Constipacy in pregnancy.pptx
Transcript of Constipacy in pregnancy.pptx
Constipacy in pregnancy a review from RCOG April 2015
Constipacy in pregnancya review from RCOG April 2015
Presenter
Dr. Roza Maulindra
Moderator
Dr. Hj. Putri Mirani, SpOG(K)
Fetomaternal Division
To understand the prevalence and pathophysiology of this condition in pregnancy.
To understand the management of constipation in pregnancy
Learning Objectives
The studies on safety of laxatives in pregnancy have small sample sizes although they have not shown any effect on congenital malformations.
When to involve a gastroenterologist or a colorectal surgeon in the care of a woman with constipation in pregnancy
Ethical Issue
Functional (primary) constipation is defined as infrequent bowel motion and/or difficulty in passing stool, which is not attributable to an underlying pathology
Secondary constipation results from either pharmacotherapy or a medical condition
Pregnancy, immobility and change in diet can also worsen constipation
Introduction
The prevalence of constipation is estimated to affect 1138% of pregnancies
Information on bowel dysfunction during pregnancy is limited
The Rome III criteria are the most commonly used classification for chronic constipation (Table 1).
The Rome III Criteria
Pathophysiology
Evaluate from its symptoms:
Evacuating infrequently
Dry hard stools with pain and strain
Excessive straining pudendal nerve weakening pelvic floor
Incomplete evacuation digital manipulation
Record: history of laxative with dosage, comorbodities; hypothyroidism, DM, bowel syndrome; haemorrhoids, IBS
Clinical Evaluation
Treatment
Relive constipation by bulking facal mass thereby stimulating peristalsis
Not absorb in GI tract
No adverse effect to fetus
Slowly act
Not effective in acute
Contraindicated to faecal impaction
Eq: Wheat bran, isphagula husk, methylcellulose, sterculia
1. Bulk-forming agents
comprises lactulose, sorbitol, polyethylene glycol (PEG), magnesium sulphate or citrate, and salts (sodium chloride, potassium chloride).
osmolar tension ammount of water in colon peristalsis and evacuation
Lactulose and PEG poorly absorbed
PEG is a choise for chronic constipation in pregnancy
2. Osmotic laxative
Side effect: flatulence and abdominal bloating, electrolyte immbalance
No adverse effect to fetus
Macrogols (like Movicol, Norgine Ltd., Middlesex, UK) are inert polymers of ethylene glycol, which sequester fluid in the bowel.
2. Osmotic laxative
Stimulant laxatives such as bisacodyl and senna act regionally within the large intestine by reducing water absorption and causing colonic hyper-motility
> effective than bulking
Senna is partially absorbed from the gastrointestinal tract.
No evidance fetal anomalies
3. Stimulant laxative
Docusate sodium acts both as a stimulant and as a softening agent
A case of neonatal hypomagnesaemia after maternal overuse of docusate sodium has been reported
excreted in breast milk
3. Stimulant laxative
Prucalopride stimulates the serotonin 5-HT4 receptor altering colonic motility propulsive force for defaecation
2010 the NICE approved prucalopride of chronic constipation in women if treatment with two different types of laxatives at maximum dose for a minimum period of 6 months had failed and were being considered for invasive treatment
Limited data
4. New agents
linaclotide and lubiprostone are pregnancy category C drugs
Linaclotide is a guanylate cyclase-C receptor agonismanagement of moderate to severe irritable bowel syndrome with constipation (IBS-C).
the concentration of extracellular cyclic guanosine monophosphate (c-GMP) reduce visceral pain by decreasing pain fibre activity
concentration of intracellular c- GMP increasing secretion of electrolytes (chloride and bicarbonate) into the intestinal lumen increased intestinal fluid to ease and accelerate passage of stool
4. New agents
Lubiprostone is a locally acting CIC-2 chloride-channel activator, which augments intestinal fluid secretion and increases motility
Chronic idiopathic constipation if treatment with two different types of laxative at maximum dose for a minimum period of 6 months have failed and invasive treatment is being considered
Experimentation, maternal toxicity and over-dosage (higher than recommended human maximum dose) have detected adverse fetal effects
4. New agents
faecal loading or impaction may benefit from use of glycerine suppositories in addition to the use of oral laxatives as necess
No study exist regarding teratogenicityry.
5. Suppositories and enemas
regular bowel movements occur without difficulty, laxatives can be withdrawn gradually
a combination of laxatives is used, one laxative should be stopped at a time, reducing stimulant laxatives first.
How to stop laxatives
physical examination play a key role in diagnosing and managing women with constipation in pregnancy effectively
The following circumstances warrant a prompt referral to a gastroenterologist:
A change in bowel habit for longer than 6 weeks.
Rectal bleeding.
Known history of gastrointestinal disorders such as inflammatory bowel disease.
A family history of colorectal cancer
Conclusion
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