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Constipation, fecal incontinence common in pregnant, postpartum women
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Defecatory disorders such as constipation and fecal incontinence are commonly associated with pregnancy and the postpartum period, and they may cause significant patient stress and health care burden, according to a recently published review.
Studies have implicated pelvic floor injury during pregnancy and mode of delivery as the main causes of defecation disorders in postpartum women. Therefore, Ron Schey, MD, FACG, and colleagues from Temple University School of Medicine in Philadelphia, co-wrote a review to “discuss the physiology of the pelvic floor and how it is affected by pregnancy, as well as expand on the current diagnosis and management of postpartum defecatory disorders.”
Ron Schey
Constipation
An estimated 40% of women experience constipation during or after pregnancy. According to a 2007 study, rates of constipation were highest in the first two trimesters, at 35% and 39%, respectively, which then fell to 21% in the third trimester and 17% postpartum.
The causes of constipation vary during the course of pregnancy, which may be:
- dehydration;
- hormonal;
- mechanical;
- drugs;
- parity;
- pre-existing disease;
- chronic idiopathic constipation;
- irritable bowel syndrome;
- congenital or acquired megacolon; and
- chronic idiopathic intestinal pseudo-obstruction.
Data are conflicting regarding whether the mode of delivery is associated with subsequent constipation, and further research is needed “to better understand the relationship between mode of delivery and rates of obstructed or dyssynergic defecation,” the authors wrote.
Treatment for constipation is similar to the general population for pregnant women and involves reassuring the patient, encouraging adequate fluid intake, using fiber supplementation and osmotic laxatives. Although these interventions have widespread use and presumed safety, polyethylene glycol is not FDA-approved for use in pregnancy and has a pregnancy category C rating, and lactulose has a pregnancy category B. Thus, “patients should be counseled with regard to the theoretical risks associated with these medications,” the authors wrote.
Fecal incontinence
Three to 4 percent of women report new symptoms related to altered anal continence after pregnancy, and reports of altered fecal continence are as high as 25% in primiparous women at 6 weeks postpartum. However, one study found that only 14% of women with these symptoms sought medical attention. The majority of these patients present later in life, with median age of onset in the patients’ 70s.
Causes of pregnancy-related incontinence include:
- vaginal delivery;
- forceps;
- emergency cesarean section;
- epidural anesthesia;
- perineal laceration; and
- obstetric genital fistula.
According to Schey, there are three key points regarding risk factors. “Anatomical damage of the anal sphincter is less common following vacuum extraction than forceps deliveries,” he said. Furthermore, “operative vaginal deliveries may contribute to unrecognized vaginal trauma and the degree of injury directly correlates to symptoms of incontinence.” Finally, he added, “despite the common belief that an elective caesarean section may be protective against the subsequent development of fecal incontinence, the current literature does not support this theory.”
Treatments include dietary modification, fiber supplementation, pharmacologic intervention with agents like loperamide, pelvic floor muscle training and surgery typically reserved for refractory patients. Many surgical advancements have been made to treat fecal incontinence, including neosphincter creation (muscle or artificial), injection of bulking agents into the anal canal, sacral nerve stimulation and percutaneous tibial nerve stimulation. – by Adam Leitenberger
Disclosure: The authors report no relevant financial disclosures.
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