DOI: 10.1111/tog.

12179

2015;17:1115

Review

The Obstetrician & Gynaecologist

http://onlinetog.org

Constipation in pregnancy
Tina Sara Verghese

a,
MBBS, *

Kaori Futaba

b
FRCS MMedSci,

Pallavi Latthe

MD MRCOG

Clinical Research Fellow, Obstetrics and Gynaecology, Birmingham Womens NHS Foundation Trust, Edgbaston, Birmingham, West Midlands B15
2TG, UK
b
Consultant Colorectal Surgeon, Department of Colorectal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS
Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2GW, UK
c
Consultant Obstetrician and Gynaecologist, Subspecialist in Urogynaecology, Department of Obstetrics & Gynaecology, Birmingham Womens
NHS Foundation Trust, Edgbaston, Birmingham, West Midlands B15 2TG, UK
*Correspondence: Tina Verghese. Email: t.s.verghese@bham.ac.uk
Accepted on 28 January 2015

Key content

Learning objectives

Constipation affects up to 38% of pregnancies.

 Rising progesterone levels in pregnancy contribute to slow
gut motility.
 The standard clinical measures of chronic constipation are the
Rome III criteria, which are based on frequency and difficulty in
the passage of stool.
 Secondary constipation is due to primary disease of the colon (anal
fissure, stricture and neoplasia), metabolic disturbances
(hypothyroidism and hypercalcaemia) and neurological disorders.
 Severe constipation may result in faecal impaction, retention of
urine, pain or abdominal discomfort, rectal bleeding and/or
rectal prolapse.
 A treatment algorithm using laxatives that are effective, safe and
non-teratogenic will be discussed.

To understand the prevalence and pathophysiology of this

condition in pregnancy.
 To understand the management of constipation in pregnancy.
Ethical issues


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.
Keywords: constipation / laxatives

Please cite this paper as: Verghese TS, Futaba K, Latthe P. Constipation in pregnancy. The Obstetrician & Gynaecologist 2015;17:1115.

Introduction
Constipation is a frequent and debilitating problem worldwide. It
affects twice as many women as men.1 In 2010, 15.9 million
prescriptions were dispensed in the community in England for
laxatives, at a cost of 70.6 million.2 Treatment of chronic
constipation can be difficult and in some cases women may
require years of treatment. Detailed prognostic data are currently
unavailable and long-term adverse effects are unknown.
Functional (primary) constipation is defined as infrequent
bowel motion and/or difficulty in passing stool, which is not
attributable to an underlying pathology.1 Secondary
constipation results from either pharmacotherapy or a
medical condition. Medical conditions include primary
disease of the gastrointestinal tract (such as, anal fissure,
colorectal strictures and neoplasia), metabolic disturbances
(such as, hypothyroidism, hypercalcaemia) and neurological
disorders. Some individuals may suffer from irritable bowel

2015 Royal College of Obstetricians and Gynaecologists

syndrome associated with constipation (IBS-C). Constipation

occurs in all age groups and can be particularly problematic
in the elderly. Pregnancy, immobility and change in diet can
also worsen constipation. Constipation is perhaps most
conveniently thought of as a symptom. In contrast, functional
and secondary constipation can be regarded as disorders.
The prevalence of constipation is estimated to affect
1138% of pregnancies.3 Information on bowel dysfunction
during pregnancy is limited. Pregnant women may develop
this symptom for the first time in pregnancy or may
experience worsening of their symptoms if they had
previously suffered from constipation. The Rome III criteria
are the most commonly used classification for chronic
constipation (Table 1).4 Although it is not specifically
designed for pregnancy, a more simplified criteria that may
be more appropriate could include: low frequency of
defaecation (less than thrice per week), passage of hard
stools and/or difficulties in regularly emptying the bowels.

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Constipation in pregnancy

Table 1. Rome III criteria for functional constipation

Clinical evaluation

Diagnostic criteria*
1 Must include two or more of the following:
a. Straining during at least 25% of defecations
b. Lumpy or hard stools in at least 25% of defecations
c. Sensation of incomplete evacuation for at least 25%
of defecations
d. Sensation of anorectal obstruction/blockage for at least 25%
of defecations
e. Manual manoeuvres to facilitate at least 25% of defecations (e.g.,
digital evacuation, support of the pelvic oor)
f. Fewer than three defecations per week
2. Loose stools are rarely present without the use of laxatives
3. Insufcient criteria for irritable bowel syndrome

Women usually report symptoms such as evacuating

infrequently, passing dry hard stools associated with pain
and straining. Excessive straining can damage the pudendal
nerve leading to weakening of the pelvic floor musculature.14
It is essential to note these key symptoms as it assists in
clinical evaluation. In addition, women may also give a
history of incomplete evacuation, which may even require
digital manipulation in severe cases to allow defaecation. It is
beneficial to recognise if these symptoms persisted prior to
pregnancy. A history of laxative or enema use should be
noted along with the dosage and frequency of treatment.
Presence of comorbidities such as hypothyroidism and
diabetes mellitus should be recorded. Constipation can be
associated with other bowel conditions like haemorrhoids,
irritable bowel syndrome (IBS) and might require input from
a
colorectal
surgeon
or
gastroenterologist
in
some individuals.

*Criteria fullled for the last 3 months with symptom onset at

least 6 months prior to diagnosis. Reproduced with permission
from the Rome Foundation

A prospective study demonstrated that pregnant women

are most prone to developing constipation in the first two
trimesters.5 The prevalence of functional constipation in the
first and second trimester varies between 35% and 39%, is
21% in the third trimester and 17% peurperium.5 Most
women can be managed with remedies such as increasing
dietary fibre and fluid intake with or without laxatives. When
symptoms are severe or refractory to conventional measures,
referral to specialist units is recommended for further
diagnostic tests and treatment.

Pathophysiology
Changes in the levels of hormones, particularly increased
progesterone levels during pregnancy, are responsible for
reduced intestinal smooth muscle motility.6 The secretion of
motilin, a peptide hormone which stimulates smooth muscle
motility, is inhibited by the rise in the level of serum
progesterone and somatostatin.7,8 Another hormone which
exhibits inhibitory effects is relaxin, which acts on the
myometrium and appears to contribute to intestinal gut
hypomotility.9 During pregnancy there is an increase in water
absorption due to activation of the renin angiotensin system
resulting from high levels of circulating estrogen and
progesterone which stimulate renin secretion and
aldosterone production.10 Aldosterone stimulates sodium
and water reabsorption from the renal tract and gut. The
reduced water content leads to hardened stools.
The forward passage of faeces becomes sluggish secondary
to the contributory passive movements of the intestinal tract
and uterus eventually leading to constipation.11 Other factors
responsible for constipation in pregnancy are insufficient
water and dietary fibre such as non starch polysaccharide.12
Haemorrhoids, anal fissures, pain at the episiotomy site,
effects of pregnancy hormones and hematinics used in
pregnancy can increase the risk of postpartum constipation.13

112

Treatment
Patient education, environmental modification and
reassurance that these symptoms are transient and normal
during pregnancy may be all that is required. The majority of
patients will find relief by increasing their dietary fibre and
fluid intake. There is evidence that increasing dietary
supplements such as bran or wheat fibre can improve
symptoms in pregnant women with constipation.3 Some
traditional herbal remedies have been used for short-term
relief such as Linseed. This is generally mixed in liquid or
food, for example, bread or muffins. It must be noted that
there is insufficient evidence regarding its safety during
pregnancy.15 Probiotics may also assist in improving bowel
function by conditioning the colonic flora.16 Laxatives are
recommended if dietary modifications fail to improve the
symptoms. A laxative that is effective, non-teratogenic, not
excreted in the breast milk and well tolerated should be
chosen. Antispasmodics and anticholinergics used in IBS are
contraindicated in pregnancy and should not be used.

Bulk-forming agents
Bulk-forming laxatives relieve constipation by bulking faecal
mass thereby stimulating peristalsis. They are not absorbed
from the gastrointestinal tract making them one of the safest
and most suitable laxatives for use during pregnancy. This
group comprises wheat bran, ispaghula husk, methylcellulose
and sterculia. No adverse effects on the fetus have been
reported.17 Women should be advised that bulk-forming
agents act slowly and therefore can take a few days before its
benefit is noticeable. These agents may not always be effective
in improving acute symptoms and is contraindicated in
faecal impaction.

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Verghese et al.

Osmotic laxatives

New agents

Osmotic laxatives comprises lactulose, sorbitol, polyethylene

glycol (PEG), magnesium sulphate or citrate, and salts
(sodium chloride, potassium chloride). They act by
increasing osmolar tension, resulting in an increased
amount of water in the colon facilitating peristalsis and
evacuation. Lactulose and PEG are poorly absorbed
systemically. PEG is approved by the American
Gastroenterology Association and is the treatment of choice
for chronic constipation in pregnancy.18 Common side
effects are flatulence and abdominal bloating as
hyperosmolar laxatives are indigestible sugars that ferment
in the gastrointestinal tract producing excess gas. Although
no published studies exist on adverse fetal effects, preclinical
data suggest that there is no increased risk of teratogenicity.17
Lactulose is a semi-synthetic disaccharide and is best avoided
in women with diabetes and those requiring a low galactose
diet. Theoretically, prolonged use of osmotic laxatives might
lead to electrolyte imbalances.
Macrogols (like Movicol, Norgine Ltd., Middlesex, UK)
are inert polymers of ethylene glycol, which sequester fluid in
the bowel. It is licensed for use in pregnancy despite limited
information in pregnancy, as the effects on the fetus of
systemic exposure to the drug are believed to be negligible.1

Prucalopride stimulates the serotonin 5-HT4 receptor thereby

altering colonic motility which provides the propulsive force
for defaecation. In 2010 the National Institute for Health and
Care Excellence (NICE) approved the use of prucalopride for
the management 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. There are limited
data available on its use in pregnancy. It is therefore not
recommended during pregnancy and breastfeeding. Women
of childbearing potential should use effective contraception
during treatment with prucalopride.22
Newer drugs such as linaclotide and lubiprostone are
pregnancy category C drugs, which means that their use
should only be considered if the inherent benefits outweigh
the possible risks to the fetus. Linaclotide is a guanylate
cyclase-C receptor agonist. Its use has been approved for the
management of moderate to severe irritable bowel syndrome
associated with constipation (IBS-C). The mode of action is
by augmenting the concentration of extracellular cyclic
guanosine monophosphate (c-GMP), which is thought to
reduce visceral pain by decreasing pain fibre activity. In
addition, it also increases the concentration of intracellular cGMP resulting in increasing secretion of electrolytes
(chloride and bicarbonate) into the intestinal lumen
leading to increased intestinal fluid to ease and accelerate
passage of stool. It is metabolised within the gastrointestinal
tract and is virtually undetectable in plasma after therapeutic
doses. There is a dearth of information available for use
during pregnancy or breastfeeding.
Lubiprostone is a locally acting CIC-2 chloride-channel
activator, which augments intestinal fluid secretion and
increases motility. It is licensed and approved by NICE for
the management of 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. In animal
experimentation, maternal toxicity and over-dosage (higher
than recommended human maximum dose) have detected
adverse fetal effects. It is unascertained whether these drugs
are excreted in breast milk and therefore should be used
with caution.23

Stimulant laxatives
Stimulant laxatives such as bisacodyl and senna act regionally
within the large intestine by reducing water absorption and
causing colonic hyper-motility. Stimulant laxatives are more
effective than bulk-forming laxatives.19 However, stimulant
laxatives should be used with caution in the third trimester as
they can stimulate uterine contractions. This has been
documented in several anthraquinone derivatives, though
not senna itself.20
Senna is partially absorbed from the gastrointestinal tract.
A large case-control surveillance study reported no increased
risk of congenital abnormalities. Senna can be excreted in
breast milk and hence caution is advised if the woman is
breastfeeding. There is minimal absorption (5%) of bisacodyl
as it has poor bioavailability. Bisacodyl has not been
associated with either teratogenic or fetotoxic effects and is
considered suitable for use in pregnancy.17
Docusate sodium acts both as a stimulant and as a
softening agent. It is an anionic wetting agent allowing
penetration of accumulated hard, dry stool by water and
salts. A case of neonatal hypomagnesaemia after maternal
overuse of docusate sodium has been reported.21 Therefore,
the use of docusate sodium should only be considered at low
doses in pregnancy if other treatments are unsuccessful.21 It is
excreted in breast milk with oral administration of docusate
sodium. Hence, it should be used with caution in
lactating mothers.

2015 Royal College of Obstetricians and Gynaecologists

Suppositories and enemas

Patients suffering from faecal loading or impaction may
benefit from use of glycerine suppositories in addition to the
use of oral laxatives as necessary. The UK Teratology
Information Service advises that glycerine suppositories can
be used in pregnancy.17 No published studies exist regarding
the use of phosphate enemas during pregnancy and potential
for teratogenicity.17

113

Constipation in pregnancy

Note: If there is no
response to one therapy,
then a combination of
medications from the
can be used

Increase dietary
moderate exercise

No improvement
or switch to one of
the following:

Bulk-forming agents
Bran, ispaghula,
methylcellulose,
sterculia
Osmotic laxatives
Lactulose,
polyethylene glycol
(PEG), sorbitol
Stimulant laxatives
Bisacodyl, senna

Improvement in
symptoms

Suppositories
Glycerol
suppositories

Figure 1. Algorithm for the management of constipation in pregnancy

How to stop laxatives

When regular bowel movements occur without difficulty,
laxatives can be withdrawn gradually. The reduction in the
dose of laxatives should be guided by the frequency and
consistency of the stools. Gradual withdrawal will reduce the
risk of requiring re-initiation of therapy for recurrent faecal
loading. If a combination of laxatives is used, one laxative
should be stopped at a time, reducing stimulant laxatives
first. Patients should be aware that the process of weaning off
laxatives may take several months. Relapses often occur and
are managed by increasing the dose of laxatives promptly.
Individuals with a medical or pharmacological cause of
constipation may require long-term continued usage
of laxatives.

dietary fibre and water intake. If the first step is unsuccessful

in alleviating symptoms then laxatives should be considered
(Figure 1). Care must be taken to use the best type of laxative
to treat their symptom with minimal risk profile for the
mother and baby in pregnancy. Robustly conducted
randomised controlled trials aimed at treating postpartum
women diagnosed with constipation would be beneficial.
These trials should also address the criteria for administering
the intervention as well as their safety and effectiveness.13

Contribution of authorship
TV researched, drafted and revised the article. KF reviewed
and revised the article. PL instigated and edited the article.
All authors approved the final version.

Disclosure of interests

Conclusion

There are no conflicts of interest

A detailed history and thorough physical examination play a

key role in diagnosing and managing women with
constipation in pregnancy effectively. If there are any red
flag signs and symptoms women should undergo further
investigation to rule out any serious gastrointestinal
pathology. 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.

References

Women should be advised that it can take several months

to be successfully weaned off all laxatives.1 The first-line
therapy for constipation should commence by increasing

114

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Corrigendum
In the following article1, the authors have acknowledged the incorrect statement regarding cardiotocography (CTG)
sensitivity and specificity on page 5, 2nd paragraph.
The sentence read:
Cardiotocography (CTG) is the main form of electronic fetal monitoring (EFM) used in many countries; approximately
300 000 pregnant women have CTG monitoring in the UK annually.3 It has been shown to have a low sensitivity but a
high specificity4 i.e. while a normal trace is reassuring that the fetus is well, an abnormal trace does not necessarily mean
that there is fetal hypoxia.
The statement should have read:
Cardiotocography (CTG) is the main form of electronic fetal monitoring (EFM) used in many countries; approximately
300 000 pregnant women have CTG monitoring in the UK annually.3 It has been shown to have a high sensitivity but a
low specificity4 i.e. while a normal trace is reassuring that the fetus is well, an abnormal trace does not necessarily mean
that there is fetal hypoxia.

Reference
1 Sacco A, Muglu J, Navaratnarajah R, Hogg M. ST analysis for intrapartum fetal monitoring. The Obstetrician & Gynaecologist 2015; 17:512.
DOI: 10.1111/tog.12194.

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