhoids are varicose veins of the rectum covered by mucosa at or near the anal canal. They are normally asymptomatic, can occur at any age and affect both males and females. In this review, we address the issue of the approach of the obstetrician to haemorrhoids and their management. Haemorrhoids are common in young women and commoner during pregnancy and the puerperium. Obstetricians and gynaecologists should be familiar with haemorrhoids, a proctological disease, diagnosis and their treatment, but they have little experience regarding the impact of pregnancy on haemorrhoids. The obstetrician must be able to relieve symptoms in patients who are pregnant, or who have just delivered.

Anorectal symptoms during pregnancy: how important is trimester?

PURPOSE

The frequency of anorectal symptoms amongst pregnant women has not been objectively investigated in the United Kingdom. The aim of this study was to determine the frequency of anorectal symptoms during each trimester of pregnancy.

METHODS

Women attending the antenatal clinics at a London teaching hospital were asked to complete a questionnaire. The presence or absence of common anorectal symptoms experienced both before and during the current pregnancy together with demographic and pregnancy data was collected. Statistical analysis was performed using Fisher's exact test.

RESULTS

Two hundred seventeen patients (first trimester n=75, second trimester n=70 and third trimester n=72) participated. A significant increase in the frequency of symptoms was observed in the third (43.1%) compared to the first (16.0%, p<0.001) and second (22.9%, p=0.013) trimesters. The incidence of per rectal bleeding was significantly greater in the third trimester (30.6%) compared to the first (10.6%, p=0.004) and the second (12.9%, p=0.014) trimesters. Similarly, anal pain was significantly more frequent in the third trimester (34.7%) compared to the first (13.3%, p=0.003) and the second (12.9%, p=0.003) trimesters.

CONCLUSION

The frequency of anorectal symptom reporting appears to increase as pregnancy progresses. Further investigation and research is warranted to determine the configuration of services that may be required to treat those affected.

Common symptoms during pregnancy to predict depression and health status 14 years post partum

OBJECTIVE

To examine the prospective association between symptoms commonly experienced during pregnancy and the mental and general health status of women 14 years post partum.

METHODS

Data used were from the Mater-University of Queensland Study of Pregnancy, a community-based prospective birth cohort study begun in Brisbane, Australia, in 1981. Logistic regression analyses were conducted.

RESULTS

Data were available for 5118 women. Women who experienced a higher burden of symptoms during pregnancy were at greater risk of becoming depressed and reporting poorer health status 14 years post partum. Women who experienced major problems during pregnancy were 4 times more likely to be depressed and nearly 8 times more likely to report poorer health status 14 years after the index pregnancy compared with women who experienced few problems.

CONCLUSIONS

Findings suggest that pregnant women who experience common symptoms during pregnancy are likely to experience poorer mental and self-reported general health 14 years after the pregnancy.

Constipation and pregnancy

Constipation is a common symptom during pregnancy. The majority of cases are simple constipation that occurs due to a combination of hormonal and mechanical factors affecting normal GI function. However, a number of women suffer from constipation prior to conception and find their symptoms worsen during pregnancy. Patients with simple constipation can usually be treated by explanation, reassurance and advice. Medications are best avoided but if necessary should be taken under supervision using best available evidence. It is important that all patients be evaluated by detailed history, physical examination and basic investigations to outrule GI pathology that may be present in a small number of cases. Those whose symptoms predated their pregnancy should be fully evaluated after the puerperium.

Changes in bowel function: pregnancy and the puerperium

Pregnancy is a time when women are susceptible to bowel habit perturbations. The purpose of this study was to provide new baseline data for a range of bowel habit parameters. Prospective 7-day bowel habit diaries were completed during each of the three trimesters of pregnancy and after birth. Sensations of incomplete evacuation and time spent defecating were significantly increased during all three trimesters of pregnancy compared with after birth (P < 0.05). Symptoms of urgency were higher in nonlactating mothers (41% of occasions) compared with lactating women (17% pf occasions) (P=0.07). This study has confirmed the importance of investigating a range of bowel habit parameters during and after pregnancy-investigation of constipation per se may obscure changes in individual bowel habit parameters.

Diet, physical inactivity and the prevalence of constipation throughout and after pregnancy

Few studies appear to have investigated the prevalence of constipation for all three trimesters of the gestative period, or indeed after birth. Using a prospective 4- to 7-day weighed food diary, International Physical Activity Questionnaire and 7-day bowel habit diary, dietary factors, physical activity levels and bowel habit parameters were assessed and examined concurrently at weeks 13, 25, 35 of pregnancy and 6 weeks post-partum. Ninety-four primiparous pregnant women were initially recruited, and 72, 59, 62 and 55 completed the first, second, third trimester and post-partum study stages, respectively. Key dietary factors and physical activity levels were compared between the constipated and non-constipated groups from each of the three trimesters and after parturition. Compared with non-constipated mothers-to-be, constipated participants consumed statistically significantly less water in the first trimester (P = 0.04), more food in the second trimester (P = 0.04), and less iron (P = 0.02) and food (P = 0.04) in the third trimester and after birth, respectively. No statistically significant differences were identified between light, moderate and vigorous physical activity levels when groups were compared. This study demonstrates that dietary factors may play a role in terms of preventing, or alleviating, bowel habit perturbations both throughout and after pregnancy. Further research is required to investigate the interrelationship between physical activity and constipation during and after pregnancy.

Controversies in the treatment of common anal problems

Treating common benign anal diseases has evolved towards more outpatient procedures with better outcome. However, minimizing post-procedure morbidities such as pain and the avoidance incontinence remain the most significant concerns. We introduce some controversies and highlight the developments in current surgical practice for the treatment of common anal problems.

Therapy Insight: drugs for gastrointestinal disorders in pregnant women

The management and treatment of gastrointestinal ailments in pregnant women requires special attention and expertise, since the safety of the mother, fetus and neonate remains the primary focus. Nausea and vomiting during pregnancy is common, as is symptomatic gastroesophageal reflux disease. Peptic ulcer disease occurs less frequently and with fewer complications. Gastroenterologists and obstetricians should be familiar with safe treatment options for these conditions, because they can profoundly impair the quality of life of pregnant women. During pregnancy, constipation can develop de novo, or chronic constipation can increase in severity. Given the array of therapies for constipation, physicians must apprise themselves of drugs that are safe for both mother and fetus. Management of acute, self-limited diarrhea should focus on supportive therapy, dietary changes and maintenance of hydration. Treatment of chronic diarrhea should be considered in the context of therapy for the underlying disorder. Inflammatory bowel disease and irritable bowel syndrome present a unique therapeutic challenge--to control the disease while minimizing toxicity to the fetus and mother. Initiation and alteration of medical therapy for gastrointestinal disorders during pregnancy must be undertaken after discussion with the patient's obstetrician.

Medical treatment of constipation

Various agents are used for the medical management of chronic constipation, but few of these have been adequately studied. This article specifically examines the medical treatment of chronic constipation and the available data concerning bulk agents, lubricating agents, stimulants, and osmotic laxatives, used alone and in combination. Most experts consider dietary fiber or medicinal bulk agents to be the initial therapeutic option for the treatment of chronic constipation. If fiber is not successful or poorly tolerated, subsequent treatments may include saline osmotic laxatives, lactulose, 5-hydroxytryptamine4 (5-HT(4)) agonists (tegaserod), or stimulants such as senna or bisacodyl. Recent data also demonstrate both polyethylene glycol laxative and tegaserod to be safe and effective as initial therapy for chronic constipation.

Management options for symptomatic hemorrhoids

Hemorrhoids remain one of the most common colorectal complaints. They are defined as a pathologic engorgement of the submucosal vascular plexus. Although they are often asymptomatic, hemorrhoids may cause bleeding, prolapse and, less commonly, pain. This review gives an update on various treatment options for symptomatic hemorrhoids, which include conservative treatments, office interventions, and surgical procedures, depending on the individual constellation of symptoms. Objective findings and expectations are also addressed. Recent advances (eg, stapled hemorrhoidectomy and use of alternate energy sources) are emphasized, and treatment under special circumstances (HIV, pregnancy, inflammatory bowel disease, and liver disease) is outlined.