Bowel habit in pregnancy

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.

Gastrointestinal Diseases in Pregnancy: Nausea, Vomiting, Hyperemesis Gravidarum, Gastroesophageal Reflux Disease, Constipation, and Diarrhea

Many disorders of the gastrointestinal tract are common in pregnancy. Elevated levels of progesterone may lead to alterations in gastrointestinal motility which could contribute to nausea, vomiting, and/or GERD. Pregnancy-induced diarrhea may be due to elevated levels prostaglandins. This article reviews the normal physiologic and structural changes associated with pregnancy that could contribute to many of the common gastrointestinal complaints in pregnant patients. Additionally, the appropriate clinical and laboratory evaluations, other pathologic conditions that should be included in the differential, as well as the nonpharmacologic and pharmacologic therapies for each of these conditions is discussed.

Functional bowel disorders in pregnancy: effect on quality of life, evaluation and management

OBJECTIVE

To characterize functional bowel disorders in a population of pregnant women, evaluating effects on quality of life, management and follow up.

DESIGN

Prospective cohort.

SETTING

University center, USA.

POPULATION

Women in the first trimester (n = 104).

METHODS

After enrollment evaluations, measures were repeated in the third trimester. Overall bowel function was assessed using the Rome III Questionnaire for Functional Bowel Disorders. Quality of life symptoms were assessed with the Irritable Bowel Syndrome Quality of Life Measure. Physician documentation of bowel symptoms and subsequent treatment in pregnancy were ascertained by retrospective chart review.

MAIN OUTCOME MEASURE

Quality of life in first trimester.

RESULTS

A majority (75%) of the women at the first trimester evaluation reported having one or more functional bowel disorders. The overall quality of life status was rated highly functional, with a total average score of 94.9. Of the 75 women reporting functional bowel disorders, only 18 (24%) were identified in the medical record. Overall documentation of any bowel function was identified in the majority (64%) of cases. Most commonly, no discussion of treatment was documented, and follow up was recorded in only 27% of women with dysfunction.

CONCLUSIONS

Nearly three-quarters of women in the first trimester report symptoms consistent with functional bowel disorders. Overall quality of life measures are highly rated. There is a discrepancy between what women report regarding bowel dysfunction and what is documented by providers within the medical record.

Is a multispecies probiotic mixture effective in constipation during pregnancy? 'A pilot study'

BACKGROUND

Constipation during pregnancy is a common problem. Nowadays only few effective interventions are published preventing or treating constipation during pregnancy. However, their use is limited due to side-effects. This uncontrolled intervention study was performed to determine if a mixture of probiotics in the treatment of constipation during pregnancy is effective.

METHODS

Women aged ≥ 18 years with functional constipation were included at the Obstetrical outpatient clinic and midwife practices. Patients received during four weeks a daily dose of Ecologic®Relief (Bifidobacterium bifidum W23, Bifidobacterium lactis W52, Bifidobacterium longum W108, Lactobacillus casei W79, Lactobacillus plantarum W62 and Lactobacillus rhamnosus W71 (total 4*10⁹ CFU)). For all analyses, the non-parametric paired Wilcoxon test was used. Primary outcome measure was change in defecation frequency. Secondary outcome measures were stool consistency, sensation of incomplete evacuation, sensation of anorectal obstruction, manual manoeuvres to facilitate defecation, abdominal pain, adverse effects, presence of reflux episodes and intake of Bisacodyl.

RESULTS

20 women were included. Defecation frequency significantly increased from 3.1 at baseline to 6.7 in week four (p < 0.01). Compared to baseline, a significant decrease in 1) sensation of anorectal obstruction from 90.0% to 45.0% (p < 0.01), 2) sensation of incomplete evacuation from 90.0% to 40.0% (p < 0.01), 3) straining during defecation from 100% to 65% (p = 0.01), 4) episodes of abdominal pain from 60% to 20% (p = 0.01) and 5) the presence of reflux episodes from 60% to 20% in week four (p = 0.01) was found. Other secondary outcomes did not decrease significantly. No side effects were reported.

CONCLUSIONS

Ecologic®Relief is effective in the treatment of constipation during pregnancy. A randomised placebo controlled trial is required to confirm these data.

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.

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.

Overexpression of progesterone receptor B increases sensitivity of human colon muscle cells to progesterone

Colon muscle strips and cells from female patients with slow-transit constipation (STC) exhibit impaired motility, signal transduction abnormalities characterized by downregulation of Gq/11 and upregulation of Gs proteins, decreased cyclooxygenase (COX)-1 and thromboxane (Tx)B2 levels, increased COX-2 and PGE2 levels, and overexpression of progesterone receptors (PGR). Progesterone (P4) treatment of normal cells reproduced these motility and signal transduction abnormalities. The purpose of the study was to examine whether overexpression of PGR-B reproduces these abnormalities by rendering the cells more sensitive to physiological concentrations of P4. Cultured human colon muscle was transfected with a plasmid DNA expressing PGR-B. The mRNAs of PGR, COX-1, COX-2, and Gq/11 were determined by quantitative real-time PCR. Their protein expression was determined by Western blot, and prostaglandins were measured by radioimmunoassay. Cultured muscle cells maintained their phenotypic features determined with myosin light chain (MLC) and h-caldesmon antibodies. Control and transfected muscle cells responded to 10(-6) M P4. In contrast, muscle cells transfected with PGR-B responded to lower P4 concentration (10(-7) M). This P4 concentration reduced MLC phosphorylation induced by CCK-8 (10(-8) M), downregulated Gq/11, and decreased COX-1 and TxB2 levels. It upregulated Gs proteins. It also increased COX-2 and PGE2 levels. We conclude that overexpression of PGR-B renders the cells more sensitive to physiological concentrations of P4. These results are consistent with the hypothesis that overexpression of PGR-B contributes to the motility and signal transduction abnormalities observed in female patients with STC and normal serum levels of P4.

Progesterone, estrogen and pregnancy do not decrease colon myoelectric activity in rats: an in vivo study

BACKGROUND

Progesterone, estrogen and the hormonal complex of pregnancy have been responsible for some degree of colon hypomotility in human pregnancy.

OBJECTIVE

To find out if estrogen, progesterone and the hormonal complex of pregnancy decrease colon myoelectric activity.

METHODS

The study was performed in 37 healthy female rats in which electrodes were implanted on the serosa of the proximal ascendent, distal ascendent, transverse, and descendent colon. We analyzed the records of colon myoelectric activity in vivo in five groups: control, ovariectomized, ovariectomized and treated with estrogen, ovariectomized and treated with progesterone, and pregnant rats.

RESULTS

We found a great variation in myoelectric activity in all groups studied. The mean of electric activity did not show statistical difference among the five groups, but pregnant rats had a statistically significant higher duration of maximum electric activity in all distances from the cecocolon junction.

CONCLUSION

Pregnant rats had a statistically higher duration of maximum electric activity. If we could transpose these results to humans, this increase in duration of colon myoelectric activity could explain, in part, the slight constipation that some pregnant women have.

Pregnancy-related constipation

Constipation is a common complaint in pregnancy. Its symptoms may include infrequent defecation, hard or scybalous stool, or excessive straining. An extensive evaluation is usually unnecessary for women who present with constipation for the first time during pregnancy. Most patients respond to dietary measures or simple laxatives. Few laxatives have been evaluated in clinical trials for use in pregnancy. Evidence supports treatment with fiber supplements and senna. The use of a pharmacologic agent for treatment of constipation during pregnancy must be weighed against possible adverse effects. Most laxatives carry a pregnancy category B or C classification. First-line therapy includes increasing fiber intake through diet or supplements. Osmotic laxatives may be beneficial for some patients. The short-term use of osmotic or stimulant laxatives is generally reserved for patients who fail to respond to dietary changes or bulking agents.

Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy

Constipation, diarrhea, and symptomatic hemorrhoids are disorders common in the general population, particularly in women. These conditions, if mild, often are self-treated with various home remedies or nonprescription preparations. Few of these patients, moreover, are referred to gastroenterologists, as primary care providers generally are confident managing these conditions, unless they are severe, refractory to conventional management, or require additional diagnostic studies.

The irritable bowel syndrome during pregnancy

The irritable bowel syndrome (IBS) is characterized by altered bowel habits and abdominal discomfort in the absence of organic disease. No markers exist for IBS, and the definition of IBS is based on the presence of specific symptoms. The Rome II criteria for defining IBS include abdominal pain or discomfort for 12 weeks or longer, which need not be continuous, over the past 12 months plus two of the following: (1) relief of discomfort with defecation; (2) association of discomfort with altered stool frequency; and (3) association of discomfort with altered stool form. Nine percent to 22% of the population report symptoms consistent with IBS. IBS is the most prevalent digestive disease, representing 12% of visits to primary care physicians and 28% of referrals to gastroenterologists.

The constipation assessment scale for pregnancy

OBJECTIVE

To determine the reliability and validity of the Constipation Assessment Scale (CAS) during pregnancy.

DESIGN

Survey.

SETTING

The assessment tool was administered first to a group of healthy women of childbearing age in a school of nursing and then to pregnant women in their physicians' offices.

PARTICIPANTS

A nonrandom sample of 16 nonpregnant women of childbearing age and 30 women pregnant 28 weeks or longer, 15 of whom had low-risk pregnancies and 15 of whom had high-risk pregnancies.

MAIN OUTCOME MEASURES

The test-retest reliability, content validity, and internal consistency of the CAS were determined.

RESULTS

An expert panel review found a calculated percentage of agreement for content validity of .75 and a Cohen's kappa of .714. Test-retest reliability based on 16 nursing students yielded high positive correlations ranging from rH = .84 to rH = .92. Internal consistency of the CAS for pregnancy based on the 30 surveys indicated an alpha coefficient of .82.

CONCLUSIONS

The CAS for pregnancy was found to be reliable and valid within the context of this study. Future studies designed to identify potential therapeutic interventions for constipation during pregnancy could use the CAS for pregnancy as a measurement instrument.

Constipation and diarrhea in pregnancy

Constipation and diarrhea are common during pregnancy, occurring in up to one-third of women. Constipation is often the result of physiologic changes that occur during pregnancy, usually from hormonal effects on gastrointestinal motility. Diarrhea, on the other hand, is often caused by the same disorders responsible for diarrhea in the nonpregnant patient. The incidence, pathophysiology, evaluation, and treatment of constipation and diarrhea during pregnancy are reviewed in this article.

Dietary factors in the aetiology and treatment of constipation during pregnancy

Using a 7-day weighed-intake method, dietary factors implicated in the aetiology of constipation were examined by comparison between the nutrient intakes of nine women with constipation in the third trimester of pregnancy who had not altered their diets, and a matched group of nine women who had not suffered constipation at any time during pregnancy. No significant differences were found for intakes of major nutrients, including dietary fibre, between the constipated and non-constipated groups, indicating that inappropriate diets do not appear to be the primary cause of constipation during pregnancy. The nutrient intakes of 40 women with constipation in the third trimester of pregnancy were examined to assess dietary changes made in attempts to treat constipation. No difference in intakes of dietary fibre were found between those who claimed to have increase their intakes, and those who had not altered their diets. Both were well below the level of dietary fibre intake known to be successful in treating constipation.

The assessment of gastric acidity and antacid effect in pregnant women by a non-invasive radiotelemetry technique

Non-invasive radiotelemetry techniques were used for the in-vivo assessment of gastric acidity and the effect of antacids in non-pregnant women and women in the third trimester of pregnancy. A particulate (magnesium trisilicate mixture) and a non-particulate (sodium citrate) antacid were studied. There was no significant difference in basal gastric acidity and gut transit time between the pregnant and non-pregnant subjects. The median and range of values for the efficacy (defined as the integrated area under the pH/time curves) of sodium citrate was 138.3 pH.min (29.8-520.7) in the non-pregnant and 103.0 pH.min (54.3-375.6) in the pregnant subjects. The median and range of values for the duration of action of sodium citrate were 38.6 (18.1-147.4) min in the non-pregnant and 30.5 (20.0-119.1) min in the pregnant women. Magnesium trisilicate mixture resulted in a greater intragastric pH change and had a greater efficacy than sodium citrate, but the duration of action of the two antacids was similar.

Ulcerative colitis in pregnancy in Israel

Sixty pregnancies in 31 ulcerative colitis patients were studied retrospectively. Twelve patients (20 per cent) improved, 11 (18.3 per cent) deteriorated, while in 37 (61.6 per cent) there was no change during pregnancy. Seven pregnancies (13.7 per cent) ended by spontaneous and two by artificial abortions. There were 50 full-term deliveries and one premature birth. Seven of the patients were treated with sulfasalazine; five were given steroids; and two, azathioprine. All gave birth to normal children. Of unplanned pregnancies 38.4 per cent were associated with activity of the disease versus only 12 per cent of planned gestations. Pregnancy does not seem to aggravate the course of pre-existing ulcerative colitis, nor does the colitis interfere with the outcome of the pregnancy.

Is your enema really necessary?

Two hundred and seventy-four women admitted for delivery of singleton infants were studied for the effects of a preparatory enema on faecal contamination, duration of labour, and the incidence of infection in the newborn. Altogether 149 of the women were given an enema (controls) and 125 were not. The two groups showed no significant difference in the degree of faecal contamination during the first and second stages of labour, and the incidences of gross contamination were similar. Contamination after an enema was especially difficult to control, since it was more likely to be fluid. Seven neonates in each group showed evidence of infection, bowel organisms being isolated from four in the no-enema group and two in the control group. Durations of labour, though not strictly comparable, were similar in the two groups. The findings suggest that when preparing for normal labour the enema should be reserved for women who have not had their bowels open in the past 24 hours and have an obviously loaded rectum on initial pelvic examination.

Liver and gastrointestinal function in pregnancy

Difficulties arise in the interpretation of liver tests in the pregnant subject, since some values increase (alkaline phosphatase) whilst others remain unchanged (transaminases) or fall during pregnancy. The diagnosis and management of some causes of jaundice in pregnancy, such as viral hepatitis, gall stones, benign intrahepatic cholestasis and acute fatty liver of pregnancy are discussed. Little is known about the commonest symptoms of pregnancy (nausea, vomiting and constipation) other than that they might be due to hormonally induced alteration of sphincter tone. However, pre-existing bowel disease has a greater effect on pregnancy. Fertility is reduced in poor nutritional states (e.g. coeliac and Crohn's diseases) and an increased occurrence of spontaneous abortion has been noted. For inflammatory bowel diseases, the time of onset is important in determining the outcome of pregnancy. Relapse in the disease is commonest in the first trimester and in the puerperium. Treatment of these conditions is essentially as in the non-pregnant subject. The controversial subject of sulphasalazine and steroid usage in pregnancy is discussed.